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Sport concussion knowledge base, clinical practises
and needs for continuing medical education:
a survey of family physicians and cross-border
comparison
Constance M Lebrun,
1
Martin Mrazik,
2
Abhaya S Prasad,
3
B Joel Tjarks,
4
Jason C Dorman,
5
Michael F Bergeron,
5
Thayne A Munce,
5
Verle D Valentine
5
▸Additional data are published
online only. To view these files
please visit the journal online
(http://dx.doi.org/10.1136/
bjsports-2012-091480).
1
Department of Family
Medicine, Faculty of Medicine &
Dentistry, Glen Sather Sports
Medicine Clinic, Edmonton
Clinic, Level 2, 11400 University
Avenue, University of Alberta,
Edmonton, Alberta, Canada
2
Department of Educational
Psychology, Faculty of
Education, University of Alberta,
Edmonton, Alberta, Canada
3
School of Public Health,
University of Alberta,
Edmonton, Alberta, Canada
4
Sanford School of Medicine,
University of South Dakota,
Vermillion, South Dakota, USA
5
Orthopedics and Sports
Medicine, Sanford USD Medical
Center, Sioux Falls, South
Dakota, USA
Correspondence to
Dr Constance M Lebrun,
Department of Family Medicine,
Faculty of Medicine & Dentistry,
Glen Sather Sports Medicine
Clinic, Edmonton Clinic, Level 2,
11400 University Avenue,
University of Alberta,
Edmonton, Alberta, Canada T6G
1Z1; ConnieLebrun@med.
ualberta.ca
Accepted 29 October 2012
ABSTRACT
Context Evolving concussion diagnosis/management
tools and guidelines make Knowledge Transfer and
Exchange (KTE) to practitioners challenging.
Objective Identify sports concussion knowledge base
and practise patterns in two family physician populations;
explore current/preferred methods of KTE.
Design A cross-sectional study.
Setting Family physicians in Alberta, Canada (CAN) and
North/South Dakota, USA.
Participants CAN physicians were recruited by mail:
2.5% response rate (80/3154); US physicians through a
database: 20% response rate (109/545).
Intervention/instrument Online survey.
Main and secondary outcome measures Diagnosis/
management strategies for concussions, and current/
preferred KTE.
Results Main reported aetiologies: sports/recreation
(52.5% CAN); organised sports (76.5% US). Most
physicians used clinical examination (93.8% CAN, 88.1%
US); far fewer used the Sport Concussion Assessment Tool
(SCAT1/SCAT2) and balance testing. More US physicians
initially used concussion-grading scales (26.7% vs 8.8%
CAN, p=0.002); computerised neurocognitive testing
(19.8% vs 1.3% CAN; p<0.001) and Standardised
Assessment of Concussion (SAC) (21.8% vs 7.5% CAN;
p=0.008). Most prescribed physical rest (83.8% CAN,
75.5% US), while fewer recommended cognitive rest
(47.5% CAN, 28.4% US; p=0.008). Return-to-play
decisions were based primarily on clinical examination
(89.1% US, 73.8% CAN; p=0.007); US physicians relied
more on neurocognitive testing (29.7% vs 5.0% CAN;
p<0.001) and recognised guidelines (63.4% vs 23.8%
CAN; p<0.001). One-third of Canadian physicians received
KTE from colleagues, websites and medical school training.
Leading KTE preferences included Continuing Medical
Education (CME) courses and online CME.
Conclusions Existing published recommendations
regarding diagnosis/management of concussion are not
always translated into practise, particularly the
recommendation for cognitive rest; predicating enhanced,
innovative CME initiatives.
BACKGROUND/INTRODUCTION
Sport-related concussions have received escalating
attention over the last decade, as they have both
immediate and potentially cumulative
health-related effects.
12
Prevalent in recreational
and competitive sports, concussion is a major
public health concern worldwide. The Centre for
Disease Control and Prevention (CDC) considers
concussions to be at an ‘epidemic level’in the
USA, with an estimated 1.6−3.8 million mild trau-
matic brain injuries (mTBI) occurring annually.
3
A recent review of hospital Emergency records
from Edmonton and the surrounding area in
Alberta, Canada documented 63 219 visits for
sports or recreation injuries in persons aged 0–
35 years, over a 10-year span. Head injuries (includ-
ing concussions) accounted for 4935 or 7.8% of
these visits, with over 70% of these occurring in
individuals under 18 years of age.
4
Other studies
report similarly alarming numbers.
5–7
According to
McCrory,
8
‘short-term’concussion disabilities
(affecting mood, memory and concentration) may
last months, with detrimental effects on quality of
life at home, school, work and sports. Randolph
9
identified potential risks from incurring multiple
concussions or repetitive head trauma, especially
when one or more subsequent concussions occur
proximate to the previous one(s): death or perman-
ent neurological injury, delayed or atypical recovery
and persistent late-life effects.
Specific to the paediatric population, Emergency
Departments in the USA have seen a tripling of
visits for concussions by the 14-year-old to
19-year-old age group between 1997 and 2007.
3
Overall, approximately 3–8% of sport-related injur-
ies in young athletes arriving in Emergency
Departments in large Canadian cities are concus-
sions. This trend is alarming, and mandates a more
deliberate and conservative management.
5
DIAGNOSIS AND MANAGEMENT
OF CONCUSSIONS
There have been considerable recent advances in
the diagnosis, classification and management of
sport-related concussions
10
; but with insufficient
knowledge transfer to end-users, there is often con-
fusion among providers. Greater clinical and scien-
tific appreciation of concussion effects and recovery
time, newly adopted legislation (such as the
Zackery Lystedt or similar state laws)
11
and revised
management guidelines
12
all have significantly
increased attention from the media and healthcare
organisations. However, with multiple sources of
available information and significant revisions to
practise standards, it remains challenging for
healthcare professionals to remain well informed of
relevant new evidence-based information.
Br J Sports Med 2012;0:1–6. doi:10.1136/bjsports-2012-091480 1
Occasional piece
BJSM Online First, published on November 23, 2012 as 10.1136/bjsports-2012-091480
Copyright Article author (or their employer) 2012. Produced by BMJ Publishing Group Ltd under licence.
In 1966, the Congress of Neurological Surgeons defined a
concussion as ‘a clinical syndrome characterised by immediate
and transient post-traumatic impairment in neural function,
such as alteration of consciousness, disturbance of vision, equi-
librium, etc. due to brain stem involvement due to mechanical
forces’.
13
Over time, lack of uniformity in the definition and
understanding of concussions led to an array of complexities in
identification, diagnosis and management. At one point, there
were at least 17 different concussion-grading systems and
guidelines—none scientifically validated.
Advancement in the field required a consensus definition of a
concussion and strict parameters for diagnosis and
return-to-sport participation after injury. In 2002, a multidiscip-
linary team of professionals formed the Concussion in Sport
Group and created a definition for concussion that included clin-
ical, pathological and biokinetic aspects.
14
This group met in
Prague in 2004, and developed a revised set of definitions, guide-
lines and recommendations.
15
In 2008, a third International
Consensus meeting in Zurich, Switzerland yielded a further revi-
sion of the consensus statement;
16
containing the most
up-to-date recommendations for diagnosis and management of
concussions. A fourth Consensus Conference (November 2012)
will likely result in further updates.
Subsequently, numerous national groups, including both
American and Canadian organisations,
17–24
have developed
their own specific guidelines. Common to all is a multifaceted,
multidisciplinary approach to the concussed athlete: immediate
sideline assessment, removal from play, evaluation by a suitably
trained physician and some form of serial neurocognitive testing
and assessment of balance/postural control. Initial management
includes both physical and cognitive rest, until symptom reso-
lution. Student-athletes may require additional special accom-
modations.
25
Return-to-play follows a graduated pattern, with
increasing levels of symptom-free activities.
The most recent clinical tool from this group includes the
Sport Concussion Assessment Tool 2 (SCAT2),
26
which incor-
porates self-report symptom scores,
27 28
the simple
Standardised Assessment of Concussion (SAC)
29
and measure-
ment of balance.
30
Computerised neurocognitive testing
decreases practise effects by using multiple versions; and pre-
cisely measures reaction time, as well as percentage of correct
and incorrect answers.
31–33
Most commonly utilised in North
America is the Immediate Post-Concussion Assessment and
Cognitive Test (ImPACT); other similarly designed tests, such
as CogSport, Automated Neuropsychological Assessment
Metrics (ANAM) and HeadMinder are also used. ImPACT
scores are even being utilised to prognosticate a prolonged
recovery from a concussion.
34 35
Some normative values exist
for ImPACT and for SCAT2 at the collegiate
36
and high-school
levels.
37 38
Importantly, baseline testing for both SCAT2 and
ImPACT is recommended to increase utility in management of
concussion and return-to-play decisions. Accurate analysis of
computerised test results for validity (by a suitably trained pro-
fessional) is also essential. Although neuropsychological testing
for a concussion is recognised and informative, some clinicians
caution against over-enthusiastic reliance on these tests.
39 40
KNOWLEDGE TRANSFER AND EXCHANGE
Notably, there has been a lag in effective communication and
knowledge transfer in this area to healthcare professionals,
coaches and athletes.
41
As such, the committee in Zurich iden-
tified Knowledge Transfer and Exchange (KTE) as critical for
dissemination of new information and to inform evidence-
based practise.
42
The needs and optimal learning styles for
physicians, physiotherapists and athletic trainers, coaches and
student athletes are not uniform; therefore, different and indivi-
dualised strategies for concussion education must be employed.
A recent update to the Team Physician Consensus Statement (a
document co-written by six different member societies) pro-
vides both essential and desirable knowledge parameters regard-
ing diagnosis and management of concussions.
12
However,
educational efforts must be targeted towards the ‘gatekeeper’
of the system, the family physician.
Previous small surveys conducted with primary care provi-
ders,
43 44
athletic trainers
45 46
and Emergency room physicians,
47
have examined practise patterns and concussion knowledge, and
documented some definite gaps and information needs. Bazarian
et al
43
showed that many primary care doctors were unaware of
the existing concussion management guidelines, and only 20%
used them; however, this was at a time when multiple guidelines
were being promoted. Among primary care providers in the state
of Maine, 68.4% used published guidelines; of those who did
not, a lack of awareness was a barrier to guideline use (71.6%).
44
An additional 16% reported not using published guidelines
because they found them confusing.
In surveys of certified athletic trainers,
45 46
their own (NATA)
position statement
17
was the most widely used for managing
concussions (61%) and making return-to-play decisions (47%).
However, approximately two-thirds of participants (66.4%) in
one study had not heard of the then current recommendations
(the Vienna guidelines), and the majority (85.9%) did not use
them.
45
In a population of Emergency physicians in Michigan,
surveys were returned by 36/49 (74%) of attending physicians
and 37/38 (97%) of resident Emergency Medicine physicians.
Of the total of 73 respondents, only 23% used a nationally
recognised guideline, with no significant difference between
attending and resident Emergency physicians.
47
Most recently, a Canadian survey at the University of
Toronto asked graduating medical students and neurology/
neurosurgery residents nine specific questions regarding diagno-
sis and management of concussions.
48
Residents (25/80 or 31%
response rate) provided significantly more correct answers than
medical students (52/222 or 23% response rate). Twenty-four
per cent of the medical students (n=18) did not think that
‘every concussed individual should see a physician’as part of
concussion management. Eight per cent of students and resi-
dents (n=6) answered that they had never learnt about concus-
sions in their medical education; furthermore, 24% (n=18)
could not even remember if they had ever learnt about concus-
sions during their undergraduate medical education.
Athletes, parents and coaches have also been shown to exhibit
serious deficiencies in concussion knowledge,
49–52
despite the
development of educational injury prevention programmes, such
as the ThinkFirst Canada, Smart Hockey and a brain and spinal
cord injuries prevention video.
53
The importance of the family
physician as a knowledge provider for coaches in particular has
been highlighted: 36% of respondents in one study reported
receiving information from family physicians about concussions;
this was generally viewed as the most helpful source of informa-
tion.
41
A strong majority of these coaches (99%) would recom-
mend that any athlete who suffers a head injury should see a
family physician. In another study of concussions understanding
and management among New England high-school football
coaches, 70–95% of coaches reported that they would consult a
healthcare professional before allowing a player to return to
action, consistent with contemporary return-to-play guidelines.
54
Therefore, it is paramount to incorporate knowledge transfer
strategies when informing family physicians of current
2Br J Sports Med 2012;0:1–6. doi:10.1136/bjsports-2012-091480
Occasional piece
concepts in diagnosis and management of concussions.
42
The
CDC has previously documented favourable changes in knowl-
edge, attitudes and practises towards the prevention and man-
agement of concussions behaviour with their initiative and a
tool kit for high-school coaches: ‘Heads Up: Concussion in
high-school sports’.
55 56
They assembled a similar comprehen-
sive multimedia toolkit specifically for physicians, and subse-
quently looked at practises in an intervention (n=183) and a
control group (n=231) of paediatricians, family physicians and
internists, either prior to, or after receiving the Tool Kit via mail
(with no accompanying instructions).
57
There were no differ-
ences in general concussion knowledge between groups, but
physicians in the intervention group were significantly less
likely to recommend next day return-to-play after a concussion
(adjusted OR=0.31, 95% CI 0.12 to 0.76). Thus, it can be seen
that there has been relatively little systematic evaluation of the
impact of these and other resources on knowledge transfer and
exchange to family physicians.
SCOPE
This research therefore examined current knowledge regarding
concussions and clinical management strategies in two distinct
populations of family physicians in Alberta, Canada and in
North and South Dakota in the USA. These sites were chosen
to compare two groups that treat the same condition, but
whose training may be different. They have two different
primary care organisations, variations in medical school, resi-
dency and fellowship training and differing cultural back-
grounds; all of which present potential for variable education
on the diagnosis and management of sports concussions. The
present and preferred sources of information were elicited from
these practitioners, with a view towards identifying and facili-
tating optimal KTE delivery methods. Future projects should
involve further development of such initiatives, dissemination
to the appropriate populations and follow-up surveys to assess
and evaluate both retention and the impact of such KTE train-
ing on physicians’practises.
METHODS/PROCEDURES
A brief survey questionnaire (21 questions) on sport-related con-
cussions was developed and put online using the SurveyGizmo.
The majority of the questions were closed, with multiple
responses permitted in some cases, and open text only allowed to
clarify the original response(s). In Alberta, Canada (CAN), the
research protocol required that recruitment letters be distributed
through the Alberta Family Practice Research Network (AFPRN),
inviting interested family physicians to either fax or email back
consent; following which, they were sent the survey link. No
further follow-up letters or phone calls were allowed. Eighty of
3154 family physicians (2.5%) responded.
A similar internet-based survey was directly distributed to
545 family physicians in North Dakota and South Dakota,
USA identified through the American Academy of Family
Physicians (AAFP) database. One hundred nine of these physi-
cians completed the survey (20% response rate). Descriptive
and frequency statistics were conducted using the SPSS statis-
tical software (V.19.0). Responses from the two populations of
family physicians were compared with STATA (V.10.0) using
test of proportions, with a statistical significance set at p<0.05.
There were minor variations between the two surveys (due to
geographical and cultural differences); certain responses and
questions were omitted from analyses if they only existed in one
survey.
RESULTS
While results in both groups were similar in many aspects
(table 1), there were notable differences in some responses
between the two different geographical regions.
The majority of these physicians (96.3% CAN, 94.5% US)
reported diagnosing and treating concussions in their work set-
tings. Significantly more US than CAN family physicians
worked in rural settings. This is likely the reason for the 13.9%
US who reported working in Emergency rooms; in rural areas,
family physicians more frequently do Emergency room shifts,
than in urban settings. If this number is added to those
working in walk-in or acute care settings (12.9%), the total per-
centage (26.8%) is not substantially different from the 28.8% of
CAN physicians who reported that work setting. The main
aetiologies of concussions seen (physician recall of patient
interviews) were reported to be sports/recreation (52.5% CAN)
and/or organised sports (76.5% US). The questionnaires given
to each group did differ slightly in responses to this question.
Initial concussion management methods by both groups
were similar (table 2), with several significant exceptions: more
US than Canadian physicians still tended to use (outdated)
concussion-grading scales; but interestingly, a larger percentage
also incorporated computerised neurocognitive testing.
Significantly, only 9.4% of US physicians reported using the
recent Zurich Guidelines for diagnosis and management of con-
cussions. Approximately one-quarter of each group also
included some form of balance testing.
For treatment, most Canadian (83.8%) and US (75.5%) physi-
cians always recommended physical rest; while far fewer
advised cognitive rest (47.5% CAN, 28.4% US; p=0.008).
Physicians relied primarily on clinical examination and player
self-report of symptoms for return-to-play decisions (table 3);
Table 1 Demographic information
Canadian physicians (CAN) US physicians (US)
Years practising post-residency
<5 25.0% 18.6%
5–10 21.3% 11.8%
10–15 17.5% 19.6%
>10 36.3% −
>15 −50.0%
Region of practise
Rural (<20 000) 27.5% 64.4%*
Urban (>20 000) 72.5% 35.6%*
Current work setting
Private clinical practise 67.5% −
Academic practise 7.5% 7.9%
Primary care network (PCN) 63.8% −
Solo practise 6.3% 4.0%
Group practise 65.0% 62.4%
Walk-in or acute care 28.8% 12.9%**
Employed health system 1.3% −
Emergency room −13.9%
Other 15.0% 5.9%
Fellowship in sports medicine?
No 95.0% 95.0%
Yes, 1 year 3.8% 4.0%
Yes, 2 year 1.3% −
Other −1.0%
−Indicates that this part of the question was different between the two surveys.
*p<0.001.
**p=0.008.
Br J Sports Med 2012;0:1–6. doi:10.1136/bjsports-2012-091480 3
Occasional piece
notably, there were disproportionally more US physicians who
also utilised computerised neurocognitive testing, and published
guidelines. Further subset analysis did not yield any obvious
reasons for these differences; but this interpretation was
limited due to a small overall sample size, and in particular, the
low CAN response rate.
The majority of respondents (84.0–93.8%) indicated their
desire for additional education on concussions. More Canadian
physicians sought information about concussions through con-
sultation with colleagues (31.3% CAN, 8.8% US; p<0.001),
from websites (27.5% CAN, 15.7% US; p=0.052) or had
received medical school training (35% CAN, 12.7% US;
p<0.001). With many physicians already taking continuing
medical education (CME) credits to increase knowledge; CME
courses (65% CAN, 37.3% US, p<0.001) and online CME in
particular (47.5% CAN, 29.4% US; p=0.012) were rated as the
recognised and desired preferred resource and delivery mechan-
ism for continuing education.
DISCUSSION
This study sought to measure knowledge, clinical practise and
CME needs of family physicians in two regions in North
America. A larger proportion of the US physician respondents
were in rural settings, but no significant correlations were
found with any of the other outcome measures; and the
numbers were too small to draw any firm conclusions. In com-
parison, a recent survey of concussions evaluation methods
among Washington State high-school football coaches and ath-
letic trainers (30% response rate) found that those in urban
schools were more likely than those in rural schools to use
SCAT2 and neurocognitive testing.
58
It is clear that concussion
management is a relevant topic, as over 95% of family physi-
cians see, assess and treat concussions but there appears to be
variance in the base knowledge level and management strat-
egies. It was concerning that only 9.4% of the US physicians
used the Zurich Guidelines, widely considered to be the most
up-to-date. Furthermore, 11.3% of Canadian and 11.9% of US
physicians reported using grading scales (outdated since 2002)
to make return-to-play decisions. In addition, less than half of
CAN and US physicians always advocated cognitive rest, when
current recommendations include both physical and cognitive rest
as cornerstones of effective concussion management.
These data, however, also contained positive signs. Over half
of surveyed family physicians reported recent CME on
sport-related concussions. An overwhelming majority desired
further education, suggesting strong interest in having
up-to-date information. Accordingly, there is significant poten-
tial to use high-quality educational tools to fine-tune knowl-
edge and clinical practise. It was encouraging to see that 90%
of these physicians relied upon physical examination skills for
clinical decision making, and 96% recommended physical rest
in their initial management of concussions.
We recognise several limitations to this survey-based study.
The response rate of 20% in the states of North and South
Dakota is low, but more typical of online surveys. The 2.5%
response rate in Alberta likely does not represent reliable sam-
pling of family physicians in this area. This problem has previ-
ously been addressed by regional researchers using the same
research network, who had an overall response rate of only 7%
in their survey of 2572 primary care physicians regarding man-
agement of asthma, a more commonly seen condition that
might attract more interest than concussions.
59
They suggested
the use of the modified Dillman method
60
(which was pre-
cluded here by the additional high cost of a second mailout), or
else purposeful sampling and focused targeted surveys. In add-
ition to larger surveys, which could also include other primary
care providers, such as paediatricians, physiatrists and
Emergency room physicians; it would be worthwhile to engage
focus groups of key informants (eg, family physicians represent-
ing urban or rural groups; new graduates or older, more experi-
enced physicians) to qualitatively assess perceived gaps, and to
explore means of bridging them in terms of knowledge
dissemination.
Because of the differing response rates between surveyed
CAN and US physicians, comparisons of their responses pro-
vides initial insight only, and cannot be generalised to the
larger population of family physicians in either area. Inherent
methodological limitations for our study may have also
included volunteer bias, recall bias and bias related to perceived
desirability of responses. Most notably, it only measured
Table 3 Preferred tools for return-to-play decision making
Canada Rank* % USA Rank % p Value
Clinical examination 59 1 73.8 90 1 89.1 0.007
Balance testing†16 5 20 28 6 27.7 0.230
Neurocognitive testing 4 9 5 30 5 29.7 <0.001
Player self-report 48 2 60 52 3 51.5 0.253
Symptom checklist 43 3 53.8 51 4 50.5 0.659
Sport concussion
assessment tool
(SCAT1 or SCAT2)
––23 7 22.8 –
Standardised
assessment of
concussion (SAC)
––411 4 –
Concussion grading 9 6 11.3 12 8 11.9 0.900
Head CT/brain MRI 7 7 8.8 10 9 9.9 0.963
Return-to-play
guidelines
19 4 23.8 64 2 63.4 <0.001
Other 6 8 7.5 6 10 5.9 0.667
Total 80 101
*Rank refers to the % of physicians choosing this response; multiple choices were
allowed.
†Romberg, Balance Error Score System, Neurocom Balance Master.
Table 2 Initial concussion management method/tools
Canada Rank* % USA Rank % p Value
Sport concussion
assessment tool
(SCAT1 or SCAT2)
27 2 33.8 27 2 26.7 0.300
Clinical exam 75 1 93.8 89 1 88.1 0.192
Balance testing†20 3 25 27 2 26.7 0.796
Concussion grading
scale
7 4 8.8 27 2 26.7 0.002
Computerised
neurocognitive testing
1 7 1.3 20 6 19.8 <0.001
Paper and pencil
neurocognitive testing
1 7 1.3 3 7 3 0.444
Standardised
Assessment of
Concussion (SAC)
6 5 7.5 22 5 21.8 0.008
Other 4 6 5 3 7 3 0.489
Total 80 101
*Rank refers to the % of physicians choosing this response; multiple choices were
allowed.
†Romberg, Balance Error Score System, Neurocom Balance Master.
4Br J Sports Med 2012;0:1–6. doi:10.1136/bjsports-2012-091480
Occasional piece
physicians’responses, not actual implementation. Furthermore,
this research did not elucidate underlying factors that might
influence practise patterns and behaviours.
CONCLUSIONS
Despite the wide availability of published guidelines emphasis-
ing up-to-date practises for clinical diagnosis and treatment of
sport-related concussions, our survey provides some initial indi-
cations that family physicians may be managing sport-related
concussions using practises inconsistent with current informa-
tion and recommendations. Accordingly, more deliberate educa-
tional efforts and training opportunities for family physicians
(KTE) are needed to optimise physician management of this
common condition, enhancing patient care in this population.
Contributors CML designed the study, provided expert content review of the
questionnaire and data interpretation, and wrote the draft manuscript. MM also
participated in the project and questionnaire design, data interpretation and review of
the manuscript. ASP formatted the online survey questionnaire, collected and
analysed the Canadian data and contributed to final data interpretation and approval
of the manuscript. BJT assisted with project design, acquisition of data in the US
group, revision of the article and approval of the final version. JCD, MFB and TAM
assisted with data interpretation, initial draught development, edits and critical
revisions of the manuscript content, clarity and flow; as well as responses to
reviewers and the final approval. VDV provided input on initial project design, expert
content review of the questionnaire, facilitation of Ethics/IRB Review at his institution
and project supervision. He assisted with data interpretation, revisions to the
manuscript and the final approval.
Funding None.
Competing interests None.
Ethics approval University of Alberta Research Health Ethics Board; Sanford
Research Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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