Health coaching intervention may reduce sitting time and improve BP in older adults: JAMA

A new Kaiser Permanente study found that a health coaching intervention successfully reduced sitting time for a group of older adults by just over 30 minutes a day. Study participants also showed meaningful improvements in blood pressure, comparable to the effect of other interventions focused on physical activity.

The study was published in JAMA Network Open and included 283 Kaiser Permanente Washington members aged 60-89.

Older adults typically sit for between 65 and 80 percent of the hours that they are awake, and strong evidence shows that sedentary time is associated with health risks like heart disease and diabetes. In the study, sitting less throughout the day led to a mean change in blood pressure of almost 3.5 millimeters of mercury (mmHg), comparable to reductions of 4 mmHg found in studies of increased physical activity and 3 mmHg in studies of weight loss.

“Our findings are really promising because sitting less is a change that may be easier for people than increasing physical activity, especially for older adults who are more likely to be living with restrictions like chronic pain or reduced physical function,” said Dori Rosenberg, PhD, MPH, the lead author of the study and a senior scientific investigator at KPWHRI.

Participants in the intervention received a tabletop standing desk, an activity tracker, and 10 health coaching sessions over 6 months, where they set goals for reducing their time spent sitting. A second group also participated in health coaching, but their goals were focused on areas of health that were not related to standing or increasing activity.

Due to the restrictions of the COVID-19 pandemic, most of the health coaching sessions were delivered remotely. Even though many participants only had virtual sessions, they were still able to improve their sitting patterns. 

Reference:

Rosenberg DE, Zhu W, Greenwood-Hickman MA, et al. Sitting Time Reduction and Blood Pressure in Older Adults: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(3):e243234. doi:10.1001/jamanetworkopen.2024.3234

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Delirium a ‘strong risk factor’ for dementia among older people: BMJ

Delirium is a strong risk factor for dementia and death among older people, finds the largest study of its kind published by The BMJ today.

The findings show that, among hospital patients with at least one episode of delirium, the risk of receiving a new dementia diagnosis was three times higher than for patients without delirium and each additional episode of delirium increased that risk by 20%.

The researchers say their findings support the theory that delirium has a strong independent effect on dementia risk in this clinical population.

Delirium is a sudden change in a person’s usual mental state. Symptoms include agitation, confusion or being unable to stay focused when awake. Delirium is much more common in hospital patients and older people.

Previous observational studies have suggested an association between delirium and subsequent dementia, but study limitations leave the size and nature of this relationship unclear.

Yet as the global burden of dementia increases, it is of critical importance to confirm the extent to which delirium is a potentially modifiable risk factor.

To try and address these uncertainties, researchers in Australia analysed data from 626,467 patients aged 65 years and older with no dementia diagnosis who were admitted to hospital in New South Wales between January 2009 and December 2014.

Of these patients, 55,211 had at least one recorded episode of delirium and were matched to another 55,211 patients without delirium by age, sex, frailty, reason for being in hospital, length of stay in hospital and length of stay in the intensive care unit.

These 110,422 patients (average age 83; 52% women) were then followed-up for five years to see how many of them were diagnosed with dementia.

Collectively, 58% (63,929) of patients died and 17% (19,117) had a newly reported dementia diagnosis over the follow-up period.

The researchers found that patients with delirium had a 39% higher risk of death and three times the risk of being diagnosed with dementia than patients without delirium.

The relationship between delirium and dementia was stronger in men than women and each additional episode of delirium was associated with a 20% increased risk of developing dementia (a dose-response relationship).

These are observational findings, so cannot establish cause, and the authors acknowledge that hospital data may not be completely accurate. Nor can they rule out the possibility that other unmeasured factors may have affected their results.

However, this was a large, well-designed study with a long follow-up period, and results were similar after further analyses to test the strength of the associations, suggesting that they are robust.

“While our results are consistent with the hypothesis that delirium plays a causative part in dementia, they are not conclusive owing to the fundamental limitations of observational studies in determining causality,” they write. “Nevertheless, the results of this study provide valuable insights because prospective randomised controlled trials are unlikely to be conducted.”

“Delirium is a factor that could triple a person’s risk of dementia. Therefore, delirium prevention and treatment are opportunities to reduce dementia burden globally,” they conclude.

Reference:

Gordon E H, Ward D D, Xiong H, Berkovsky S, Hubbard R E. Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study BMJ 2024; 384 :e077634 doi:10.1136/bmj-2023-077634.

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Patients of Chronic and acute sinusitis more likely to develop rheumatic diseases, suggests study

Patients of Chronic and acute sinusitis are more likely to develop rheumatic diseases suggests a study published in the RMD Open.

A study was done to determine whether antecedent sinusitis is associated with incident rheumatic disease. This population-based case–control study included all individuals meeting classification criteria for rheumatic diseases between 1995 and 2014. We matched three controls to each case on age, sex and length of prior electronic health record history. The primary exposure was presence of sinusitis, ascertained by diagnosis codes (positive predictive value 96%). We fit logistic regression models to estimate ORs for incident rheumatic diseases and disease groups, adjusted for confounders. Results We identified 1729 incident rheumatic disease cases and 5187 matched controls (mean age 63, 67% women, median 14 years electronic health record history). After adjustment, preceding sinusitis was associated with increased risk of several rheumatic diseases, including antiphospholipid syndrome (OR 7.0, 95% CI 1.8 to 27), Sjögren’s disease (OR 2.4, 95% CI 1.1 to 5.3), vasculitis (OR 1.4, 95% CI 1.1 to 1.9) and polymyalgia rheumatica (OR 1.4, 95% CI 1.0 to 2.0).

Acute sinusitis was also associated with increased risk of seronegative rheumatoid arthritis (OR 1.8, 95% CI 1.1 to 3.1). Sinusitis was most associated with any rheumatic disease in the 5–10 years before disease onset (OR 1.7, 95% CI 1.3 to 2.3). Individuals with seven or more codes for sinusitis had the highest risk for rheumatic disease (OR 1.7, 95% CI 1.3 to 2.4). In addition, the association between sinusitis and incident rheumatic diseases showed the highest point estimates for never smokers (OR 1.7, 95% CI 1.3 to 2.2). Preceding sinusitis is associated with increased incidence of rheumatic diseases, suggesting a possible role for sinus inflammation in their pathogenesis.

Reference:

Kronzer VL, Davis JM, Hanson AC, et alAssociation between sinusitis and incident rheumatic diseases: a population-based studyRMD Open 2024;10:e003622. doi: 10.1136/rmdopen-2023-003622

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Consumption of dietary live microbes directly associated with improved periodontal health suggests study

Consumption of dietary live microbes directly associated with improved periodontal health suggests a study published in the Oral Diseases.

Investigate the link between live dietary microbe consumption and the prevalence of periodontitis. National health and nutrition examination survey (2009–2014) data was used to assess the association among adults. Live dietary microbe intake was categorized as low or medium to high. Regression models were employed to assess this association, adjusting for demographic variables and other covariates. Examined dose–response relationship and conducted subgroup analyses by ethnicity, age and gender. Multiplicative interactions were evaluated using likelihood ratio tests.

Results: The analysis included 8574 participants. After adjusting for various factors including age, gender, ethnicity, dietary habits, dietary inflammatory index, alcohol consumption, smoking status, hypertension, diabetes mellitus and oral health behaviors, individuals with daily intake of medium to high levels of live dietary microbes showed a significantly reduced risk of periodontitis compared to those who did not consume such microbes with a dose–response trend (p for trend <0.0001, p < 0.01). Significant differences in the impact of live microbe intake on periodontitis were also observed across different age groups in all Models (p for interaction ≤0.05). Medium to high live dietary microbe consumption independently correlates with lower periodontitis risk, irrespective of traditional risk factors and demographics.

Reference:

Lin, J., Yang, H., Lin, Z., & Xu, L. (2024). Live dietary microbes and reduced prevalence of periodontitis: A cross-sectional study. Oral Diseases, 00, 1–11. https://doi.org/10.1111/odi.14869

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Stuck hemodialysis catheter, a case of dreaded, rare complication after kidney transplantation

Australia: A recent case study published in BMC Nephrology describes a challenging case of a stuck hemodialysis catheter in the acute post-transplantation period.

Tunneled cuffed hemodialysis catheters are at an elevated risk of incarceration or becoming ‘stuck’ via fibrotic adhesion to the central veins when left in situ for prolonged periods. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. While several strategies have been published for the removal of these incarcerated lines, there is a lack of consensus on the best approach.

Cameron Burnett, Princess Alexandra Hospital, Woolloongabba, QLD, Australia, and colleagues described the case of a 66-year-old female on hemodialysis presented for kidney transplantation with a tunneled-cuffed hemodialysis catheter in situ for five years. Following the transplantation, line removal was unsuccessful despite cuff dissection, with traction causing a choking sensation with tracheal movement. Eventually, line removal was done without complications utilizing sequential balloon dilatation by interventional radiology, and the patient was discharged without complications.

The patient was a 66-year-old female on maintenance hemodialysis with a history of hypertension, lupus nephritis, and post-menopausal osteoporosis. She had no previous lines or central vascular devices. She had been maintained on hemodialysis via a left internal jugular tunneled cuffed catheter that had been in situ for five years due to patient preference. When she presented for deceased donor kidney transplantation, she was clinically well.

The patient underwent kidney transplantation with immediate graft function and without surgical or medical complications. On day five postoperatively, the line was planned for routine removal and attempted at the bedside with local anesthesia infiltration. Following the uncomplicated dissection of the cuff, the tension on the catheter led to a choking sensation in the patient with the evident ipsilateral movement of the midline structures including the trachea.

Further attempts at bedside, and later in theater by cardiothoracic and vascular surgeons had the same result. A CT venogram showed a contracted superior vena cava around the vascular catheter as it passed into the right atrium. An initial attempt by interventional radiology with dissection of the tract using blunt forceps and fluoroscopy was abandoned after fluoroscopy again revealed discomfort with attempted traction and tracheal displacement. The laser sheath was considered unsuitable due to the excessive size of the patient’s hemodialysis catheter.

Following a multidisciplinary team discussion, a decision was made to undertake a second fluoroscopic technique using the Hong technique. A guidewire was passed down into the IVC from a lumen of the central venous catheter, and the doctors undertook sequentially from the distal to proximal component of the line. Following this, the line was able to be removed safely. The patient suffered no complications and was discharged home on day eight post-transplantation.

“This case serves as a timely reminder of the risks of long-term tunneled hemodialysis catheters and as a caution towards proceeding with kidney transplantation in patients with long-term hemodialysis catheters,” the team wrote. “More invasive strategies could be avoided by greater nephrologist awareness of interventional radiology techniques for this challenging situation.”

“The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient,” they concluded.

Reference:

Burnett, C., Chandler, S., Jegatheesan, D. et al. The stuck haemodialysis catheter—a case report of a rare but dreaded complication following kidney transplantation. BMC Nephrol 25, 104 (2024). https://doi.org/10.1186/s12882-024-03507-z

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Injection of GIP and GLP-2 may reduce bone resorption biomarker CTX in type 2 diabetes patients: Study

Denmark: A recent study published in The Journal of Clinical Endocrinology and Metabolism has shed light on the effects of exogenous glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-2 (GLP-2) on burn turnover in patients with type 2 diabetes (T2D).

The researchers revealed that the acute effects of exogenous GIP and GLP-2 on bone turnover are also present in patients with T2D, presenting a promising avenue for exploring novel treatment options that could potentially reduce the risk of fractures linked with type 2 diabetes.

“Subcutaneous GIP and GLP-2 affect the bone resorption markers, collagen type 1 C-terminal telopeptide (CTX) and procollagen type 1 N-terminal propeptide (P1NP) in individuals with T2D to the same extent as previously demonstrated in healthy individuals,” Kirsa Skov-Jeppesen, University of Copenhagen, Copenhagen, Denmark, and colleagues wrote.

Individuals with type 2 diabetes are at increased risk of bone fractures despite normal or increased bone mineral density (BMD). There is no clear understanding of the underlying causes, but could include disturbances in the gut-bone axis, in which GIP and GLP-2 are regulators of bone turnover. Thus, in healthy fasting participants both exogenous GLP-2 and GIP reduce bone resorption.

Against the above background, Dr. Skov-Jeppesen and colleagues aimed to investigate the acute effects of subcutaneously administered GIP and GLP-2 on bone turnover in individuals with T2D.

The study included ten men with type 2 diabetes. Participants met fasting in the morning on three separate test days and were given subcutaneous injections of GIP, GLP-2, or placebo, in a randomized crossover design.

Blood samples were drawn at baseline and regularly after injections. Bone turnover was estimated by circulating CTX, P1NP, sclerostin, and PTH levels.

The study revealed the following findings:

  • GIP and GLP-2 significantly reduced CTX to (mean ± SEM) 66 ± 7.8% and 74 ± 5.9% of baseline, respectively, compared with after a placebo.
  • P1NP and sclerostin increased acutely after GIP, whereas there was a decrease in P1NP after GLP-2.
  • PTH levels decreased to 67 ± 2.5% of baseline after GLP-2 and to only 86 ± 3.4% after GIP.

GIP and GLP-2 injected subcutaneously reduce the bone resorption marker CTX in type 2 diabetes. Additionally, GIP increases the bone formation marker P1NP, whereas GLP-2 decreases it.

“Whether chronic GIP and/or GLP-2 treatments are tied to a reduced fracture risk in individuals with T2D is unexplored but could potentially be a novel treatment option for T2D-associated fracture risk,” the researchers concluded.

Reference:

Christiansen, C. B., Hansen, L. S., Windeløv, J. A., Hedbäck, N., Gasbjerg, L. S., Hindsø, M., Svane, M. S., Madsbad, S., Holst, J. J., Rosenkilde, M. M., & Hartmann, B. Effects of Exogenous GIP and GLP-2 on Bone Turnover in Individuals With Type 2 Diabetes. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgae022

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Robot-assisted prostatectomy improved continence recovery and erectile function post-surgery: Study

A recent study published in the World Journal of Urology, researchers have compared the outcomes of open retropubic radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) for treating prostate cancer. The study was conducted at a single tertiary referral center from 2008 to 2022 and analyzed data from a substantial cohort of 18,805 patients.

The research evaluated oncological, functional and surgical outcomes that were associated with both ORP and RARP procedures. After utilizing a propensity score-based matched cohort, the impact of the surgical approach on biochemical recurrence-free survival, salvage radiotherapy-free survival and metastasis-free survival was examined through log-rank tests and Kaplan–Meier analysis. Intraoperative and postoperative surgical outcomes were assessed with continence rates at 1 week, 3 months, and 12 months, as well as erectile function at 12 months post-surgery.

The results of the study revealed no statistically significant differences in oncological outcomes between the two surgical approaches. However, RARP demonstrated a slight advantage in terms of urinary continence recovery, with statistically significant differences observed at both the 3-month and 12-month marks. Also, the continence rates at 3 months were 81% for RARP when compared to 77% for ORP, and at 12 months, 91% for RARP when compared to 89.3% for ORP, respectively.

This study highlighted a significant disparity in erectile function outcomes, with RARP showing a markedly higher rate of erectile function recovery when compared to ORP. Also, RARP resulted in a 60% erectile function rate when compared to 45% for ORP that signifies a marked improvement in postoperative sexual function associated with the robotic approach. While both ORP and RARP demonstrated comparable oncological outcomes, RARP showed advantages in terms of urinary continence recovery and significant improved erectile function post-surgery.

Reference:

Ambrosini, F., Knipper, S., Tilki, D., Heinzer, H., Salomon, G., Michl, U., Steuber, T., Pose, R. M., Budäus, L., Maurer, T., Terrone, C., Tennstedt, P., Graefen, M., & Haese, A. (2024). Robot-assisted vs open retropubic radical prostatectomy: a propensity score-matched comparative analysis based on 15 years and 18,805 patients. In World Journal of Urology (Vol. 42, Issue 1). Springer Science and Business Media LLC. https://doi.org/10.1007/s00345-024-04824-6

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Study shows ‘bidirectional’ benefit of tofacitinib in rheumatoid arthritis patients with comorbid type 2 diabetes: Study

Italy: Treatment with tofacitinib in rheumatoid arthritis (RA) with type 2 diabetes (T2D) may simultaneously improve inflammatory disease activity and insulin resistance (IR), inducing a “bidirectional” benefit in these patients, a recent study has shown. The findings were published online in Arthritis Research & Therapy on January 4, 2024.

Previous studies have shown a connection between rheumatoid arthritis, insulin resistance, and type 2 diabetes. The β-cell apoptosis induced by pro-inflammatory cytokines, which could be exaggerated in the context of RA, is associated with increased expression of pro-apoptotic proteins, which is dependent on JAnus Kinase/Signal Transducer and Activator of Transcription (JAK/STAT) activation. Tofacitinib is a potent and selective JAK inhibitor. 

Against the above background, Piero Ruscitti, University of L’Aquila, Delta 6 Building, L’Aquila, Italy, and colleagues aimed to evaluate if tofacitinib administration could simultaneously improve glycaemic parameters and inflammatory markers in patients with RA and comorbid T2D.

The study’s primary endpoint was the change in the 1998-updated homeostatic model assessment of IR (HOMA2-IR) following 6 months of tofacitinib treatment in RA patients with type 2 diabetes. The proof-of-concept, open, prospective, clinical study, which was planned before the recent emergence of safety signals about tofacitinib, included consecutive RA patients with T2D diagnosis. Additional endpoints regarding RA disease activity and metabolic parameters were also assessed.

Forty consecutive rheumatoid arthritis patients with type 2 diabetes were included (female sex 68.9%, the mean age of 63.4 ± 9.9 years).

The study led to the following findings:

· During 6-month follow-up, a progressive reduction of HOMA2-IR was observed in RA patients with T2D treated with tofacitinib.

· Tofacitinib demonstrated a significant effect on the overall reduction of HOMA2-IR (β = − 1.1). Also, HOMA2-β enhanced in these patients highlighting an improvement of insulin sensitivity.

· Although there is a need for longer follow-up, a trend in glycated haemoglobin reduction was also recorded.

· The administration of tofacitinib induced an improvement in RA disease activity, and a significant reduction of DAS28-CRP and SDAI was observed; 76.8% of patients achieved a good clinical response.

· No major adverse events (AEs) were retrieved without the identification of new safety signals. Specifically, no life-threatening AEs and thromboembolic and/or cardiovascular events were recorded.

“Tofacitinib administration in rheumatoid arthritis with type 2 diabetes led to a simultaneous improvement of inflammatory disease activity and insulin resistance, leading to a “bidirectional” benefit in these patients with concomitant rheumatic and metabolic diseases,” the researchers wrote.

“Further powered and specifically designed studies are warranted to entirely evaluate the metabolic effects of tofacitinib in RA patients with T2D,” they concluded.

Reference:

Di Muzio, C., Di Cola, I., Shariat Panahi, A. et al. The effects of suppressing inflammation by tofacitinib may simultaneously improve glycaemic parameters and inflammatory markers in rheumatoid arthritis patients with comorbid type 2 diabetes: a proof-of-concept, open, prospective, clinical study. Arthritis Res Ther 26, 14 (2024). https://doi.org/10.1186/s13075-023-03249-7

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Glucose Fluctuations Impact Cognitive Performance in Type 1 Diabetes Patients: Study

A recent research published in the Digital Medicine Journal explored the intricate relationship between glucose levels and cognitive function in individuals with Type 1 diabetes (T1D). This recent study employed cutting-edge continuous glucose monitoring (CGM) technology with cognitive ecological momentary assessment (EMA), that found unprecedented insights into how natural fluctuations in glucose affect cognitive performance. This study was conducted on 200 adults with T1D to elucidate the dynamic interplay between glucose levels and cognitive abilities, like the processing speed and sustained attention, in the real-world settings.

After utilizing hierarchical Bayesian modeling this study observed that cognitive performance was compromised during both hypoglycemic (low glucose) and hyperglycemic (high glucose) states. The large fluctuations in glucose levels were associated with slower and less accurate processing speed by highlighting the vulnerability of cognitive functions to glycemic variability.

Also, the study employed data-driven lasso regression to identify the clinical factors that influence the individual differences in cognitive susceptibility to glucose fluctuations. The factors such as age, frequency of hypoglycemic episodes, presence of microvascular complications and overall glucose variability emerged as significant predictors of cognitive vulnerability.

These findings underscore the critical importance of reducing glucose fluctuations to effectively manage cognitive function among individuals with T1D. Overall, the outcomes of this research deepens the understanding of the critical interplay between glucose metabolism and cognitive performance but also pave the way for more targeted interventions tailored to address cognitive vulnerabilities in T1D patients.

Reference:

Hawks, Z. W., Beck, E. D., Jung, L., Fonseca, L. M., Sliwinski, M. J., Weinstock, R. S., Grinspoon, E., Xu, I., Strong, R. W., Singh, S., Van Dongen, H. P. A., Frumkin, M. R., Bulger, J., Cleveland, M. J., Janess, K., Kudva, Y. C., Pratley, R., Rickels, M. R., Rizvi, S. R., … Germine, L. T. (2024). Dynamic associations between glucose and ecological momentary cognition in Type 1 Diabetes. In npj Digital Medicine (Vol. 7, Issue 1). Springer Science and Business Media LLC. https://doi.org/10.1038/s41746-024-01036-5

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Patient recovery after surgery for esophageal cancer not influenced by using standard or keyhole incisions: Study

New research has found no evidence of a difference between recovery time and complications when comparing standard and keyhole surgical incisions for the treatment of oesophageal cancer (cancer of the gullet).

The study, led by the University of Bristol Medical School and published in theBritish Journal of Surgery, showed surgeons treating patients with oesophageal cancer do not need to change their practice if they have a strong preference for either procedure type.

Oesophageal cancer is the tenth most common cancer globally. It causes one in 18 cancer-related deaths. If only the oesophagus and local lymph nodes are affected surgeons usually perform a procedure called an oesophagectomy. This means they remove the oesophagus to try and cure the cancer. The two most common ways of doing this use either standard incisions (two large cuts) or ‘keyhole’ incisions (one large cut and several small ones)

The ROMIO study was funded by the National Institute for Health and Care Research (NIHR). It involved patients being randomly assigned to two groups. One of the groups had standard surgery (263 people) and the other had keyhole surgery (264 people).

Researchers found no differences between the groups in relation to:

recovery three months after surgery, as measured by patient completed questionnaires about physical function

how often patients developed complications and how severe the complications were

the extent to which the cancer was removed (it was equally well removed in both groups)

Chris Metcalfe, Professor of Medical Statistics at Bristol Medical School: Population Health Sciences (PHS), said: “Our study didn’t confirm findings from previous trials, which suggested that minimally invasive approaches to oesophagectomy reduced the number of complications patients would develop.

“We found no evidence of differences between standard and keyhole approaches in relation to short-term clinical outcomes or patient reported recovery of physical function over three months. There was no strong evidence that the costs of NHS resources in the first three months differed between the two approaches to the procedure.

“We will report about the longer-term recovery (24-month follow-up) and health of ROMIO participants in a separate publication. We will also publish the findings from a nested study on totally keyhole surgery.”

Jane Blazeby, Professor of Surgery in the Bristol Medical School: PHS, added: “These results show us that recovery after this type of major surgery is not influenced by the type of incision used by surgeons, despite prior beliefs that the keyhole approach is better than standard incisions.

“Future research is now needed to carefully evaluate robotic surgical techniques for oesophageal cancer surgery.”

References: British Journal of Surgery, Volume 111, Issue 3, March 2024, znae023, https://doi.org/10.1093/bjs/znae023

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