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Journal of Hospital Infection 88 (2014) 170e176
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Journal of Hospital Infection
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Impact of contact precautions on falls, pressure ulcers
and transmission of MRSA and VRE in hospitalized
patients
S. Gandra a, *, C.M. Barysauskas b, D.A. Mack c, B. Barton b, R. Finberg a,
R.T. Ellison III a
a
Division of Infectious Disease and Immunology, University of Massachusetts Medical School, Worcester, MA, USA
Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
c
Infection Control Department, UMass Memorial Medical Center, Worcester, MA, USA
b
A R T I C L E
I N F O
Article history:
Received 27 February 2014
Accepted 10 September 2014
Available online 28 September
2014
Keywords:
Contact precautions
MRSA
VRE
Falls
Pressure ulcers
Transmission
S U M M A R Y
Background: Hospitals use contact precautions to prevent the spread of meticillinresistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).
There is concern that contact precautions may have adverse effects on the safety of
isolated patients. In November 2010, the infection control policy at an academic medical
centre was modified, and contact precautions were discontinued for patients colonized or
infected with MRSA or VRE (MRSA/VRE patients).
Aim: To assess the rates of falls and pressure ulcers among MRSA/VRE patients and other
adult medical-surgical patients, as well as changes in MRSA and VRE transmission before
and after the policy change.
Methods: A single-centre retrospective hospital-wide cohort study was performed from 1st
November 2009 to 31st October 2011.
Findings: Rates of falls and pressure ulcers were significantly higher among MRSA/VRE
patients compared with other adult medical-surgical patients before the policy change
(falls: 4.57 vs 2.04 per 1000 patient-days, P < 0.0001; pressure ulcers: 4.87 vs 1.22 per
1000 patient-days, P < 0.0001) and after the policy change (falls: 4.82 vs 2.10 per 1000
patient-days, P < 0.0001; pressure ulcers: 4.17 vs 1.19 per 1000 patient-days, P < 0.0001).
No significant differences in the rates of falls and pressure ulcers among MRSA/VRE patients were found after the policy change compared with before the policy change. There
was no overall change in MRSA or VRE hospital-acquired transmission.
Conclusion: MRSA/VRE patients had higher rates of falls and pressure ulcers compared
with other adult medical-surgical patients. Rates were not affected by removal of contact
precautions, suggesting that other factors contribute to these complications. Further
research is required among this population to prevent complications.
ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Center for Disease Dynamics, Economics and Policy, 1616 P Street NW, Suite 430, Washington, DC 20036, USA.
Tel.: þ91 9810912566; fax: þ1 202 939 3460.
E-mail address: [email protected] (S. Gandra).
http://dx.doi.org/10.1016/j.jhin.2014.09.003
0195-6701/ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
S. Gandra et al. / Journal of Hospital Infection 88 (2014) 170e176
Introduction
171
All adult patients were reviewed retrospectively one year
before and one year after the policy change at the University of
Massachusetts Memorial Medical Center (Memorial and University campuses). The hospital-wide cohort study was
approved by the University of Massachusetts Medical School
Institutional Review Board.
The Centers for Disease Control and Prevention (CDC)
recommend the use of transmission-based contact precautions
for patients with documented or suspected infection or colonization with epidemiologically important pathogens.1 Based
on these recommendations, many acute care facilities use
infection control contact precautions to prevent the spread of
multi-drug-resistant organisms, such as meticillin-resistant
Staphylococcus aureus (MRSA) and vancomycin-resistant
enterococci (VRE). Patients placed under contact precautions
are housed in private hospital rooms, and all healthcare
workers involved in patient care are required to wear a gown
and gloves while in the patient’s room. However, while contact
precautions are in common use, their efficacy in controlling the
transmission of multi-drug-resistant organisms is unclear,
compliance is poor, and contact precautions may result in unintended harmful consequences.2e7 Specifically, reported
consequences of contact precautions include: reduced patient
contact with healthcare workers;2,8e12 increased numbers of
preventable adverse events;13e15 decreased psychological
well-being;7 decreased patient satisfaction;13 delays in access
to radiological examinations;16 and decreased quality of hospital care.17 Stelfox et al. reported that patients placed under
contact precautions were eight times more likely to experience
supportive care failures (e.g. falls, pressure ulcers, and fluid or
electrolyte disturbances) than patients who were not placed
under contact precautions.13 Unfortunately, the prevalence of
MRSA and VRE infection has increased in acute care, chronic
care and community settings, thus increasing the number of
patients at risk of potential complications from contact
precautions.
On 1st November 2010, the infection control policy of the
University of Massachusetts Memorial Medical Center,
Worcester, MA, USA was changed to discontinue the use of
contact precautions among patients colonized or infected
with MRSA or VRE (MRSA/VRE patients). Noting the work of
Stelfox et al.,13 the impact of the policy change on rates of
falls and new-onset pressure ulcers among MRSA/VRE patients compared with the general patient population was
studied. It was hypothesized that the rates of complications
would decrease among MRSA/VRE patients, and the rate of
hospital-acquired MRSA or VRE transmission would remain
constant.
All patients admitted to the University of Massachusetts
Memorial Medical Center adult medical-surgical inpatient units
from 1st November 2009 to 31st October 2011 were included in
this study. Paediatric, maternity and psychiatric inpatient
wards were excluded. Patients who fell or developed a newonset Stage 2 (or greater) pressure ulcer during hospitalization were identified through mandatory reports entered into
the web-based incident reporting system (STARZ, Chicago,
USA). Only one fall and one pressure ulcer per admission were
included amongst patients with multiple events. All MRSA/VRE
patients admitted during the study period were identified using
an infection control data management system (Theradoc, Salt
Lake City, USA). All colonized or infected inpatient falls and
pressure ulcers were identified at least two days after MRSA or
VRE identification. As the study objective was to assess the
impact of contact precautions, MRSA/VRE patients who were
placed under contact precautions for other reasons after the
policy change were excluded from the analysis. The total
number of MRSA and VRE patient-days was calculated from
Theradoc, and the total number of adult medical-surgical patient-days was calculated from hospital census data.
Hospital MRSA and VRE acquisition rates were calculated
using the standard CDC national healthcare safety network
definition for all actively and passively obtained cultures.18
Active surveillance was performed on admission and weekly
for both MRSA and VRE in the institution’s seven adult intensive care units, and for VRE alone in the bone marrow transplant unit. Passive surveillance for MRSA and VRE was
performed throughout the study period in all other inpatient
units.
Patient characteristics including age, gender, date and unit
of occurrence, length of hospital stay and Braden scale score19
(risk for pressure ulcer development) were obtained from
STARZ, and the Charlson comorbidity index was calculated
through medical record review.
Methods
Outcome measures
Design and setting
First, the rates of falls and pressure ulcers among adult
MRSA/VRE patients were compared before and after the
policy change. In addition, the rates of falls and pressure
ulcers among adult MRSA/VRE patients were compared with
the rates among other adult medical-surgical patients
before and after the policy change. Further, due to the association between disease severity and the occurrence of
falls20 and pressure ulcers,21 the degree of comorbidity in
MRSA/VRE patients was compared with the degree of comorbidity in other medical-surgical patients using the
Charlson comorbidity index.22 Finally, the impact of the
policy change on hospital-associated MRSA and VRE transmission was assessed.
On 1st November 2010, the University of Massachusetts Memorial Medical Center discontinued the use of contact precautions for MRSA/VRE patients. Patients colonized or infected
with selected multi-drug-resistant organisms (e.g. extendedspectrum beta-lactamase-positive or carbapenemase-positive
Gram-negative organisms, other highly multi-drug-resistant
Gram-negative bacteria or vancomycin-resistant S. aureus),
as well as those soiling the environment with secretions due to
active draining wounds, diarrhoeal disease or uncontrolled
respiratory secretions, continued to be placed under contact
precautions.
Study participants and data collection
172
S. Gandra et al. / Journal of Hospital Infection 88 (2014) 170e176
Statistical methods
Demographic and clinical characteristics of MRSA and VRE
patient groups were compared using Chi-squared statistic for
categorical data and Student’s t-test for continuous data.
Rates of falls and pressure ulcers for each group were reported
as per 1000 patient-days. A Z-test was used to compare the
rates between the groups. A sensitivity analysis was performed
to assess the difference in the rates of falls and pressure ulcers
between MRSA/VRE patients and other adult medical-surgical
patients if there was misassignment of 2500 patient-days between the groups.
Fifty MRSA/VRE patients with falls and pressure ulcers were
matched at random [1:1 on hospital unit and admission date (
30 days)] with 50 MRSA/VRE patients without falls and pressure
ulcers, 50 other adult medical-surgical patients with falls and
pressure ulcers, and 50 other adult medical-surgical patients
without falls and pressure ulcers. Student’s t-test was used to
compare the Charlson comorbidity indexes between groups.
An interrupted time-series analysis was performed to estimate monthly changes in MRSA and VRE acquisition rates
before and after the policy change for the study period.
P 0.05 was considered to indicate significance. All statistical analyses were performed using SAS Version 9.3 (SAS
Institute, Inc., Cary, NC, USA).
Results
compared with before the policy change (Table I). No significant difference in the Braden score for MRSA/VRE patients who
developed pressure ulcers was found after the policy change
compared with before the policy change.
Number of falls and pressure ulcers during study
period
In total, 741 falls and 491 new-onset Stage 2 (or greater)
pressure ulcers occurred during the two-year study period.
Among MRSA/VRE patients, there were 77 falls and 82 pressure
ulcers during the year before the policy change, and 82 falls
and 71 pressure ulcers during the year after the policy change.
Corresponding figures for other adult medical-surgical patients
were 288 falls and 172 pressure ulcers, and 294 falls and 166
pressure ulcers.
Total number of patient-days
For MRSA/VRE patients, there were 16,822 patient-days
during the year before the policy change and 17,012 patientdays during the year after the policy change. Corresponding
figures for other adult medical-surgical patients were 140,690
and 139,466 patient-days.
Rates of falls and pressure ulcers before and after the
policy change
Patient characteristics
No significant differences were observed between demographic and clinical covariates for MRSA/VRE patients who
had a fall or developed a pressure ulcer after the policy change
No significant differences in the rates of falls among
MRSA/VRE patients and among other adult medical-surgical
patients were found after the policy change compared with
before the policy change (Table II). The rate of pressure ulcers
Table I
Demographic and clinical characteristics of patients colonized or infected with meticillin-resistant Staphylococcus aureus (MRSA) or
vancomycin-resistant enterococci (VRE) who sustained a fall or developed a pressure ulcer
Falls before policy Falls after policy P-value Pressure ulcers before
Pressure ulcers after
P-value
change (N ¼ 77) change (N ¼ 82)a
policy change (N ¼ 82) policy change (N ¼ 71)b
Patient characteristics
Age, mean (SD)
Male (%)
LOS, mean days (SD)
MRSA (%)
VRE (%)
MRSA and VRE (%)
Colonized (%)
Infected (%)
CCI, mean (SD)
Braden score,
mean (SD)
Unit characteristics
Medicine (%)
Surgery (%)
Critical care (%)
66.1
47
15.4
25
38
14
69
8
3
(14.3)
(61%)
(14.7)
(32.5%)
(49.4%)
(18.2%)
(89.6%)
(10.4%)
(2.1)
NA
59 (76.6%)
9 (11.7%)
9 (11.7%)
63.7
51
18.2
37
29
16
69
13
3.4
(15.8)
(62%)
(17.6)
(45.1%)
(35.4%)
(19.5%)
(84.2%)
(15.8%)
(2.7)
NA
0.32
0.88
0.27
0.10
0.07
0.83
0.31
0.31
0.33
e
64 (78.1%)
11 (13.4%)
7 (8.5%)
0.83
0.74
0.51
64.5
52
30.1
27
34
21
57
25
3.9
9.5
(15.5)
(63%)
(24.7)
(39.2%)
(41.5%)
(25.6%)
(69.5%)
(30.5%)
(2.6)
(7.4)
31 (37.8%)
8 (9.8%)
43 (52.4%)
65.7
40
23.8
21
33
17
48
23
3.5
8.3
(15)
(57%)
(18.6)
(29.6%)
(46.5%)
(23.9%)
(67.6%)
(32.4%)
(1.8)
(8.2)
0.63
0.47
0.08
0.66
0.53
0.81
0.80
0.80
0.34
0.34
28 (39.4%)
9 (12.7%)
34 (49.9%)
0.84
0.57
0.57
CCI, Charlson comorbidity index; LOS, length of stay in hospital; NA, not applicable; SD, standard deviation.
a
Eight patients colonized or infected with MRSA or VRE were excluded as they were placed under contact precautions (Clostridium difficile,
N ¼ 2; multi-drug-resistant organisms, N ¼ 3; extended-spectrum beta-lactamase-positive organisms, N ¼ 3).
b
Seventeen patients colonized or infected with MRSA or VRE were excluded as they were placed under contact precautions (extendedspectrum beta-lactamase-positive organisms, N ¼ 8; Clostridium difficile, N ¼ 7; multi-drug-resistant organisms, N ¼ 2).
S. Gandra et al. / Journal of Hospital Infection 88 (2014) 170e176
Table II
Rates of falls and pressure ulcers in patients colonized or infected
with meticillin-resistant Staphylococcus aureus (MRSA) or
vancomycin-resistant enterococci (VRE) and other adult medicalsurgical patients before and after the policy change
MRSA/VRE
patients
(rate per 1000
patient-days)
Before policy change
Falls
4.57
Pressure
4.87
ulcers
After policy change
Falls
4.82
Pressure
4.17
ulcers
P-value
Falls
0.74a
Pressure
0.33c
ulcers
Other adult
medical-surgical
patients (rate per
1000 patient-days)
P-value
2.04
1.22
<0.0001
<0.0001
2.10
1.19
<0.0001
<0.0001
0.72b
0.80d
a
Comparing rate of falls among MRSA/VRE patients.
Comparing rate of falls among other adult medical-surgical
patients.
c
Comparing rate of pressure ulcers among MRSA/VRE patients.
d
Comparing rate of pressure ulcers among other adult medicalsurgical patients.
b
among MRSA/VRE patients decreased after the policy change;
however, this was not statistically significant.
Rates of falls and pressure ulcers in MRSA/VRE
patients compared with other adult medical-surgical
patients
A significant difference was found between the rate of falls
among MRSA/VRE patients compared with other adult medicalsurgical patients before the policy change (4.57 vs 2.04 per
1000 patient-days; P < 0.0001) and after the policy change
(4.82 vs 2.10 per 1000 patient-days; P < 0.0001) (Table I).
Similarly, there was a significant difference in the rate of
pressure ulcers among MRSA/VRE patients compared with other
adult medical-surgical patients before the policy change (4.87
vs 1.22 per 1000 patient-days; P < 0.0001) and after the policy
change (4.17 vs 1.19 per 1000 patient-days; P < 0.0001)
(Table II).
173
Table III
Comparison of mean Charlson comorbidity index among various
groups of patients colonized or infected with meticillin-resistant
Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) and other adult medical-surgical patients
Groups compared
1. All MRSA/VRE patients vs other
adult medical-surgical patients
2. All patients before vs after
policy change
3. MRSA/VRE patients with fall vs
no fall before policy change
4. MRSA/VRE patients with fall vs
no fall after policy change
5. Other adult medical-surgical
patients with fall vs no fall
before policy change
6. Other adult medical-surgical
patients with fall vs no fall
after policy change
7. MRSA/VRE patients with fall
before vs after policy change
8. Other adult medical-surgical
patients with fall before vs
after policy change
9. MRSA/VRE patients with PU vs
no PU before policy change
10. MRSA/VRE patients with PU vs
no PU after policy change
11. Other adult medical-surgical
patients with PU vs no PU before
policy change
12. Other adult medical-surgical
patients with PU vs no PU after
policy change
13. MRSA/VRE patients with PU
before vs after policy change
14. Other adult medical-surgical
patients with PU before vs
after policy change
Mean Charlson P-value
comorbidity
index
3.32 vs 2.75
0.002
3.08 vs 3.12
0.81
3.04 vs 2.97
0.86
3.43 vs 2.93
0.23
2.48 vs 2.30
0.68
2.70 vs 2.88
0.73
3.04 vs 3.44
0.33
2.48 vs 2.70
0.64
3.75 vs 2.90
0.03
3.42 vs 3.52
0.81
3.46 vs 2.48
0.04
3.46 vs 2.22
0.006
3.75 vs 3.43
0.38
3.46 vs 3.46
1.00
PU, pressure ulcer.
The mean Charlson comorbidity index was also significantly
higher for individuals who developed a pressure ulcer, but not
for those who sustained falls (Table III).
Sensitivity analysis
The sensitivity analysis revealed that the rates of falls and
pressure ulcers among MRSA/VRE patients and other adult
medical-surgical patients remained unaffected by the policy
change.
Charlson comorbidity index score in MRSA/VRE
patients vs other adult medical-surgical patients
The mean Charlson comorbidity index was significantly
higher among MRSA/VRE patients compared with other adult
medical-surgical patients (3.32 vs 2.75; P ¼ 0.0002) (Table III).
Hospital-associated MRSA and VRE transmission using
interrupted time-series analysis
The MRSA acquisition rate prior to the policy change was
0.77 cases per 1000 patients. After the policy change, acquisition increased immediately by 0.12 cases per 1000 patients
(P ¼ 0.510), and then decreased by 0.017 cases per 1000 per
month for the remainder of the study period (Figure 1). Overall, there was no change in MRSA acquisition during the study
period (P ¼ 0.695).
The VRE acquisition rate was 1.39 cases per 1000 patients.
After the policy change, acquisition increased immediately by
S. Gandra et al. / Journal of Hospital Infection 88 (2014) 170e176
a
b
0.4
MRSA acquisition rate (per 1000)
0.6
0.8
1
1.2
174
0
5
10
15
Study month
20
25
Figure 1. Hospital-associated acquisition rates for meticillin-resistant Staphylococcus aureus (MRSA) from November 2009 to October
2011. (a) Before implementation of policy change, (b) after implementation of policy change.
0.80 cases per 1000 patients (P ¼ 0.004), and then decreased by
0.016 cases per 1000 per month for the remainder of the study
period (Figure 2). There was no overall change in VRE acquisition during the study period (P ¼ 0.438).
Discussion
a
b
0.5
VRE acquisition rate (per 1000)
1.0
1.5
2
Several studies have assessed the harmful effects of contact
precautions.2,8e12,15e17 However, only two studies have reported on falls and pressure ulcers.13,14 Stelfox et al. performed a matched cohort study between 1999 and 2002 at two
academic medical centres in North America.13 Among patients
colonized or infected with MRSA, they found that patients
placed under contact precautions were eight times more likely
to experience supportive care failures including falls and
pressure ulcers compared with patients who were not placed
under contact precautions.13 Karki et al. compared the rates of
adverse events among Australian patients colonized or infected
with VRE prior to and subsequent to initiation of contact precautions, and demonstrated an increased risk among patients
with pressure ulcers after initiation of contact precautions.14
Both studies hypothesized that the use of contact precautions contributed to adverse events. The present study
demonstrated among an inpatient population that MRSA/VRE
patients were at a greater risk of falls or pressure ulcers
compared with other medical-surgical patients, regardless of
the use of contact precautions.
To the authors’ knowledge, this is the first study to assess
the impact of discontinuation of contact precautions on the
rates of falls and pressure ulcers among MRSA/VRE patients,
and hospital transmission of MRSA and VRE. This study included
all adult hospitalized patients admitted to the regular acute
0
5
10
15
Study month
20
25
Figure 2. Hospital-associated acquisition rates for vancomycin-resistant enterococci (VRE) from November 2009 to October 2011. (a)
Before implementation of policy change, (b) after implementation of policy change.
S. Gandra et al. / Journal of Hospital Infection 88 (2014) 170e176
care medical and surgical floors of a two-campus academic
medical centre over the two-year study period. The study
population consisted of 6400 MRSA/VRE patients and 65,000
general medical-surgical patients.
The rates of falls and pressure ulcers were significantly
higher among MRSA/VRE patients compared with other adult
medical-surgical patients before and after the policy change.
The rate of falls was two times higher in MRSA/VRE patients
compared with other adult medical-surgical patients before
and after the policy change. Similarly, the rate of pressure
ulcers was at least three times higher in MRSA/VRE patients
compared with other adult medical-surgical patients before
and after the policy change. These results are consistent with
the findings of Stelfox et al. that patients who are colonized or
infected with MRSA and placed under contact precautions are
at significantly higher risk of falls and pressure ulcers.13
It was hypothesized that the removal of contact precautions
would decrease the rates of falls and pressure ulcers among
MRSA/VRE patients to rates similar to the general adult patient
population. However, after the policy change, the overall
increased risk of these adverse events persisted among
MRSA/VRE patients. Previous studies have shown an association
between higher Charlson comorbidity indexes and the occurrence of falls20 and pressure ulcers,21 and further analysis
demonstrated that MRSA/VRE patients had higher Charlson
comorbidity indexes compared with other adult medicalsurgical patients.
No overall change in MRSA and VRE transmission was identified during the two-year study period. However, an initial
spike in VRE acquisition after the policy change was noted in
the analysis. This increased incidence correlated with a cluster
of patients with VRE in one intensive care unit. The increased
rate of VRE acquisition decreased steadily after the policy
change, with rates returning to just below the level at the
beginning of the study. There was no significant increase in VRE
acquisition at the end of the study compared with the beginning of the study. It is unclear whether this initial increase was
due to factors related to the policy change, or due to normal
cyclical trends seen with VRE acquisition at the study
institution.
This study has several limitations. First, it was a retrospective study; therefore, causality cannot be inferred. It has
been assumed that all institution-based infection control
practices were followed throughout the study period. Second,
it was hypothesized that removing contact precautions would
increase the access of healthcare workers to patients; however, this was not addressed in the study. Third, previous reviews identified several risk factors for falls23 and pressure
ulcers;24 however, it was not possible to investigate these risk
factors further in this study. Fourth, this study was limited as it
was an unadjusted analysis given the large population size.
Fifth, the surveillance database used in patient identification
of MRSA or VRE was not confirmed. Therefore, the number of
newly infected or colonized patients in the study population
may have been overestimated if the patients in the study
period had been colonized or infected with MRSA or VRE previously but this was not active at the time of acute hospitalization. In addition, patients were identified as being infected
with MRSA or VRE based on microbiology results; however, the
presence of organisms in culture may not verify true infection
in some cases. Sixth, the accuracy of the falls and pressure
ulcer data obtained from the risk management database was
175
not verified; however, this information must be publicly reported to the Centers of Medicare and Medicaid Services by
acute care hospitals as hospital-acquired condition measures.
Seventh, MRSA and VRE surveillance in the study hospital only
involves active screening in the intensive care units. This
technique is accepted by infectious disease societies as a sufficient method to determine hospital-wide MRSA/VRE disease
incidence and prevalence adequately and accurately;25 however, it could theoretically lead to under-recognition of MRSA/
VRE cases and acquisition. The surveillance standard and the
potential for underestimation remained constant throughout
the study period; therefore, it is not believed to have had a
significant impact on the observed results. Lastly, the study
findings are limited by the short two-year study period. During
this period, only a small number of falls and pressure ulcers
occurred in the MRSA/VRE patients, and the time period may
have been too short to allow accurate assessment of longitudinal changes in the rates of MRSA or VRE transmission. Given
these limitations, there is a need for a more rigorous multicentre prospective study with adequate follow-up time to
confirm the findings of this study.
In summary, this study found that patients colonized or
infected with MRSA or VRE were at significantly higher risk of
falls and pressure ulcers than the general adult medical- surgical patient population. Simply removing the routine use of
contact precautions for this patient population did not affect
the increased incidence of falls, although it was associated
with a decreasing trend in the incidence of pressure ulcers.
This study demonstrated that MRSA/VRE patients are significantly more ill than other medical-surgical patients; this is a
major concern given that the previous literature suggests that
patients placed under contact precautions receive less interaction with healthcare workers. These findings should be
considered when planning the treatment of infected or colonized patients, and the modification of infection control
isolation polices.
Acknowledgements
Preliminary data were published in abstract form and presented at the Annual Meeting of the Infectious Disease Society
of America on 19th October 2012.
Conflict of interest statement
None declared.
Funding source
None.
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