Assessment of Compliance With the Global Initiative for Chronic Obstructive Lung Disease Protocols in Chronic Obstructive Pulmonary Disease Patients PDF Free Download
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DOI: 10.7759/cureus.96190
Assessment of Compliance With the Global
Initiative for Chronic Obstructive Lung Disease
Protocols in Chronic Obstructive Pulmonary
Disease Patients
Abdullah Umer , Bilawal Ali , Muhammad Rasikh , Syed Asjad Ur Rehman Omer , Ali Raza
1. Internal Medicine, Combined Military Hospital, Lahore, PAK 2. Internal Medicine, DHQ Teaching Hospital, Dera
Ghazi Khan, PAK 3. Internal Medicine, Jinnah Hospital, Lahore, PAK 4. Internal Medicine, Mayo Hospital, Lahore, PAK
5. Emergency Medicine, Shalamar Hospital, Lahore, PAK
Corresponding author: Bilawal Ali, bilawalyousuf121@gmail.com
Abstract
Background
Chronic obstructive pulmonary disease (COPD) is a chronic, progressive respiratory condition characterized
by airflow limitation, frequent exacerbations, and substantial impact on quality of life and healthcare
utilization. Effective management requires adherence to standardized international guidelines to optimize
outcomes.
Objective
This study aimed to evaluate the management of COPD patients in accordance with Global Initiative for
Chronic Obstructive Lung Disease (GOLD) recommendations, with particular emphasis on the
appropriateness of pharmacological and non-pharmacological interventions relative to disease severity and
risk classification.
Methods
This retrospective study included 350 COPD patients, confirmed by spirometry, conducted at Jinnah
Hospital, Lahore, Pakistan, from January 2022 to January 2025. Data were collected from hospital records,
including demographics, smoking status, comorbidities, spirometry results, GOLD classification, treatment
regimens, exacerbation frequency, and non-pharmacological interventions. Patients were categorized into
GOLD ABE groups based on symptom burden and exacerbation history.
Results
The mean age of patients was 61.4 ± 9.8 years, with a male predominance of 218 (62.3%). Smoking history
was present in 272 (77.7%) patients, while 64 (18.3%) reported biomass exposure. Most patients had
advanced disease, with 256 (73.1%) in GOLD 3-4 stages and 173 (49.4%) classified as GOLD Group E. The
mean forced expiratory volume in 1 second (%) predicted was 48.7 ± 13.4. Exacerbation burden was high,
with 108 (30.9%) patients reporting ≥2 exacerbations annually and 98 (28.0%) requiring hospitalization.
Pharmacological management showed that 142 (40.6%) patients received dual therapy (long-
acting muscarinic antagonist (LAMA) + long-acting beta 2-agonist (LABA)) and 128 (36.6%) received triple
therapy (inhaled corticosteroid or ICS + LABA + LAMA). Non-pharmacological measures were variably
implemented: smoking cessation counseling was documented in 320 (91.4%) patients, though only 114
(35.6%) achieved abstinence; influenza and pneumococcal vaccination coverage was 122 (34.9%) and 88
(25.1%) patients, respectively; and pulmonary rehabilitation was accessed by 96 (27.4%).
Conclusion
It is concluded that while pharmacological treatment in COPD patients largely followed GOLD guidelines,
significant deficiencies were observed in the adoption of non-pharmacological interventions, vaccination,
and early disease detection.
Categories: Internal Medicine, Pulmonology, Allergy/Immunology
Keywords: chronic bronchitis, chronic obstructive pulmonary disease, emphysema, gold guidelines, smoking
Introduction
Chronic obstructive pulmonary disease (COPD) is a significant health problem worldwide with a
disproportionate prevalence in developed countries and sequential airflow obstruction and persistence of
respiratory symptoms that cannot be completely reversed. The disease is caused by the development of
1 2 3 4 5
Open Access Original Article
How to cite this article
Umer A, Ali B, Rasikh M, et al. (November 06, 2025) Assessment of Compliance With the Global Initiative for Chronic Obstructive Lung Disease
Protocols in Chronic Obstructive Pulmonary Disease Patients. Cureus 17(11): e96190. DOI 10.7759/cureus.96190
chronic inflammatory processes in the airways and lung parenchyma as a result of exposure to harmful
particles or gases, and cigarette smoking is the most significant risk factor [1]. Other risk factors include
biomass fuel exposure, work risks, habitual respiratory infections, and genetic conditions such as alpha-1
antitrypsin deficiency. COPD is one of the leading three causes of mortality in the world, and it is expected
that the disease will only grow in prevalence and mortality, particularly in low- and middle-income nations
where healthcare access is limited and smoking prevalence is still high [2]. Not only does the disease affect
survival, but it is also a costly disease in terms of economic consequences because of frequent
hospitalizations, long-term treatment needs, and severe deterioration of the quality of life [3]. With the
common burden of COPD identified, in 1998, the Global Initiative for Chronic Obstructive Lung Disease
(GOLD) was initiated as a systematic evidence-based model of diagnosis, assessment, and management.
GOLD guidelines have been periodically revised according to emerging research findings and changing
clinical challenges and are currently the most referenced among clinicians across the globe [4]. According to
GOLD, COPD is not a generalized disease, but a heterogeneous disease that requires treatment on an
individual basis. It must be confirmed through spirometry that the mean forced expiratory volume in 1
second (FEV1)/forced vital capacity (FVC) ratio is below 0.70 following the intake of bronchodilators [5]. One
of the most significant changes in the GOLD guidelines has been the replacement of the use of airflow
limitation as the single marker of respiratory disease by a multidimensional approach. The current ABE
classification system stratifies patients based on their symptom burden and history of exacerbations, rather
than relying exclusively on spirometric severity grading [6]. This change shows the awareness that
symptoms and exacerbations, rather than deterioration of FEV1 alone, are more informative prognosticators
of outcome, such as hospitalization and mortality. Patients with a heavier symptom burden (based on the
validated scales, e.g., the Modified Medical Research Council (mMRC) dyspnea scale or COPD Assessment
Test (CAT)) and those who have many exacerbation events should be treated with more intensive
management methods [7]. GOLD management offers non-pharmacologic and pharmacologic management.
The pharmacological treatment centers on bronchodilators, such as the long-acting beta 2-agonists (LABAs)
and long-acting muscarinic antagonists (LAMAs), which are the most frequently used so far [8]. Inhaled
corticosteroids (ICS) may serve as triple therapy in patients who have been receiving dual therapy but still
experience persistent attacks; however, GOLD warns against their carefree use due to the risk of pneumonia.
It is important to mention that treatment selection is not fixed and must be reconsidered on a continuous
basis and according to the evolving symptoms and risk of exacerbation, including step-up or step-down
therapy [9].
Non-pharmacology plays an important role in the management of COPD. The most effective intervention in
modifying the progression of a disease is smoking cessation, and it should be prioritized at all stages [10].
Exercise training, with education and behavioral support (as pulmonary rehabilitation), has been
demonstrated to increase exercise capacity, symptom control, and quality of life. Influenza, pneumococcus,
and most recently COVID-19 vaccinations are highly advised to decrease the risk of serious infections and
follow-up exacerbations [11]. In selected patients with advanced disease, surgical interventions such as lung
volume reduction or transplantation and long-term oxygen therapy can be used. Another characteristic of
GOLD is the focus on a patient-centered and multidisciplinary approach [12]. Management is carried out not
only by physicians, but also by respiratory therapists, physiotherapists, nutritionists, and psychologists,
considering the dual physical and psychosocial aspects of COPD [13]. The guidelines also promote shared
decision-making, during which patients participate actively in the understanding of their disease and in
formulating their treatment objectives. Other new concepts included in recent updates in GOLD relate to
the role of comorbidities (e.g., cardiovascular disease, osteoporosis, anxiety, and depression) that often
complicate COPD and worsen outcomes [14]. The treatment of these comorbidities is an important
component of holistic care. Also, GOLD recognizes the importance of digital health assists, telemedicine,
and remote monitoring in promoting continuity of care, especially in the context of patients who have
limited mobility or are in resource-constrained environments [15].
Objective
This study aimed to evaluate the management of COPD patients in accordance with GOLD
recommendations, with particular emphasis on the appropriateness of pharmacological and non-
pharmacological interventions relative to disease severity and risk classification.
The primary endpoint was the adherence of pharmacological management to GOLD guideline
recommendations based on disease severity and ABE classification. The secondary endpoints include rates
of non-pharmacological intervention implementation (smoking cessation, vaccination, and pulmonary
rehabilitation), frequency of exacerbations, and the association between disease severity and management
adherence.
Materials And Methods
Methodology
This was a retrospective study conducted at Jinnah Hospital, Lahore, Pakistan, from January 2022 to January
2025. A total of 350 patients were included in the study. The study was approved by the Institutional Review
Board (IRB) of Jinnah Hospital, Lahore (Approval No. JHL/IRB/2021/23). As this was a retrospective audit
2025 Umer et al. Cureus 17(11): e96190. DOI 10.7759/cureus.96190 2 of 9
using anonymized patient records, the requirement for informed consent was waived by the ethics
committee in accordance with institutional policy and the Declaration of Helsinki.
Inclusion and exclusion criteria
Patients aged over 18 years with a confirmed diagnosis of COPD established by spirometry, defined as a
post-bronchodilator FEV₁/FVC ratio of less than 0.70, in accordance with the GOLD criteria, and with
complete medical records, were included in the study. Patients with a known diagnosis of asthma or asthma-
COPD overlap were excluded, where such documentation was available in the medical records. Additionally,
patients with incomplete records, concomitant active pulmonary tuberculosis, interstitial lung disease, or
any other major chronic respiratory disorder were excluded.
Data collection
A non-probability purposive sampling technique was employed, including all eligible COPD patients whose
records met the inclusion criteria. Data were retrospectively extracted from hospital records, including
demographic details, smoking history, spirometry results, comorbid conditions, treatment regimens,
exacerbation frequency, and hospital admissions. To ensure accuracy and reliability, all extracted data were
double-checked by two independent investigators, and any discrepancies were resolved through consensus.
Records with missing key variables (e.g., spirometry results or treatment details) were excluded from the
final dataset to maintain data integrity. The classification of patients into ABE groups was performed
according to GOLD criteria, incorporating symptom burden (assessed by CAT or mMRC dyspnea scale) and
exacerbation history. The primary variables studied included patient demographics (age, sex, and smoking
status), severity of airflow limitation (FEV1 (%) predicted), symptom assessment scores, number of
exacerbations in the previous year, pharmacological therapy received, and non-pharmacological
management such as pulmonary rehabilitation or vaccination status.
Data analysis
All collected data were coded and entered into SPSS version 26.0 (IBM Corp., Armonk, NY) for analysis.
Descriptive statistics were applied to summarize baseline characteristics, with means and standard
deviations presented for continuous variables and frequencies with percentages for categorical variables.
Group comparisons between GOLD classifications and treatment modalities were performed using Chi-
square tests for categorical data and independent sample t-tests. A p-value <0.05 was considered
statistically significant.
Results
Data were collected from 350 patients; the mean age was 61.4 ± 9.8 years. Of these, 218 (62.3%) patients were
male, while 132 (37.7%) were female. A smoking history was present in 272 (77.7%) patients, whereas 78
(22.3%) were non-smokers. Biomass exposure was documented in 64 (18.3%) patients. The duration of COPD
since diagnosis averaged 6.2 ± 3.7 years. Comorbid conditions were frequent: 135 (38.6%) patients had
hypertension, 102 (29.1%) diabetes mellitus, 66 (18.9%) ischemic heart disease, 54 (15.4%) osteoporosis, 48
(13.7%) anxiety/depression, and 37 (10.6%) other chronic conditions (Table 1).
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Variable Total (N = 350)
Age (years), mean ± SD 61.4 ± 9.8
Gender, n (%)
• Male 218 (62.3)
• Female 132 (37.7)
Lifestyle factors
• Current/ex-smoker 272 (77.7)
• Non-smoker 78 (22.3)
Biomass exposure, n (%) 64 (18.3)
Duration of COPD (years), mean ± SD 6.2 ± 3.7
Comorbidities, n (%)
• Hypertension 135 (38.6)
• Diabetes mellitus 102 (29.1)
• Ischemic heart disease 66 (18.9)
• Osteoporosis 54 (15.4)
• Anxiety/depression 48 (13.7)
• Other chronic conditions 37 (10.6)
TABLE 1: Baseline demographic characteristics of patients (N = 350)
Data are presented as mean ± SD for continuous variables and n (%) for categorical variables. No inferential tests were performed, as this table presents
descriptive characteristics of the total study population only.
COPD: Chronic obstructive pulmonary disease; SD: Standard deviation.
The mean post-bronchodilator FEV₁ was 48.7 ± 13.4% of the predicted value among the study participants.
By spirometric grading, 24 (6.9%) patients were classified as GOLD 1 (mild), 70 (20.0%) as GOLD 2
(moderate), 168 (48.0%) as GOLD 3 (severe), and 88 (25.1%) as GOLD 4 (very severe). Using the GOLD ABE
schema, 72 (20.6%) patients were assigned to Group A, 105 (30.0%) to Group B, and 173 (49.4%) to Group E
(Table 2).
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Variable Value Test statistic p-value
Mean FEV₁₁ (%) predicted ± SD 48.7 ± 13.4 t = 3.24 0.001
GOLD spirometric stage, n (%)
• GOLD 1 – mild (FEV₁ ≥ 80%) 24 (6.9) χ² = 98.5 <0.001
• GOLD 2 – moderate (50%–79%) 70 (20.0) — —
• GOLD 3 – severe (30%–49%) 168 (48.0) — —
• GOLD 4 – very severe (<30%) 88 (25.1) — —
GOLD ABE classification, n (%)
• Group A 72 (20.6) χ² = 64.3 <0.001
• Group B 105 (30.0) — —
• Group E 173 (49.4) — —
TABLE 2: Pulmonary function (spirometry results) (N = 350)
Continuous variables are expressed as mean ± SD and categorical variables as n (%). Group differences in continuous outcomes were assessed using
independent sample t-tests; categorical distributions were compared using χ² tests. Test statistics and p-values are reported, with p < 0.05 considered
significant.
GOLD: Global Initiative for Chronic Obstructive Lung Disease; FEV₁: Forced expiratory volume in 1 second; SD: Standard deviation; χ²: Chi-square.
Regarding inhaled regimens, 22 (6.3%) patients used short-acting bronchodilators only, 58 (16.6%) received
LABA or LAMA monotherapy, 142 (40.6%) were on dual therapy (LAMA + LABA), and 128 (36.6%) received
triple therapy (ICS + LABA + LAMA). On the non-pharmacological side, smoking-cessation counseling was
documented for 320 (91.4%) patients, with sustained abstinence reported by 114 (35.6%). Vaccination
uptake included 122 (34.9%) patients for influenza and 88 (25.1%) for pneumococcal vaccines. A total of 96
(27.4%) patients accessed pulmonary rehabilitation, and 74 (21.1%) were on long-term oxygen therapy
(Table 3).
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Therapy type n (%) Test statistic p-value
Short-acting bronchodilators only 22 (6.3) χ² = 76.2 <0.001
LABA or LAMA monotherapy 58 (16.6) — —
Dual therapy (LAMA + LABA) 142 (40.6) — —
Triple therapy (ICS + LABA + LAMA) 128 (36.6) — —
Non-pharmacological measures
Smoking cessation counseling 320 (91.4) χ² = 210.4 <0.001
Successful abstinence from smoking 114 (35.6) — —
Influenza vaccination 122 (34.9) χ² = 45.7 <0.001
Pneumococcal vaccination 88 (25.1) — —
Pulmonary rehabilitation 96 (27.4) — —
Long-term oxygen therapy 74 (21.1) — —
TABLE 3: Pharmacological and non-pharmacological distribution (N = 350)
Values are shown as n (%). χ² tests were applied to evaluate differences in treatment distribution across GOLD categories. Test statistics and p-values are
presented, with p < 0.05 considered statistically significant.
ICS: Inhaled corticosteroid; LABA: Long-acting beta 2-agonist; LAMA: Long-acting muscarinic antagonist; χ²: Chi-square.
Exacerbations in the previous year were distributed as follows: 68 (19.4%) patients reported no events, 76
(21.7%) had one non-hospitalized exacerbation, 108 (30.9%) had ≥2 moderate/severe exacerbations, and 98
(28.0%) experienced at least one hospitalization. The mean annual exacerbation rate was 1.7 ± 1.1 events per
patient (Table 4).
Variable n (%) Test statistic p-value
No exacerbation 68 (19.4) χ² = 84.2 <0.001
1 exacerbation (no hospitalization) 76 (21.7) — —
≥2 exacerbations (moderate/severe) 108 (30.9) — —
≥1 hospitalization for exacerbation 98 (28.0) — —
Mean number of exacerbations ± SD 1.7 ± 1.1 t = 4.12 <0.001
TABLE 4: Exacerbation profile of patients in the past 12 months (N = 350)
Categorical variables are reported as n (%) and continuous variables as mean ± SD. Exacerbation frequency distributions were compared using χ² tests;
mean exacerbation rates were compared using t-tests. Test statistics and p-values are displayed, with significance set at p < 0.05.
SD: Standard deviation; χ²: Chi-square.
Symptom scores were elevated overall, with a mean CAT score of 18.2 ± 5.7 and mean mMRC score of 2.3 ±
0.8. A total of 294 (84.0%) patients had a CAT score ≥10 (high symptom burden) compared with 56 (16.0%)
who had a score <10. By dyspnea grade, 266 (76.0%) patients had an mMRC score ≥2 and 84 (24.0%) had a
score of 0-1 (Table 5).
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Symptom score Mean ± SD/n (%) Test statistic p-value
Mean CAT score 18.2 ± 5.7 t = 5.01 <0.001
Mean mMRC dyspnea scale score 2.3 ± 0.8 t = 3.27 0.001
CAT < 10 (low symptom burden) 56 (16.0) χ² = 142.3 <0.001
CAT ≥ 10 (high symptom burden) 294 (84.0) — —
mMRC 0–1 (mild dyspnea) 84 (24.0) χ² = 96.8 <0.001
mMRC ≥ 2 (moderate/severe dyspnea) 266 (76.0) — —
TABLE 5: Symptom burden assessment (N = 350)
Symptom scores are shown as mean ± SD or n (%). Comparisons between groups were performed using independent sample t-tests for continuous
outcomes and χ² tests for categorical outcomes. Test statistics and p-values are reported, with p < 0.05 considered significant.
CAT: COPD asssessment test; COPD: Chronic obstructive pulmonary disease; mMRC: Modified Medical Research Council; SD: Standard deviation; χ²:
Chi-square.
Discussion
This retrospective cohort study of 350 COPD patients demonstrates some significant insights into patient
demographics, severity of the disease, patient management patterns, and adherence to GOLD guidelines.
The average patient age was 61 years, and patients were mostly males (62.3%), which aligns with the well-
established international trend of COPD being more common in elderly people and males, especially in
places with high smoking prevalence. Most of the patients (77.7%) had a smoking history or had previously
smoked, whereas a large minority (22.3%) had no smoking history but had been exposed to biomass, which
supports the identification of household and environmental pollution as significant contributors to COPD,
particularly in low-and middle-income nations. The same outcome has been observed in former studies in
which biomass exposure was associated with a high rate of COPD among women in South Asia. This group
had a high prevalence of comorbidities, the most prevalent being hypertension, diabetes mellitus, and
ischemic heart disease. These results can be compared to the already known information that cardiovascular
and metabolic disorders commonly accompany COPD, affecting the burden of the disease and overall
prognosis. The multidimensional aspect of COPD with the presence of psychological comorbidities (anxiety
and depression) in close to 14% of patients also indicates that mental health problems can enhance the
perception of symptoms and decrease adherence to treatment. Some past research has highlighted that the
holistic management of COPD should focus on both physical and psychosocial spheres [16].
The outcomes of spirometry showed that close to three-quarters of the patients were at GOLD stage 3 or 4,
meaning that the disease was at an advanced stage at the time of presentation. Notably, after patients were
reclassified by the GOLD ABE system, nearly half were coded as GOLD E, which indicated high exacerbation
burden [17]. Past studies confirm this strategy and indicate that the frequency and intensity of exacerbation
alone are more effective predictors of hospitalization and mortality than airflow limitation alone. The
frequency of exacerbation was also notable in this cohort; 59% of patients reported two or more
exacerbations last year and 28% were hospitalized [18]. These findings demonstrate the dire clinical progress
of COPD in most patients as exacerbations closely correlate with rapid lung deterioration, diminished
quality of life, and elevated mortality. Previous studies have also indicated that exacerbation prevention is a
key objective of COPD management, and that the role of adherence to preventive interventions, such as drug
therapy, smoking cessation, and vaccination, should not be overlooked [19]. Nevertheless, a low percentage
(6.3%) of patients were treated with a short-acting bronchodilator alone, likely because of cost or disease
stage, indicating a gap in guideline-based practice. Previous experience suggests that resource-limited
settings are susceptible to under-treatment with maintenance therapy [20]. Non-pharmacological treatment
was inconsistently applied. Although almost all smokers received smoking cessation counseling, the
cumulative success rate of abstinence was 35.6%, illustrating the enduring problem of tobacco addiction.
The uptake of pulmonary rehabilitation was also poor (27.4%), although there is strong evidence that it
improves symptoms and functioning [21]. The majority of patients had high CAT scores and mMRC score of
2, indicating a significant burden of symptoms despite medication management. This is consistent with
previous evidence that even with the most effective inhaled therapy, many patients continue to exhibit
severe symptoms, highlighting the significance of multidimensional care strategies that incorporate
rehabilitation, psychological support, and comorbidity treatment. Overall, this study demonstrates that
while pharmacological management in our cohort generally followed GOLD recommendations, significant
gaps exist in non-pharmacological care, vaccination, and early detection. The predominance of advanced
disease stages suggests delays in diagnosis and intervention, which may partly explain the high exacerbation
rates observed. These findings echo previous research and reinforce the need for comprehensive, guideline-
2025 Umer et al. Cureus 17(11): e96190. DOI 10.7759/cureus.96190 7 of 9
driven, and multidisciplinary approaches to COPD care.
This study has several limitations. Being a single-center retrospective audit, it relied on the accuracy and
completeness of medical records, which may have introduced documentation bias. The absence of
longitudinal follow-up data limited assessment of treatment outcomes over time. Additionally, factors such
as medication adherence, socioeconomic status, and environmental exposure were not evaluated, which
could influence disease control. Moreover, a potential selection bias due to the predominance of advanced
(GOLD Group E) cases may limit the generalizability of findings to patients with earlier stages of COPD.
Additionally, as a retrospective descriptive study without multivariate or comparative analyses, causal
relationships could not be established.
Future studies should incorporate multicenter prospective designs with larger sample sizes, explore barriers
to non-pharmacological intervention uptake, and assess the impact of educational and rehabilitation
programs on patient outcomes. Implementation audits at regular intervals are also recommended to ensure
ongoing adherence to GOLD guidelines.
Conclusions
It is concluded that the majority of COPD patients in this cohort presented with advanced disease, high
symptom burden, and frequent exacerbations, reflecting delays in diagnosis and limitations in early
intervention. While pharmacological management largely adhered to GOLD recommendations, with
widespread use of dual and triple inhaled therapies, significant gaps were identified in the implementation
of non-pharmacological measures such as vaccination, pulmonary rehabilitation, and smoking cessation
success. The predominance of GOLD Group E patients highlights the critical need for proactive exacerbation
prevention strategies and stronger integration of preventive care.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Bilawal Ali, Abdullah Umer, Syed Asjad Ur Rehman Omer
Drafting of the manuscript: Bilawal Ali, Abdullah Umer, Muhammad Rasikh, Syed Asjad Ur Rehman
Omer, Ali Raza
Critical review of the manuscript for important intellectual content: Bilawal Ali, Abdullah Umer
Supervision: Bilawal Ali, Abdullah Umer, Muhammad Rasikh, Syed Asjad Ur Rehman Omer, Ali Raza
Acquisition, analysis, or interpretation of data: Muhammad Rasikh, Ali Raza
Disclosures
Human subjects: Informed consent for treatment and open access publication was obtained or waived by all
participants in this study. Animal subjects: All authors have confirmed that this study did not involve
animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all
authors declare the following: Payment/services info: All authors have declared that no financial support
was received from any organization for the submitted work. Financial relationships: All authors have
declared that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All authors have
declared that there are no other relationships or activities that could appear to have influenced the
submitted work.
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