Peer Review History

Original SubmissionDecember 6, 2022
Decision Letter - Jasna Karacic Zanetti, Editor

PONE-D-22-33528Stress and burnout amongst mental health professionals in Singapore during Covid-19 endemicityPLOS ONE

Dear Dr. Yang Suyi

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by 1 of May. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.
If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Jasna Karacic Zanetti, Ph.D

Academic Editor

PLOS ONE

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When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

“This research is supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (Grant No.: NMRC/CG1/005/2021-IMH).”

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This research is supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (Grant No.: NMRC/CG1/005/2021-IMH). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear authors,

it was my pleasure to read your article.

Please correct step by step all comments from the reviewers, as well you can mention how political decisions that are made affect burnout ( https://pubmed.ncbi.nlm.nih.gov/34828596/)

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for allowing me to review this interesting paper on stress and burnout amongst mental health professionals in Singapore during COVID-19 endemicity. As COVID-19 is part of our everyday lives currently, and as mental health issues gain prominence, making sure that mental health professionals who provide care to patients that need this help is very important. This paper has the potential to inform clinical practice.

I have a few minor suggestions for the authors to consider:

1. In the statistical section, state what p value as considered significant.

2. It would be helpful to provide some context on the clinical workload of the centre, including how this changed during the different time periods, even if discussed in a qualitative fashion that would be helpful.

3. Discuss the potential impact of the limitations on the estimates seen in the results.

Reviewer #2: please refer to my reviewers comments that i have attached above.

I think this it is an important topic.

The study aimed to highlight the high prevalence of burn out and stress in the mental health professionals

Nonetheless the low response rate of the survey limits the strength of the study to draw meaningful conclusions.

The comparative data was drawn from previous publications without elaborations of consistency of methodology or study population

Authors should also consider drawng references from previous multi-institutional, longitudinal study that were conducted in similar healthcare setting.

kindly refer to my atached comment above.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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Attachments
Attachment
Submitted filename: Screenshot 2023-04-21 at 00.44.37.png.png
Revision 1

(Please refer to the attached "Responses to reviewers" file.)

Dear Editor and reviewers,

Thank you for your feedback and suggestions. Please find below the responses to each point raised by the editor/ reviewers.

Responses to editor

Please correct step by step all comments from the reviewers, as well you can mention how political decisions that are made affect burnout.

Response: Thank you for highlighting the importance of health politics. We have added more suggestions on how health policy can improve the well-being of MHP in p19 (Discussion section).

Responses to reviewer#1

Reviewer #1: Thank you for allowing me to review this interesting paper on stress and burnout amongst mental health professionals in Singapore during COVID-19 endemicity. As COVID-19 is part of our everyday lives currently, and as mental health issues gain prominence, making sure that mental health professionals who provide care to patients that need this help is very important. This paper has the potential to inform clinical practice.

I have a few minor suggestions for the authors to consider:

1. In the statistical section, state what p value as considered significant.

Response: Thank you for the feedback and suggestions. We have added in “P-value <0.05 was used to determine whether the ANOVA/ post-hoc tests were statistically significant” in p7 (Data analysis section).

2. It would be helpful to provide some context on the clinical workload of the centre, including how this changed during the different time periods, even if discussed in a qualitative fashion that would be helpful.

Response: Thank you for the suggestion. We have added in some context on the clinical workload of MHP and how it changed during the different time periods in p13-14 (Discussion section).

3. Discuss the potential impact of the limitations on the estimates seen in the results.

Response: We are unsure what estimates you are referring to here. We have indicated in the limitation section that due to low response rate, finding cannot be generalised to all MPH working in Singapore). We have also added that use of different sample cohort limits interpretation of causality and a longitudinal follow-up study is recommended. These can be found in p 19 (Limitation section).

Responses to reviewer#2

Reviewer #2: please refer to my reviewers comments that i have attached above.

I think this it is an important topic. The study aimed to highlight the high prevalence of burn out and stress in the mental health professionals. Nonetheless the low response rate of the survey limits the strength of the study to draw meaningful conclusions. The comparative data was drawn from previous publications without elaborations of consistency of methodology or study population

Authors should also consider drawing references from previous multi-institutional, longitudinal study that were conducted in similar healthcare setting.

Response to item 1: Thank you for your feedback and suggestions. The first study in May 2020 was carried out 2 months after strict lockdown measures were implemented in April 2020 in Singapore. The aim was to collect baseline burnout data among healthcare workers. The second study in September 2021 was carried out after about 80% of the population have been vaccinated against COVID-19 by August 2021. Despite the high vaccination rate in Singapore, the healthcare system was still strained by a high volume of COVID-19 cases and it was unclear whether there was any change in burnout rate among healthcare workers. The aim of the September 2021 study was to compare the burnout rate to the baseline rate. The third study in June 2022 was carried out 6 months after Singapore has transited into a state of COVID-19 endemicity. The aim was to assess whether burnout among healthcare workers has lessened to an acceptable level during COVID-19 endemicity. We have added a summarized timeline of the major covid related events in p.3-4 (Introduction section). This will help provide context to the timing of the 3 studies.

Response to item 2: The decision to implement the study was based on major COVID-19 related events as explained in point 1. We did not time our studies based on when the COVID-19 waves spikes as these spikes are hard to predict. We have added how some COVID-19 related events might have an impact on MHP burnout rate in p.13-14 (Discussion section)

Response to item 3: The possible factors that may aggravate or mitigate stress and burnout were drawn from a study conducted in the same psychiatry hospital (IMH) in 2014 by the same author. Though only the quantitative findings were published then, the qualitative findings were analyzed internally to provide a better understanding of causes of burnout among mental health professionals. These findings were contributed by mental health professionals working in the same workplace (with similar work conditions and work culture) and provide valuable and relevant insights into possible factors that may aggravate or mitigate stress and burnout for mental health professionals working in IMH. Thus they were used to formulate the survey question in this study.

In the discussion section, we have referenced some studies from Asian region when discussing factors that impact stress and burnout. Please refer to page 16-17. Thank you for bringing our attention to Teo el al study. We have added a discussion point in reference to this study in p16 (Discussion section).

Response to item 4: Yes, we agree that the low response rate and the use of different sample cohorts to trend the burnout rate is a limitation to the study. We have added these limitations in p 19 (Limitation section).

Attachments
Attachment
Submitted filename: Responses to reviewers.docx
Decision Letter - Jasna Karacic Zanetti, Editor

PONE-D-22-33528R1Stress and burnout amongst mental health professionals in Singapore during Covid-19 endemicityPLOS ONE

Dear Dr. Suyi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 23 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.
If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jasna Karacic Zanett

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Authors,

Thank you for your updated version of the manuscript. Please consider the comments from the review and then send it back to us again.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

********** 

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #4: Yes

********** 

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Please go over the manuscript once again to avoid any minor grammatical, punctuation and consistent style of writing.

Thank you for adequately revising.

Reviewer #4: Overall, there are grammatically some incorrect parts (Line 369:exitant,line 91:this 2 months, line 266: exitant, line108:April2022, line 112 :June2022)->grammatical correction required

Methodology

-The author should show a sampling method used (how participants have been chosen from population) and the period of data collection

-it would be good to add Ethical part that would gather clear information on ethic (from line 106-108 and Line 115-117). Some informations of ethic appear in the study methods and data collection.

-I would like to know if the data extracted from burnout scores from two early multi-centre studies were only about burnout, as there is no information on stress from the two studies?

-It would good to state the statistical method used on each specific objective, as there is information on the statistical method used to assess factors contributing to stress and burnout and areas of improvement.

-There is a need of explanation in methodology part on how analysis has been made on each items(stress and burnout) as it seems the three time comparison has been made on burnout only while for stress the information is given on the survey conducted by the author in this study(year 2022)

Discussion

In reducing the discussion part Somme parts should be removed. For example the information given in lines 350-353 and lines 364-366 should be removed or moved at the last paragraph.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: Yes: Innocent Yandemye

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Revision 2

Dear Editor and reviewers,

Thank you for your feedback and suggestions. Please find below the responses to each point raised by the reviewers.

Responses to reviewer#4

Overall, there are grammatically some incorrect parts (Line 369:exitant,line 91:this 2 months, line 266: exitant, line108:April2022, line 112 :June2022)->grammatical correction required

The above listed grammatical errors have been corrected.

Methodology

-The author should show a sampling method used (how participants have been chosen from population) and the period of data collection

All staffs working at IMH were send the email with the survey link and the period of data collection was one month. These are now added in the methodology (data collection) section.

-it would be good to add Ethical part that would gather clear information on ethic (from line 106-108 and Line 115-117). Some informations of ethic appear in the study methods and data collection.

Line 115-117 have been moved to the ethical section (starting with line 106) as suggested.

-I would like to know if the data extracted from burnout scores from two early multi-centre studies were only about burnout, as there is no information on stress from the two studies?

Yes, the earlier 2 studies did not collect stress (PSS) data.

-It would good to state the statistical method used on each specific objective, as there is information on the statistical method used to assess factors contributing to stress and burnout and areas of improvement.

We have added in line103 that the method used to assess factors contributing to stress and burnout is ANOVA in line 106.

-There is a need of explanation in methodology part on how analysis has been made on each items(stress and burnout) as it seems the three time comparison has been made on burnout only while for stress the information is given on the survey conducted by the author in this study(year 2022)

As the earlier 2 studies did not collect stress (PSS) data, only burnout (OLBI) data is available for comparison across 3 timepoint. We have added this in line 125-127.

Discussion

In reducing the discussion part Somme parts should be removed. For example the information given in lines 350-353 and lines 364-366 should be removed or moved at the last paragraph.

Line 350-353 have been removed as suggested. However, we have kept line 364-366 (line 371-373 in the revised manuscript with track change) as it is useful information to know that an external help service is now available and that further investigation into its effectiveness is needed in the future. This information fits better in its current place than in the last paragraph.

Attachments
Attachment
Submitted filename: Response to reviewers.docx
Decision Letter - Kenji Hashimoto, Editor

Stress and burnout amongst mental health professionals in Singapore during Covid-19 endemicity

PONE-D-22-33528R2

Dear Dr. Suyi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kenji Hashimoto, PhD

Section Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: The author should remove test method from the end of Introduction part. I was stisfied with the response of test method, there is no need to add test methodology in Introduction part

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: No

**********

Formally Accepted
Acceptance Letter - Kenji Hashimoto, Editor

PONE-D-22-33528R2

PLOS ONE

Dear Dr. Yang,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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on behalf of

Prof. Kenji Hashimoto

Section Editor

PLOS ONE

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