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IMPACT OF EVACUATING SKILLED NURSING HOME RESIDENTS TESTING POSITIVE FOR COVID-19 TO AN INPATIENT ACUTE CARE SETTING

 

R.J. Fischer

Corresponding author: Robert J. Fischer, MD, Mann-Grandstaff Veterans Affairs Medical Center, 4815 N. Assembly Street, Spokane, WA 99205, USA, Email: robert.fischer@va.gov, Phone: 509-434-7200

Jour Nursing Home Res 2020;6:69-72
Published online September 10, 2020, http://dx.doi.org/10.14283/jnhrs.2020.19

 


Abstract

We report a case series of 38 patients infected with coronavirus disease 2019 (COVID-19) evacuated to Mann-Grandstaff Veterans Affairs Medical Center (MGVAMC) in Spokane, Washington following disease outbreak in a skilled nursing home (SNH). Range of symptoms were none to mild on transfer. Patients were admitted to stem the outbreak, provide enhanced medical care and improve clinical outcome. The nursing home outbreak was arrested within two weeks of the initial patient transfer and mortality in this cohort was 13.2%.

Key words: COVID-19, skilled nursing home, outbreak, evacuation, mortality.


 

Introduction

As of July 7, the United States has suffered the largest number of COVID-19 confirmed cases (2,980,906) and deaths (131,248) worldwide, representing roughly a quarter of all cases and deaths globally (1). According to the American Geriatrics Society, nursing home residents are among the most vulnerable to complications and death from COVID-19 and represent a particular challenge in diagnosis and infection control owing to the frequent absence of typical symptoms along with the highly contagious nature of the disease (2), even among asymptomatic patients (3).
As of June 28, there have been 126,402 COVID-19 confirmed cases in nursing homes and 33,517 deaths with a fatality rate of 28% (4). Nursing home cases represent 4% of all COVID-19 cases in the US but 26% of deaths (33,509 of 131,248). Of the 1.3 million residents in 15,600 nursing homes, 9.7% have contracted COVID-19 by recent reporting. Two or more cases were experienced in 30.1% of the 14,577 reporting nursing homes, however, 129 facilities suffered 100 or more cases as of June 28. Overall, 5,522 (37.9%) had at least one infected resident (5).
Here we report on a COVID-19 outbreak in a SNH and the results of our efforts to stem infection and improve resident outcome.

 

Methods

This observational case series describes a cohort of 38 COVID-19 patients evacuated from a 100-bed local SNH to a designated acute care unit in the MGVAMC in Spokane, Washington between April 24 and June 2, 2020 after testing positive for infection. Patients were asymptomatic or only mildly symptomatic at time of transfer and would normally not meet hospital admission criteria. The goals of hospitalization were to stem the outbreak by removing infected patients from the SNH and provide enhanced medical care to prevent disease progression. At a minimum, daily physician rounding was conducted and a high nurse-to-patient ratio maintained (1:3 to 1:4). Consultation with physical and respiratory therapy, nutritional services, pharmacy, physiatry, rehabilitation services, audiology, social work, chaplaincy and other services were readily provided as necessary. Oral and fluid intake were monitored closely, and electrolyte imbalance corrected when identified.
Real-time reverse-transcriptase polymerase chain reaction (RT-PCR) sample collection was performed at MGVAMC by swabbing the nasopharynx. Testing was accomplished using the Cepheid GeneXpert™ rapid testing platform. All sample collection and processing followed CDC guidelines. Demographic and clinical data and information related to comorbidities were abstracted from electronic medical records (Department of Veteran Affairs Computerized Patient Records System, CPRS). A case was determined to be symptomatic if there was presence of fever, cough, shortness of breath or if the attending physician diagnosed symptomatic COVID-19 at any point during the hospitalization. The duration of viral shedding is defined as the number of days between the first positive COVID-19 test and the last positive test prior to two serial negative tests at least 24 hours apart. The COVID-19 case duration is the number of days between an initial positive test and the second negative test 24 hours after the initial negative test (test of cure). For those who succumbed, the date of decease was used as an end date for both measures. Data to calculate the Modified National Early Warning System (NEWS) (6) score was obtained from review of admission notes in the electronic health record.
Patients were returned to the SNH following hospitalization at MGVAMC only after strict discharge criteria were met: two negative RT-PCR tests at least 24 hours apart, or a period of 30 days had elapsed since the first positive test if negative testing could not be achieved; and no new resident or staff cases identified in the SNH for two consecutive weeks. For those residents still shedding virus after 30 days and returned to the SNH, isolation was required until two serial negative tests were obtained. At the time of the outbreak, there were 86 residents present in the SNH with a first resident case identified on April 6. By the time of evacuation (April 24), 35 residents and 12 staff had already tested positive for COVID-19.

 

Findings

Table 1 is a summary of the demographic and clinical findings of the cohort of 38 patients on admission to MGVAMC. The median age was 83 with a male to female ratio of 3 to 1. The most prevalent underlying conditions associated with severe COVID-19 disease were hypertension (68.4%) and cardiac disease (57.9%). The median number of these comorbidities was 2.0 (IQR, 1.3-3.0) with a maximum of 5 conditions. Additionally, 57.9% of patients suffered from dementia. The median number of medical problems listed in the electronic health record was 22. Moreover, 76.3% of patients requested to continue or initiate “do not attempt resuscitation” status after goals of care discussions with the attending physician. Many in the cohort suffered from a wide array of serious conditions such as Huntington’s disease, Parkinson’s disease, liver disease, post-traumatic stress disorder and history of stroke.

Table 1
Demographics and Findings

*Underlying conditions (comorbidities) known to be a risk for Severe COVID-19 (as of April 24, 2020); †Electronic Health Record; ‡A count of problems excluding COVID-19; §Modified National Early Warning Score of 5-6 represents medium risk progression to severe disease; ||Viral shedding is duration between initial RT-PCR positive test and last positive test; {Among those who died – duration is between initial test and date of decease; #Case duration is days between a first positive test and second negative testing for COVID-19; **A second negative RT-PCR test for COVID-19 repeated 24 hours after previous negative test. Results of RT-PCR testing obtained from Apr 24 to June 24.

Notably, 44.7% of the cohort remained asymptomatic throughout hospitalization with 13.2% unable to respond verbally to questions owing to underlying conditions. The median Modified National Early Warning Score (an indicator of risk of clinical deterioration) was 5.0 (IQR, 3.0-6.0). A score of 5-6 indicates a medium risk for progression to severe COVID-19. Twenty patients (52.6%) had a score equal to or greater than 5 while 7 (18.4%) a score compatible with high risk. The mortality rate for the cohort was 13.2% (5 patients). One of 38 evacuated patients received RemdesivirTM (Gilead Sciences) antiviral therapy by protocol and did well. No patients received hydroxychloroquine, but several patients did receive antibiotic therapy for community-acquired pneumonia. One patient in the cohort was transiently admitted to the ICU for cardiac-related issues unrelated to COVID-19.
Viral shedding showed a median duration of 29.0 days (IQR, 20.3-36.8) with a maximum of 71. Case duration, a median of 49.0 days (IQR, 24.0-56.8) and a maximum of 77. The cohort underwent serial RT-PCR testing at intervals between one and two weeks to minimize patient discomfort and test kit consumption.
Prior to SNH resident evacuation to MGVAMC, 35 residents and 12 staff were infected between March 23 and April 24 (32 days). Following evacuation, the last case occurred on May 11 (staff member), 17 days later. As of this publication, no additional resident cases have been detected (Figure 1). Overall, 46 of 83 residents contracted COVID-19 (55.4%) and 10 patients died (21.7%) during the period of this study. Of the 38 patients evacuated to MGVAMC, the case fatality rate was 13.2%.

Figure 1
Skilled Nursing Home Outbreak and Testing

 

Discussion

With respect to infection transmission in nursing homes, it is important to recognize that there is frequent, prolonged and close contact between frail patients and staff during activities of daily living (ADLs). Assistance is required for ambulating, feeding, dressing, personal hygiene, continence and toileting (7). Lai et al. (2020) point out that nursing home “residents share the same sources of air, food, water, caregivers, and medical care” and are exposed to visitors who come and go at will (8). These factors contribute to the high degree of COVID-19 penetration in skilled nursing homes in the US (5) and may explain the difficulty with outbreak control experienced by the SNH we observed before evacuation of infected residents to MGVAMC.
Our findings serve to highlight the extent of underlying health and cognitive conditions and disabilities among SNH residents. There is also growing evidence nursing home resident comorbidities including Alzheimer’s disease and related dementias (ADRD) contribute strongly to coronavirus mortality in skilled nursing homes (9). For example, it is difficult to elicit a reliable history from cognitively impaired patients and they often present with atypical symptoms (10); as a consequence, they are at risk for delay in diagnosis of symptomatic and serious infection. Fully 60% of our cohort were cognitively impaired. Comorbidities, cognitive disability, persistent absence of symptoms of infection and the impact of immunosenescence (11) combined to mask typical signs and symptoms of disease and made detection of progressive COVID-19 a challenge for the MGVAMC caregivers. This difficulty with accurate assessment, triage and treatment would be an even greater challenge in the SNH setting.
The duration of viral shedding may provide important insight into the severity of COVID-19 in our cohort. These patients experienced a median duration of viral shedding of 29 days. This is comparable to findings from Wuhan, China showing a median of 31 days in patients with severe COVID-19 (12). The duration of viral shedding in asymptomatic and mildly symptomatic younger patients has been reported to show a median of only 19 days (13). Furthermore, advanced age and comorbidities do not appear to play a role in the duration of viral shedding (12, 14). A possible explanation for prolonged viral shedding in our cohort, therefore, may be more advanced COVID-19 than is apparent on daily clinical assessment in the SNH. This is borne out by our findings that over half of the cohort had a Modified NEWS score of 5 or more on evacuation and admission to MGVAMC.
Our cohort is likely representative of nursing home residents everywhere insofar as they are elderly, poor historians, suffer from numerous serious health conditions, and may often present atypically (2) and with blunted fever response to infection (15). The ability to distinguish symptoms of COVID-19 from those associated with underlying health conditions along with an attenuated physiologic response to infection combine to place nursing home residents at serious risk for delay in appropriate comprehensive supportive care with subsequent rapid progression of infection and suboptimal outcome.
Our decision to evacuate the SNH residents to our hospital appeared to have a salutary effect on outbreak control. Seventeen days after implementing evacuation procedures, no further cases of COVID-19 had been identified among residents or staff.
There are significant limitations to this case series. The number of patients is small (38), observations are retrospective, and the study does not have a matched control group for comparison purposes.
Our findings do suggest that early evacuation of COVID-19 residents from the SNH stemmed the outbreak and improved patient outcomes by timely hospitalization and robust multidisciplinary medical care following positive testing. In order to avoid prolonged isolation, however, additional research is needed to resolve the question of infectivity in residents who continue to test positive for COVID-19 over very long periods of time.

Acknowledgments: This material is the result of work supported with resources and the use of facilities at the Mann-Grandstaff Veterans Affairs Medical Center, Spokane, Washington, USA. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. I would like to acknowledge the men and women of Mann-Grandstaff VA Medical Center for their dedication and skill in the care of community patients during the COVID-19 pandemic and in fulfilling Veterans Affairs’ fourth mission. I also would like to recognize Stephen D. Fischer for his invaluable assistance in proofreading this submission.

Funding: This observational study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Conflict of interest: None.

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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1. COVID-19 Dashboard, Center for Systems Science and Engineering (CSSE), Johns Hopkins University (JHU), Coronavirus Resource Center. Accessed 7 June 2020. Available at: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
2. Goldstein A, Hollmann P, Lundebjerg N, Ouslander J, Saliba D, Unroe K. American Geriatrics Society Policy Brief: Covid-19 and Nursing Homes, American Geriatrics Society, Special Article. JAGS 2020; 68:908-911. Accessed 20 May 20 2020. Available at: https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16477
3. Mizumoto K, Kagaya K, Zarebski A, Chowell G. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill 2020;25(10):pii=2000180. Accessed 12 June 2020. Available at: https://doi.org/10.2807/1560-7917.ES.2020.25.10.2000180
4. Data.CMS.gov; COVID-19 Nursing Home Data, Submitted Data as of Week Ending: 6/21/2020. Accessed 7 July 2020. Available at: https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg
5. Data.CMS.gov. COVID-19 Nursing Home Dataset. Accessed 12 July 2020. Available at: https://data.cms.gov/Special-Programs-Initiatives-COVID-19-Nursing-Home/COVID-19-Nursing-Home-Dataset/s2uc-8wxp/data
6. Liao X, Wang B, Kang Y. Novel coronavirus infection during the 2019–2020 epidemic: preparing intensive care units—the experience in Sichuan Province, China. Intensive Care Med 2020; 46:357–360. Accessed May 19, 2020. Available at: https://doi.org/10.1007/s00134-020-05954-2
7. Edemokong P, Bomgaars D, Sukumaran S. Activities of Daily Living (ADLs), StatPearls [Internet], updated 12 Apr 2020. Accessed 7 June 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470404/
8. Lai C-C, Wang J-H, Ko, W-C, et al. COVID-19 in long-term care facilities: An upcoming threat that cannot be ignored. Journal of Microbiology, Immunology and Infection 2020; 53(3):444-446. Accessed 20 June 2020. Available at: https://doi.org/10.1016/j.jmii.2020.04.008
9. Brown E, Kumar S, Rajii T, Pollock B, Mulsant B. Anticipating and Mitigating the Impact of the COVID-19 Pandemic on Alzheimer’s Disease and Related Dementias. Am J of Geriatric Psychiatry 2020; 28(7):712-721. Accessed 7 June 2020. Available at: https://www.sciencedirect.com/science/article/pii/S1064748120302943?via%3Dihub
10. Isaia G, Marinello R, Tibaldi V, Tamone C, Bo M. Atypical Presentation of Covid-19 in an Older Adult with Severe Alzheimer Disease. Letter to the Editor. Am J of Geriatric Psychiatry 2020; 28(7)790-791. Accessed 6 June 2020. Available at: https://doi.org/10.1016/j.jagp.2020.04.018
11. Aw D, Silva A, Palmer D. Immunosenescence: emerging challenges for an ageing population. Immunology 2007; 120(4):435–446. Accessed 6 June 2020. Available at: https://doi.org/10.1111/j.1365-2567.2007.02555.x
12. Zhou B, She J, Wang Y, Ma X. The duration of viral shedding of discharged patients with severe Covid-19. Clinical Infectious Disease 2020; XX(XX):1-3 [Preprint]. Accessed 24 May 2020. Available at: https://doi.org/10.1093/cid/ciaa451
13. Miyamae Y, Hayashi T, Yonezawa H, et al. Duration of viral shedding in asymptomatic or mild cases of novel coronavirus disease 2019 (COVID-19) from a cruise ship: A single-hospital experience in Tokyo, Japan. IJID 2020; 97: 293-295. Accessed 12 July 2020. Available at: https://www.sciencedirect.com/science/article/pii/S1201971220304562
14. Qi L, Yang Y, Jiang D, et al. Factors associated with the duration of viral shedding in adults with COVID-19 outside of Wuhan, China: a retrospective cohort study, International Journal of Infectious Diseases 2020; 96:531-537. Accessed 12 July 2020. Available at: https://www.sciencedirect.com/science/article/pii/S1201971220303520
15. Castle S, Normal D, Yeh M, Miller D, Yoshikawa T. Fever response in elderly nursing home residents: Are the older truly colder? JAGS 39(9):853-857. Accessed 12 July 2020. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/j.15325415.1991.tb04450.x?sid=nlm%3Apubmed

STAY OR GO: NURSING HOMES’ NATURAL DISASTER RESPONSE IN A CHANGING CLIMATE

 

D.A. Harris1, G.A. Wellenius2

 

1. Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, CA; 2. Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA.  Corresponding author: Daniel Harris, MPH, Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, (781) 733-5291
daniel.harris@mail.utoronto.ca, daniel_harris2@alumni.brown.edu

Jour Nursing Home Res 2018;4:64-66
Published online December 6, 2018, http://dx.doi.org/10.14283/jnhrs.2018.12

 


Abstract

The Centers for Medicare & Medicaid Services (CMS) reported 15,634 certified nursing homes in the United States in 2014. Approximately 1.4 million older adults reside in nursing homes due to a variety of clinical and social factors. Older adults who transition into nursing home care tend to have a greater prevalence of cognitive and physical morbidities, such as cognitive impairment and chronic obstructive pulmonary disease. Given their clinical vulnerabilities, nursing home residents are at an increased risk of adverse events due to climate change. Major hurricane systems over the past several decades have contributed to significant and avoidable loss of life among nursing homes residents. Currently, evidence from both the qualitative and quantitative literatures consistently suggest that the evacuation of nursing homes residents leads to greater morbidity and mortality compared to sheltering in place due to a host of clinical and environmental factors. However, as extreme weather events intensify due to climate change, policy makers, health officials, and nursing homes will need to reassess their disaster plans amidst the increasing risk of facility damage and need for evacuation from worsening storm systems. In this commentary we review the evidence regarding the risks of sheltering in place versus evacuation during extreme weather events and propose that climate-change projections be integrated into the conversation and development of nursing home disaster preparation.

Key words: Climate change, nursing home, evacuation, shelter in place.


 

 

Introduction

Older adults living in nursing homes are at an increased risk of adverse health outcomes as a result of extreme weather events such as hurricanes and severe storms. Since Hurricanes Katrina and Rita in the United States, several studies and reports have compared the health risks of evacuating nursing home residents versus sheltering in place (1-3). These studies have shown that with adequate preparations, sheltering in place tends to be safer compared to evacuation procedures, leading local health departments to advocate and prioritize this method of hurricane response (4). However, if extreme weather events become more frequent and more severe, as currently projected under climate change scenarios (5), will sheltering in place remain the preferred response to extreme weather events? In other words, what is the future generalizability of previous studies’ findings in the context of a changing climate?
Our aims in this commentary are to briefly review the history and population of nursing homes, survey past research measuring the effects of evacuation compared to sheltering in place, and ultimately propose that future legislative decisions and recommendations for nursing homes’ hurricane response be proactively informed by climate science.

 

The challenges of nursing home evacuation

In 2014, the Centers for Medicare & Medicaid Services (CMS) reported that there were 15,634 certified nursing homes in the United States, serving approximately 1.4 million nursing home residents (6). Notably, among the older adults living in nursing homes, 7.8% were older than 95 years old, 69.3% had three or more impairments of activities of daily living, and 61.4% had moderate to severe cognitive impairment (6). The high prevalence of poor physical and cognitive health lends insight into the medical complexity and vulnerability of older adults living in nursing homes.
The fragility of the nursing home population has facilitated a number of tragedies during past hurricanes. Evacuating a medically complex senior population is associated with several adverse health outcomes (7). As one nurse administrator expressed, maneuvering older adults into buses for transport is not only a formidable task, but also risky, as this population cannot quickly evacuate a bus during a secondary emergency (2). For example, these risks became a reality when twenty-four nursing home residents died when their evacuation bus caught fire during Hurricane Katrina (8).
The quantitative and qualitative evidence regarding the impact of evacuation on nursing home residents has been consistent in highlighting the risks and challenges of evacuating nursing home residents. One qualitative study of twenty nursing home administrators affected by Hurricane Katrina reported consistent themes of inadequate support from government response teams, challenges associated with evacuating a medically acute population, and poor staff retention (2).Similarly, a report by the Office of Inspector General (OIG) of twenty nursing homes in the Gulf States (Alabama, Florida, Louisiana, Mississippi, and Texas), revealed that evacuation led to unforeseen problems with contractual agreements with transportation services (9). Among the thirteen facilities reporting prior contracts with transportation services, five were unable to access the contracted service due to “overbooking”, as several other nursing homes contracted with the same transportation service. The OIG report also noted that nursing homes reported evacuation taking substantially longer than anticipated, with the median journey to a new host facility taking 3 hours. One nursing home detailed an arduous 19-hour evacuation, marred by numerous vehicle failures, ill residents, 100-degree temperatures, and diminishing supplies. A more recent study that quantified the increase in morbidity and mortality associated with evacuation during hurricanes found that 90-days after Hurricanes Katrina, Gustav, Rita and Ike, evacuation was associated with a 2.7% to 5.3% higher risk of death and a 1.8% to 8.3% higher risk of hospitalization compared to non-hurricane periods (3).

 

Sheltering in place

In contrast to evacuation, prior studies have shown that nursing homes residents who sheltered in place during extreme weather events have had better health outcomes compared to their evacuated peers (3). One qualitative study of nursing home administrators affected by Hurricanes Katrina and Rita found that only one of eleven (9%) nursing homes that sheltered in place reported being concerned about resident morbidity and mortality, whereas six of fifteen (40%) administrators who evacuated reported morbidity and mortality as a concern.
Although the results from these previous studies and reports identify the high risk associated with evacuating this vulnerable population, sheltering in place is not without danger.  The most prevalent concerns from nursing home administrators who sheltered in place during Hurricanes Katrina and Rita were facility damage, reduced staffing, and limited supplies (2). Many of the concerns and risks associated with sheltering in place are related to the local government’s recovery time and sustainability of resources within the nursing home. For example, in one Florida nursing home, staff were able to care for residents during Hurricane Irma, but limited power resources, high temperatures, and a slow emergency response after the storm contributed to the unnecessary loss of eight lives (10). Clearly, sheltering in place is not without risk, with its success often dependent on external factors, such as the storm’s relative impact and community-level disaster planning and execution. However, the many negative findings evaluating evacuation suggests that keeping residents in place is perhaps, on average the lesser of two risks, leading health systems to recommend that nursing homes prepare accordingly and shelter in place (4).

 

Introducing climate science into disaster preparedness

We propose that a crucial element is missing from the interpretation of past research findings and the implementation of current and future emergency preparedness policies. Increasing temperatures intensify extreme weather events, such as hurricanes, and pose significant risks to population health (especially for vulnerable populations like older adults) (11, 12). Although some nursing homes may have withstood hurricanes in the past, climate projections suggest that further increases in storm system intensity will likely render more catastrophic infrastructural damage (5). Moreover, barriers such as limited supplies and limited support from emergency services will likely worsen as infrastructural damage from severe storms becomes more widespread. Therefore, in the context of a rapidly changing climate, the debate regarding evacuation versus sheltering in place deepens in complexity, requiring substantially greater thought and preparation into the drafting of legislation, allocation of resources, and initiation of disaster plans. Addressing these challenges is not just a matter of policy or legislation. Nursing homes should consider and invest in their own emergency preparedness in advance, in the context of a diverse set of growing climate-related threats. This may include infrastructural improvements to be able to better shelter in place.
As the literature currently stands, the debate between evacuation or sheltering place during a hurricane or severe storm appears to favor the latter; however, as extreme weather events become more common and more severe due to climate change, the relative risks become markedly less clear, highlighting the need to develop policies that extend beyond past experience and take into account the hazards projected for the future. Moreover, the debate of whether or not to evacuate or shelter in place must move beyond the minds of nursing home administrators and be brought into a wider discussion of how to weigh and consider evacuation amidst worsening storm systems, especially as other climate-related threats also exist for this population (e.g., extreme heat, heavy precipitation, and displacement from sea level rise). Now is the time to begin crafting climate-informed policies, and not rely previous findings unlikely to generalize to a changing climate.

 

Funding: The authors have no funding source(s) to report.

Acknowledgements: The authors would like to acknowledge Geetika Kalloo for reviewing and providing thoughtful feedback on earlier drafts. Authors DAH and GAW contributed equally to the conception, writing, and revision of the commentary.

Conflict of Interest: None to declare.

 

References

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