{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T11:24:06Z","timestamp":1793273046116,"version":"4.5.0"},"reference-count":32,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100009827","name":"Alexandria University","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100009827","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Neurosurg Rev"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    Background: Although external ventricular drains (EVDs) are crucial in neurosurgical care, they carry a high risk of healthcare-associated ventriculitis, with reported infection rates. Numerous interventions were thought to aid in infection control, but there is still an ongoing increase in infection incidence. Recently, bundled interventions with standardized protocols, antimicrobial\u2010impregnated catheters, tunneling techniques, chlorhexidine dressings, and limited antibiotic prophylaxis have shown an interesting efficacy in shunt-related infection control. Methods: A systematic review was conducted using PubMed, Scopus, Google Scholar, Cochrane CENTRAL, and Web of Science to search for published articles on care bundles with at least three discrete preventive measures. Data analysis was performed using R software, estimating mean difference and risk ratios. Results: Seventeen studies (9 quasi-experimental, 6 retrospective, and 2 prospective cohorts) were included in this study. Implementation of bundle care was associated with a significant reduction in the following outcomes: infection risk and drain stay duration (pooled RR\u2009=\u20090.32; 95% CI 0.20\u20130.51;\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.0001; I\u00b2=73.7%), (pooled MD=-1.57; 95% CI -5.80\u20132.67;\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.0038; I\u00b2=0%), respectively. Interestingly, there was no significant difference in risk with bundle of care regarding mortality (pooled RR\u2009=\u20091.09; 95% CI 0.62\u20131.92;\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.6924; I\u00b2=63.5%). However, no significant differences were observed in ventriculitis rates or hospital stay duration, with\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.0509,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.3855, respectively. Conclusions: Bundle of care implementation significantly reduced infection risk and drain days among patients with external ventricular drains, but failed to reduce ventriculitis, mortality, and hospital stay duration. These findings support approving standardized care bundles to improve outcomes, though further high-quality research is needed to assess their impact on specific complications like ventriculitis, mortality, and hospital stay.\n                  <\/jats:p>","DOI":"10.1007\/s10143-025-04029-4","type":"journal-article","created":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:46:40Z","timestamp":1768783600000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Is there a way to reduce the infection associated with external ventricular shunts? A systematic review and meta-analysis of the recent bundle of care"],"prefix":"10.1007","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1543-0690","authenticated-orcid":false,"given":"Moustapha","family":"Ramadan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6675-0678","authenticated-orcid":false,"given":"Shrouk Fawze","family":"Mohamed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-6780-772X","authenticated-orcid":false,"given":"Ahmed A.","family":"Abdulalim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-0317-8713","authenticated-orcid":false,"given":"Anas Ashraf","family":"Elassal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-2343-8482","authenticated-orcid":false,"given":"Aya","family":"Abdelsamad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-4794-9801","authenticated-orcid":false,"given":"Belal","family":"Shehata","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-3915-0774","authenticated-orcid":false,"given":"Yasmeen","family":"Farag","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-4130-3321","authenticated-orcid":false,"given":"Mohamed","family":"Elshaer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6647-8611","authenticated-orcid":false,"given":"Samar","family":"Kolkas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-8274-4634","authenticated-orcid":false,"given":"Nesrine Fathi","family":"Hanafi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,19]]},"reference":[{"key":"4029_CR1","doi-asserted-by":"publisher","DOI":"10.3390\/jcm8091422","author":"CYC Chau","year":"2019","unstructured":"Chau CYC, Craven CL, Rubiano AM, Adams H, T\u00fcl\u00fc S, Czosnyka M et al (2019) The evolution of the role of external ventricular drainage in traumatic brain injury. J Clin Med. https:\/\/doi.org\/10.3390\/jcm8091422","journal-title":"J Clin Med"},{"key":"4029_CR2","doi-asserted-by":"publisher","DOI":"10.1007\/s00701-024-06166-z","author":"TJ Hallenberger","year":"2024","unstructured":"Hallenberger TJ, Tharmagulasingam T, Licci M, Mariani L, Guzman R, Soleman J (2024) Management of external ventricular drain: to wean or not to wean? Acta Neurochir (Wien). https:\/\/doi.org\/10.1007\/s00701-024-06166-z","journal-title":"Acta Neurochir (Wien)"},{"key":"4029_CR3","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1177\/1941874416663281","volume":"7","author":"A Lewis","year":"2017","unstructured":"Lewis A, Czeisler BM, Lord AS (2017) Variations in strategies to prevent Ventriculostomy-Related infections. Neurohospitalist 7:15\u201323. https:\/\/doi.org\/10.1177\/1941874416663281","journal-title":"Neurohospitalist"},{"key":"4029_CR4","doi-asserted-by":"publisher","first-page":"296","DOI":"10.1080\/02688690600999901","volume":"20","author":"D Dasic","year":"2006","unstructured":"Dasic D, Hanna SJ, Bojanic S, Kerr RSC (2006) External ventricular drain infection: the effect of a strict protocol on infection rates and a review of the literature. Br J Neurosurg 20:296\u2013300. https:\/\/doi.org\/10.1080\/02688690600999901","journal-title":"Br J Neurosurg"},{"key":"4029_CR5","doi-asserted-by":"publisher","DOI":"10.1186\/s12941-023-00612-z","author":"M Rojas-Lora","year":"2023","unstructured":"Rojas-Lora M, Corral L, Zabaleta-Carvajal I, L\u00f3pez-Ojeda P, Fuentes-Mila V, Romera-Peregrina I et al (2023) External ventriculostomy-associated infection reduction after updating a care bundle. Ann Clin Microbiol Antimicrob. https:\/\/doi.org\/10.1186\/s12941-023-00612-z","journal-title":"Ann Clin Microbiol Antimicrob"},{"key":"4029_CR6","doi-asserted-by":"publisher","first-page":"368","DOI":"10.1016\/j.jhin.2024.07.004","volume":"162","author":"AYT De Andrade","year":"2025","unstructured":"De Andrade AYT, Canicoba ARB, Oliveira RA, Gnatta JR, de Brito Poveda V (2025) Risk factors for infection associated with the use of external ventricular drainage: a systematic review with meta-analysis. J Hosp Infect 162:368\u2013376. https:\/\/doi.org\/10.1016\/j.jhin.2024.07.004","journal-title":"J Hosp Infect"},{"issue":"4","key":"4029_CR7","doi-asserted-by":"publisher","DOI":"10.1212\/CPJ.0000000000200156","volume":"13","author":"J Zhou","year":"2023","unstructured":"Zhou J, Zhong Y, Li X, Li H, Wang J, Yang S et al (2023) Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis. Neurol Clin Pract 13(4):e200156. https:\/\/doi.org\/10.1212\/CPJ.0000000000200156","journal-title":"Neurol Clin Pract"},{"key":"4029_CR8","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3171\/2014.12.JNS14908","volume":"122","author":"\u0391 Konstantelias","year":"2015","unstructured":"Konstantelias \u0391, Vardakas K, Polyzos K, Tansarli G, Falagas M (2015) Antimicrobial-impregnated and -coated shunt catheters for prevention of infections in patients with hydrocephalus: a systematic review and meta-analysis. J Neurosurg 122:1\u201317. https:\/\/doi.org\/10.3171\/2014.12.JNS14908","journal-title":"J Neurosurg"},{"key":"4029_CR9","doi-asserted-by":"publisher","unstructured":"Cui Z, Wang B, Zhong Z, Sun Y, Sun Q, Yang G et al (2015) 1;43(7):e23-32 Impact of antibiotic- and silver-impregnated external ventricular drains on the risk of infections: A systematic review and meta-analysis. Am J Infect Control. https:\/\/doi.org\/10.1016\/j.ajic.2015.03.015","DOI":"10.1016\/j.ajic.2015.03.015"},{"key":"4029_CR10","doi-asserted-by":"publisher","unstructured":"Blacker SN, Prabhakar H, Moreton EO, Burbridge M, Dunn L, Gouker LN et al (2025) Effect of bundled care on external ventricular drain infections: A systematic review and Meta-analysis. J Neurosurg Anesthesiol 17. https:\/\/doi.org\/10.1097\/ANA.0000000000001071","DOI":"10.1097\/ANA.0000000000001071"},{"key":"4029_CR11","doi-asserted-by":"publisher","unstructured":"Kubilay Z, Amini S, Fauerbach L, Archibald L, Friedman W, Layon A (2012) Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution. J Neurosurg 118. https:\/\/doi.org\/10.3171\/2012.11.JNS121336","DOI":"10.3171\/2012.11.JNS121336"},{"key":"4029_CR12","doi-asserted-by":"publisher","first-page":"n71","DOI":"10.1136\/bmj.n71","volume":"372","author":"MJ Page","year":"2021","unstructured":"Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https:\/\/doi.org\/10.1136\/bmj.n71","journal-title":"BMJ"},{"key":"4029_CR13","doi-asserted-by":"publisher","first-page":"550","DOI":"10.5137\/1019-5149.JTN.26864-19.3","volume":"30","author":"N Ates","year":"2020","unstructured":"Ates N, Kafadar A, Aygun G, Yildirim A (2020) Usage of a bundle application process in decreasing ventriculoperitoneal shunt infections. Turk Neurosurg 30:550\u2013556. https:\/\/doi.org\/10.5137\/1019-5149.JTN.26864-19.3","journal-title":"Turk Neurosurg"},{"key":"4029_CR14","doi-asserted-by":"publisher","DOI":"10.3346\/jkms.2023.38.e386","author":"YH Choo","year":"2023","unstructured":"Choo YH, Shim Y, Kim H, Goh HY, Kim SJ, Kim EJ et al (2023) Significant reduction in external ventricular drain-related infections after introducing a novel bundle protocol: a before and after trial. J Korean Med Sci. https:\/\/doi.org\/10.3346\/jkms.2023.38.e386","journal-title":"J Korean Med Sci"},{"key":"4029_CR15","doi-asserted-by":"publisher","first-page":"993","DOI":"10.1227\/NEU.0b013e31828e8dfd","volume":"72","author":"AC Flint","year":"2013","unstructured":"Flint AC, Rao VA, Renda NC, Faigeles BS, Lasman TE, Sheridan W (2013) A simple protocol to prevent external ventricular drain infections. Neurosurgery 72:993\u2013999. https:\/\/doi.org\/10.1227\/NEU.0b013e31828e8dfd","journal-title":"Neurosurgery"},{"key":"4029_CR16","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0050708","author":"EF Camacho","year":"2013","unstructured":"Camacho EF, Boszczowski \u00cd, Freire MP, Pinto FCG, Guimaraes T, Teixeira MJ et al (2013) Impact of an educational intervention implanted in a neurological intensive care unit on rates of infection related to external ventricular drains. PLoS One. https:\/\/doi.org\/10.1371\/journal.pone.0050708","journal-title":"PLoS One"},{"key":"4029_CR17","doi-asserted-by":"publisher","first-page":"647","DOI":"10.1007\/s00701-010-0905-1","volume":"153","author":"M Rivero-Garv\u00eda","year":"2011","unstructured":"Rivero-Garv\u00eda M, M\u00e1rquez-Rivas J, Jim\u00e9nez-Mej\u00edas ME, Neth O, Rueda-Torres AB (2011) Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters. Acta Neurochir (Wien) 153:647\u2013651. https:\/\/doi.org\/10.1007\/s00701-010-0905-1","journal-title":"Acta Neurochir (Wien)"},{"key":"4029_CR18","doi-asserted-by":"publisher","unstructured":"Hong B, Apedjinou A, Heissler HE, Chaib H, Lang JM, Al-Afif S et al Effect of a bundle approach on external ventricular drain-related infection n.d. https:\/\/doi.org\/10.1007\/s00701-020-04698-8\/Published","DOI":"10.1007\/s00701-020-04698-8\/Published"},{"key":"4029_CR19","doi-asserted-by":"publisher","DOI":"10.1016\/j.clineuro.2019.105641","author":"C Whyte","year":"2020","unstructured":"Whyte C, Alhasani H, Caplan R, Tully AP (2020) Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance. Clin Neurol Neurosurg. https:\/\/doi.org\/10.1016\/j.clineuro.2019.105641","journal-title":"Clin Neurol Neurosurg"},{"key":"4029_CR20","doi-asserted-by":"publisher","first-page":"e814","DOI":"10.1016\/j.wneu.2019.04.261","volume":"128","author":"J Sweeney","year":"2019","unstructured":"Sweeney J, Zyck S, Tovar-Spinoza Z, Krishnamurthy S, Chin L, Bodman A (2019) Evidence-based perioperative protocol for ventriculoperitoneal shunt infection reduction at a single institution. World Neurosurg 128:e814\u2013e822. https:\/\/doi.org\/10.1016\/j.wneu.2019.04.261","journal-title":"World Neurosurg"},{"key":"4029_CR21","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1080\/02688697.2020.1725436","volume":"34","author":"SS Talibi","year":"2020","unstructured":"Talibi SS, Silva AHD, Afshari FT, Hodson J, Roberts SAG, Oppenheim B et al (2020) The implementation of an external ventricular drain care bundle to reduce infection rates. Br J Neurosurg 34:181\u20136. https:\/\/doi.org\/10.1080\/02688697.2020.1725436","journal-title":"Br J Neurosurg"},{"key":"4029_CR22","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1097\/CCM.0b013e31829a70a5","volume":"42","author":"M Chatzi","year":"2014","unstructured":"Chatzi M, Karvouniaris M, Makris D, Tsimitrea E, Gatos C, Tasiou A et al (2014) Bundle of measures for external cerebral ventricular drainage-associated ventriculitis. Crit Care Med 42:66\u201373. https:\/\/doi.org\/10.1097\/CCM.0b013e31829a70a5","journal-title":"Crit Care Med"},{"key":"4029_CR23","doi-asserted-by":"publisher","first-page":"1620","DOI":"10.3171\/2018.5.JNS172881","volume":"131","author":"D Dasgupta","year":"2019","unstructured":"Dasgupta D, D\u2019Antona L, Cat DA, Toma AK, Curtis C, Watkins LD et al (2019) Simulation workshops as an adjunct to perioperative care bundles in the management of external ventricular drains: improving surgical technique and reducing infection. J Neurosurg 131:1620\u20134. https:\/\/doi.org\/10.3171\/2018.5.JNS172881","journal-title":"J Neurosurg"},{"key":"4029_CR24","doi-asserted-by":"publisher","first-page":"644","DOI":"10.1016\/j.ajic.2022.08.029","volume":"51","author":"LA Reiter","year":"2023","unstructured":"Reiter LA, Taylor OL, Jatta M, Plaster SE, Cannon JD, McDaniel BL et al (2023) Reducing external ventricular drain associated ventriculitis: an improvement project in a level 1 trauma center. Am J Infect Control 51:644\u201351. https:\/\/doi.org\/10.1016\/j.ajic.2022.08.029","journal-title":"Am J Infect Control"},{"key":"4029_CR25","doi-asserted-by":"publisher","unstructured":"Lozano M, Wang AS, Siddiqi I, Dy O, Ko K, Sweiss R et al (2024) Extraventricular Drain Care Bundle Decreases Cerebrospinal Fluid Infection Rates Associated With Extraventricular Drain-Related Procedures and Systemic Infection. Cureus. https:\/\/doi.org\/10.7759\/cureus.52440","DOI":"10.7759\/cureus.52440"},{"key":"4029_CR26","unstructured":"Ciorba VCGAMLCD (2015) Reducing external drainage-related cerebrospinal fluid infections through implementation of a multidisciplinary protocol: experience in a paediatric hospital"},{"key":"4029_CR27","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1007\/s00701-004-0416-z","volume":"147","author":"AM Korinek","year":"2005","unstructured":"Korinek AM, Reina M, Boch AL, Rivera AO, De Bels D, Puybasset L (2005) Prevention of external ventricular drain - related ventriculitis. Acta Neurochir (Wien) 147:39\u201346. https:\/\/doi.org\/10.1007\/s00701-004-0416-z","journal-title":"Acta Neurochir (Wien)"},{"key":"4029_CR28","doi-asserted-by":"publisher","first-page":"1218","DOI":"10.3171\/2020.2.JNS192051","volume":"134","author":"A Sweid","year":"2021","unstructured":"Sweid A, Weinberg JH, Abbas R, El Naamani K, Tjoumakaris S, Wamsley C et al (2021) Predictors of ventriculostomy infection in a large single-center cohort. J Neurosurg 134:1218\u201325. https:\/\/doi.org\/10.3171\/2020.2.JNS192051","journal-title":"J Neurosurg"},{"key":"4029_CR29","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1186\/s12879-014-0712-z","volume":"15","author":"M Ramanan","year":"2015","unstructured":"Ramanan M, Lipman J, Shorr A, Shankar A (2015) A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections. BMC Infect Dis 15:3. https:\/\/doi.org\/10.1186\/s12879-014-0712-z","journal-title":"BMC Infect Dis"},{"key":"4029_CR30","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1136\/jnnp-2017-316415","volume":"89","author":"AAB Jamjoom","year":"2018","unstructured":"Jamjoom AAB, Joannides AJ, Poon MTC, Chari A, Zaben M, Abdulla MAH et al (2018) Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland. J Neurol Neurosurg Psychiatry 89:120\u2013126. https:\/\/doi.org\/10.1136\/jnnp-2017-316415","journal-title":"J Neurol Neurosurg Psychiatry"},{"key":"4029_CR31","doi-asserted-by":"publisher","first-page":"96","DOI":"10.1093\/cid\/ciu239","volume":"59","author":"K Blot","year":"2014","unstructured":"Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D (2014) Prevention of central line\u2013associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clin Infect Dis 59:96\u2013105. https:\/\/doi.org\/10.1093\/cid\/ciu239","journal-title":"Clin Infect Dis"},{"key":"4029_CR32","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-019-0894-2","volume":"14","author":"D Gilhooly","year":"2019","unstructured":"Gilhooly D, Green SA, McCann C, Black N, Moonesinghe SR (2019) Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review. Implement Sci 14:47. https:\/\/doi.org\/10.1186\/s13012-019-0894-2","journal-title":"Implement Sci"}],"container-title":["Neurosurgical Review"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10143-025-04029-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s10143-025-04029-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10143-025-04029-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T13:03:36Z","timestamp":1768827816000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s10143-025-04029-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,19]]},"references-count":32,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["4029"],"URL":"https:\/\/doi.org\/10.1007\/s10143-025-04029-4","relation":{},"ISSN":["1437-2320"],"issn-type":[{"value":"1437-2320","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,19]]},"assertion":[{"value":"28 July 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 November 2025","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 December 2025","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 January 2026","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Human ethics and consent to participate declarations"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Clinical trial number"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"133"}}