Presentation on theme: "Metastatic spinal cord compression"— Presentation transcript:
1 Metastatic spinal cord compression Implementing NICE guidanceThis slide set was updated in October 2011 to include the NICE Pathway, and to update information content. The NICE Guideline has not changed.NOTES FOR PRESENTERS:ABOUT THIS PRESENTATION:This presentation has been written to help you raise awareness of the NICE clinical guideline on Metastatic spinal cord compression: Diagnosis & management of adults at risk of and with MSCC. This guideline has been written for healthcare professionals and other staff who care for people with metastatic spinal cord compression.The guideline is available in a number of formats. See the end of the presentation for versions of the guideline.You can add your own organisation’s logo alongside the NICE logo.We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in you presentation, and ‘additional information’ that you may want to draw on, such as rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.DISCLAIMERThis slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.PROMOTING EQUALITYImplementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.2nd edition Oct 2011NICE clinical guideline 75
2 Click here to go to NICE Pathways website The NICE metastatic spinal cord compression pathway coversClick here to go to NICE Pathways websiteNOTES FOR PRESENTERS:Key points to raiseIf you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered.NICE Pathways: guidance at your fingertipsOur new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended. The NICE pathway can be found atMetastatic spinal cord compression (MSCC) is defined in this pathway as spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability.It is important to recognise the impact of an MSCC diagnosis on people with MSCC and their families and carers, and understand their needs and the support required throughout their care.Some people with MSCC experience delays in their treatment and care and may, as a result, develop avoidable disability and die prematurely.This pathway will help to ensure that facilities are available for early diagnosis and that treatment is coordinated, follows best practice and whenever possible prevents paralysis from adversely affecting the quality of life of people living with cancer.
3 Related NICE guidanceImproving outcomes for people with brain and other CNS tumours. NICE cancer service guidance (2006)Improving outcomes for people with sarcoma. NICE cancer service guidance (2006)Improving supportive and palliative care for adults with cancer. NICE cancer service guidance (2004)NOTES FOR PRESENTERS:NICE has published guidance relevant to the management of MSCC.Improving outcomes for people with brain and other CNS tumours. NICE cancer service guidance (2006)Improving outcomes for people with sarcoma. NICE cancer service guidance (2006)Improving supportive and palliative care for adults with cancer. NICE cancer service guidance (2004)You may also find it helpful to refer to the following NICE guidelines:Faecal incontinence: the management of faecal incontinence in adults. NICE clinical guideline 49 (2007)Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE clinical guideline 46 (2007)The management of pressure ulcers in primary and secondary care. NICE clinical guideline 29 (2005)Referral guidelines for suspected cancer. NICE clinical guideline 27 (2005)The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. NICE clinical guideline 7 (2003).All guidance is available from
4 What this presentation covers BackgroundKey priorities for implementationCosts and savingsDiscussionFind out moreNOTES FOR PRESENTERS:In this presentation we will start by providing some background to the guideline and why it is important.We will then present the key priorities for implementation. The NICE guideline contains 10 key priorities for implementation.Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.Finally, we will end the presentation with further information about the support provided by NICE.
5 BackgroundMSCC is a rare complication of cancer and is usually an oncological emergencySome patients experience significant delays from the time when they first develop symptoms to referralNearly half of all patients with MSCC are unable to walk at the time of diagnosisEarly detection, treatment and care can reduce the risk of developing avoidable disability and premature deathEarly surgery may be more effective than radiotherapy at maintaining mobilityNOTES FOR PRESENTERS:Key points to raise:Metastatic spinal cord compression (MSCC) is defined as spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability. It can be caused by any solid tumour.The true incidence of MSCC in England and Wales is unknown. Research1,2 suggests that the incidence may be up to 80 cases per million people every year. This equates to approximately 4000 cases each year in England and Wales, or more than 100 cases per cancer network each year.The Scottish audit1 showed that there were significant delays from the time when patients first develop symptoms to when general practitioners and hospital doctors recognise the possibility of MSCC and make an appropriate referral. The median times from the onset of back pain and nerve root pain to referral were 3 months and 9 weeks, respectively. Nearly half of all patients with MSCC were unable to walk at the time of diagnosis and of these, the majority (67%) had recovered no function after 1 month. Of those who could walk unaided at the time of diagnosis, 81% were able to walk (either alone or with aid) at 1 month. The ability to walk at diagnosis was also significantly related to overall survival.One of the aims of the MSCC guideline is to reduce the proportion of patients unable to walk at the time of diagnosis.Once paraplegia develops it is usually irreversible. This can affect the quality of life of both the patient and also of their carers. These patients may often need 24 hour nursing care either in hospital or in the community setting.Early surgery may be more effective than radiotherapy at maintaining mobility in some patients. Presently, few patients with MSCC in the UK receive surgery for the condition.It is important that the patient and all health care professionals are aware of the early symptoms and signs of MSCC.Early symptoms of MSCC include back pain in the spine, pain down the leg or arm, severe increasing pain in the spine that changes with position or posture, pain which starts in the spine and goes around the chest or abdomen, a new feeling of clumsiness or weakness of the arms or legs or difficulty walking, numbness in the arms or legs, difficulty in control water or bowels, nocturnal spinal pain preventing sleepReferences: Levack P et al (2001) A prospective audit of the diagnosis, management and outcome of malignant cord compression (CRAG 97/08). Edinburgh: CRAG. Loblaw DA, Laperriere NJ, Mackillop WJ (2003) A population-based study of malignant spinal cord compression in Ontario. Clinical Oncology 15 (4): 211–17.
6 Key priorities for implementation Service configuration and urgency of treatmentEarly detectionImagingTreatment of spinal metastases and MSCCSupportive care and rehabilitationNOTES FOR PRESENTERS:The NICE guideline contains 106 recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into five areas and we will consider each in turn.The guideline includes detailed recommendations for the management of complications which do not form part of the key priorities for implementation but are an essential component of the care pathway for patients. These include:Venous thromboembolismPressure ulcersBladder and bowel continence managementCirculatory and respiratory functioningDosage and monitoring recommendations are also made for corticosteroids. In addition there are detailed treatment options for pain relief and to prevent MSCC.
7 Service configuration and urgency of treatment Every cancer network should ensure that appropriate services are commissioned and in place for the efficient and effective diagnosis, treatment, rehabilitation and ongoing care of patients with MSCCThese services should be monitored regularly through prospective audit of the care pathwayNOTES FOR PRESENTERS:Additional information:Cancer networks should:have a clear care pathway for the diagnosis, treatment, rehabilitation and ongoing care of patients with MSCCensure that access to MRI is available within 24 hours for all patients with suspected MSCCensure 24-hour availability (including outside normal working hours) of MRI in centres treating patients with MSCChave a network site specific group for MSCC with representatives from primary, secondary and tertiary careappoint a network lead for MSCC who should:- advise the network, commissioners and providers about the provision and organisation of relevant clinical services- ensure that the care pathway is documented, agreed and consistent across the network- ensure that telephone contact to an MSCC coordinator and to senior clinical advisers is available at all times- maintain a network-wide audit of the care pathway and patient outcomes- arrange and chair twice-yearly meetings of the network site specific group to discuss patient outcomes and review the care pathwayEvery centre that treats patients with MSCC should:ensure 24-hour availability of senior clinical advisers to support and advise the MSCC coordinator and other healthcare professionals and undertake treatment. Please refer to the quick reference guide for the responsibilities of the senior clinical adviser.identify or appoint individuals to the role of MSCC coordinator and ensure its availability at all timeshave a single point of contact for access to the MSCC coordinator to advise clinicians and coordinate the care pathwayThe guideline sets out the responsibilities of the MSCC coordinator.Secondary or tertiary care centres should have a lead healthcare professional for MSCC whose responsibilities are outlined in the NICE guideline.
8 Early detectionInform patients with cancer who are at risk of MSCC information about the symptoms of MSCC and what to do and who to contact if those symptoms developDiscuss with the MSCC coordinatorimmediately patients with cancer who have symptoms of spinal metastases and neurological symptoms or signs suggestive of MSCC and view as an emergencywithin 24 hours patients with cancer who have symptoms suggestive of spinal metastasesNOTES FOR PRESENTERS:Additional information:Ensure that patients with MSCC and their families and carers know who to contact if their symptoms progress while they are waiting for urgent investigation of suspected MSCCDiscuss with the MSCC coordinator urgently (within 24 hours) patients with or without a cancer diagnosis who have symptoms suggestive of spinal metastasesDiscuss with the MSCC coordinator immediately patients with or without a cancer diagnosis who develop neurological symptoms or signs suggestive of MSCCPerform frequent clinical reviews of patients with or without a cancer diagnosis who develop neurological symptoms or signs suggestive of MSCCRecommendations in full:Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about the symptoms of MSCC. Offer information (for example, in the form of a leaflet; see appendix D of the NICE guideline) to patients and their families and carers which explains the symptoms of MSCC, and advises them (and their healthcare professionals) what to do if they develop these symptoms. [ ]Contact the MSCC coordinator urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:- pain in the middle (thoracic) or upper (cervical) spine- progressive lower (lumbar) spinal pain- severe unremitting lower spinal pain- spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)- localised spinal tenderness- nocturnal spinal pain preventing sleep. [ ]Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:- neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction- neurological signs of spinal cord or cauda equina compression. [ ]
9 ImagingIt is important that MRI should be done quickly, dependent upon signs and symptomsNOTES FOR PRESENTERS: Key points to raiseMRI should be done in time to allow definitive treatment to be planned within 1 week of the suspected diagnosis in the case of spinal pain suggestive of spinal metastasesMRI should be done in time to allow definitive treatment to be planned within 24 hours in the case of spinal pain suggestive of spinal metastases and neurological symptoms or signs suggestive of MSCCand occasionally sooner if there is a pressing clinical need for emergency surgeryAdditional information: Magnetic resonance imagingPerform magnetic resonance imaging (MRI) of the whole spine in patients with suspected MSCC, unless contraindicated.Include sagittal T1, short T1 inversion recovery and sagittal T2 weighted sequences.Perform supplementary axial imaging through any significant abnormality noted on the sagittal scan.Configure lists to allow MRI at short notice. Out-of-hours MRI should be available in emergency situations if immediate treatment is planned.If MRI is not available at the referring hospital, transfer patients with suspected MSCC to a unit with 24-hour capability.Perform MRI in time to plan definitive treatment:– within 1 week in patients with symptoms suggestive of spinal metastases– within 24 hours in patients with symptoms suggestive of spinal metastases and neurological symptoms or signs suggestive of MSCC– sooner (including out-of-hours) if emergency treatment is neededMRI of the spine in patients with suspected MSCC should be supervised and reported by a radiologistOther imaging optionsIf MRI is contraindicated, contact the MSCC coordinator to determine the best imaging option.Consider myelography if other imaging options are contraindicated or inadequate. Undertake myelography only at a neuroscience or spinal surgery centre.Consider targeted computerised tomography to assess spinal stability and plan vertebroplasty, kyphoplasty or surgery.Do not use plain radiographs to diagnose or exclude spinal metastases or MSCC.Do not routinely image the spine if patients with malignancy are asymptomatic.Serial imaging of the spine in asymptomatic patients with cancer at high risk of developing spinal metastases should only be done as part of a randomised controlled trial.Recommendation in full:Perform MRI of the whole spine in patients with suspected MSCC, unless there is a specific contraindication. This should be done in time to allow definitive treatment to be planned within 1 week of the suspected diagnosis in the case of spinal pain suggestive of spinal metastases, and within 24 hours in the case of spinal pain suggestive of spinal metastases and neurological symptoms or signs suggestive of MSCC, and occasionally sooner if there is a pressing clinical need for emergency surgery. [ ]
10 Treatment of spinal metastases and MSCC: 1 Nurse flat with spine in neutral alignment patients with severe mechanical pain suggestive ofspinal instability orneurological symptoms orsigns suggestive of MSCC until spinal and neurological stability are ensuredNOTES FOR PRESENTERS:Key points to raise:Use ‘log rolling’ techniques or turning beds, and a slipper pan for toiletDo this until bony and neurological stability are ensured and cautious remobilisation may beginAdditional information:Once any spinal shock has settled and neurology is stable, monitor during gradual sitting (to 60 degrees) over 3–4 hoursIf blood pressure is stable and there is no significant increase in pain or neurological symptoms, continue to unsupported sitting, transfers and mobilisationIf pain or neurological symptoms increase, return to a position where these changes reverse and reassess spinal stabilityIf patients are not suitable for definitive treatment they should be helped to position themselves and mobilise as symptoms allow after discussing the risks. Provide orthoses or specialist seating, if appropriateEncourage patients who are not on bed rest to mobilise regularlyEncourage and assist patients who are unable to stand or walk to perform pressure relieving activities at least every hourRecommendation in full:Patients with severe mechanical pain suggestive of spinal instability, or any neurologicalsymptoms or signs suggestive of MSCC, should be nursed flat with neutral spine alignment(including ‘log rolling’ or turning beds, with use of a slipper pan for toilet) until bony andneurological stability are ensured and cautious remobilisation may begin [ ]
11 Treatment of spinal metastases and MSCC: 2 Start definitive treatment, if appropriate, before any further neurological deterioration and ideally within 24 hours of the confirmed diagnosis of MSCCNOTES FOR PRESENTERS:Additional information:When planning definitive treatment:attempt to establish the primary histology of spinal metastases (by tumour biopsy, if necessary)determine the number, anatomical sites, and extent of spinal and visceral metastasestake into account:- patient preferences- neurological ability- functional status- general health and fitness- previous treatments- magnitude of surgery- likelihood of complications- fitness for general anaesthesiaoverall prognosisDo not deny surgery or radiotherapy on the basis of age alone
12 Treatment of spinal metastases and MSCC: 3 Carefully plan surgery to maximise the probability of preserving spinal cord function without undue risk to the patient, taking into account their overall fitness, prognosis and preferencesNOTES FOR PRESENTERS: Additional information:Eligibility for surgery:When deciding whether surgery is appropriate:– use recognised prognostic factors (including the revised Tokuhashi scoring system and American Society of Anaesthetists grading)– record and take into account relevant comorbiditiesConsider speed of onset, duration, degree, and site of origin of neurological symptoms and signs when assessing urgency of surgeryPerform surgery before patients lose the ability to walkOffer surgery, regardless of ability to walk, if patients have residual distal sensory or motor function and a good prognosisDo not offer surgery to patients with MSCC who have been completely paraplegic or tetraplegic for more than 24 hoursOnly consider major surgical treatments for patients expected to survive longer than 3 monthsType of surgery:Offer surgery to achieve spinal cord decompression and durable spinal column stabilityDo not perform posterior decompression alone in patients with MSCC, except when patients have isolated epidural tumour or neural arch metastases without bony instabilityOffer posterior decompression with internal fixation if spinal metastases involve the vertebral body or threaten spinal stabilityConsider vertebral body reinforcement with cement for patients with MSCC and vertebral body involvement who are suitable for instrumented decompression and are expected to survive for less than 1 yearConsider vertebral body reconstruction with anterior bone graft for patients with MSCC and vertebral body involvement who are suitable for instrumented decompression, expected to survive for 1 year or longer, and fit to undergo a more prolonged procedureDo not attempt en bloc excisional surgery except if a solitary renal or thyroid metastasis is confirmed following complete staging
13 Treatment of spinal metastases and MSCC: 4 Ensure urgent (within 24 hours) access to and availability of radiotherapy and simulator facilities in daytime sessions, 7 days a week, for patients with MSCC requiring definitive treatment or who are unsuitable for surgeryNOTES FOR PRESENTERS:Additional information:Offer fractionated radiotherapy as the definitive treatment of choice to patients with epidural tumour without neurological impairment, mechanical pain or spinal instabilityOffer urgent fractionated radiotherapy (within 24 hours) to all patients with MSCC who are not suitable for surgery, unless:- they have had complete tetraplegia or paraplegia for more than 24 hours and their pain is well controlled, or- their prognosis is too poorDo not carry out preoperative radiotherapyOffer postoperative fractionated radiotherapy to patients with a satisfactory outcome, once the wound has healedSelection of treatment following previous radiotherapy:If patients respond well to radiotherapy and symptoms recur after 3 months, consider further radiotherapy or surgeryDiscuss the possible benefits and risks of further radiotherapy with the patient and keep the total dose below 100 Gy2
14 Supportive care and rehabilitation Start discharge planning and ongoing care including rehabilitation on admissionNOTES FOR PRESENTERS:Key points to raise:This should be led by a named individual from within the responsible clinical team.It should involve the patient and their family and carers, their primary oncology site team, rehabilitation team and community support, including primary care and specialist palliative care, as required.Additional information:Offer specialist psychological and spiritual support at diagnosis, during treatment and on discharge from hospital. Explain how to access these servicesOffer bereavement support to families and carers1Offer support services for assessment, advice and rehabilitationFocus rehabilitation on the patient’s goals and outcomes, including functional independence, participation in normal activities of daily life and quality of lifeOffer admission to a specialist rehabilitation unit to people who are most likely to benefitEnsure community-based rehabilitation and supportive care services are available to people with MSCC following their return homeEnsure that equipment and care are provided in a timely fashionOffer support and training to families and carers before people with MSCC are discharged homeRecommendation in full:Discharge planning and ongoing care, including rehabilitation for patients with MSCC, should start on admission and be led by a named individual from within the responsible clinical team. It should involve the patient and their families and carers, their primary oncology site team, rehabilitation team and community support, including primary care and specialist palliative care, as required. [ ]1 See the three component model in ‘Improving supportive and palliative care for adults with cancer’, NICE cancer service guidance.
15 Costs and savings Estimated cases per year in England: 3,100 Recommendations with significant costsEstimated annual incremental costs resulting from increase in surgical activity(£000s per year)Surgery for treatment and prevention of MSCC14,023Recommendations with significant savingsSavingsSupportive care and rehabilitation post discharge of patients-17,513Net resource impact of MSCC guideline-3,490ADAPTING THIS SLIDE FOR LOCAL USE:We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.NOTES FOR PRESENTERS:NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing this guideline.The estimated national annual changes in costs and savings arising from implementing the guideline on MSCC net to savings of £3.5m.NICE has produced a costing report that provides detailed estimates of the national costs and savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local costs associated with implementing this guideline.Additional Information:CostsThe total cost of surgery is estimated to be £12k per patient based on the tariff for admitted patient care for spinal cord surgery, this includes the average cost of implants (£3k) plus post operative hospital rehabilitation on a HDU costs of around £1.4k per patient based on HES data and the National Schedule of reference costs This produces estimated incremental costs of £14 million nationally when based on the estimated annual incidence of MSCC from the guidance. This also takes into account the expected increase in surgical activity following more referrals for surgery as a result of recognition that surgical treatment has greater benefits where previously surgery may not have been considered for patients with metastatic disease.SavingsThe savings are based on the health economics included in the full guidance. This uses evidence from the trial carried out by Patchell et al and published in the Lancet The findings of the trial established that surgery as a combined treatment with radiotherapy resulted in increased length of time to paraplegia for patients able to walk after treatment. These results, when combined with the study on survival rates for patients able to walk after treatment who underwent surgery for MSCC carried out by Thomas et al and published in 2006, show that patients able to walk who receive surgery are likely to maintain the ability to walk up to the time of death. The importance of this is that costs associated with patients who become paraplegic are avoided resulting in sustainable cost savings. These are estimated to be £17.5m and represent the difference in health service costs included the full guidance for the care of patients who are able to walk when compared to costs of caring for patients who are not able to walk.Implementing the clinical guideline may bring the following benefits:Earlier diagnosis of MSCC is essential to preventing irreversible neurological damage. This may result in cost savings as a result of reduced hospital stays and draw on hospital resources as patients would become paraplegic if diagnosis is too late. Cost savings may include 24 hour nursing care either in hospital or in the community setting.Evidence suggests surgery has better outcomes for patients than radiotherapy in terms of increased life expectancy and patients remaining ambulant for a longer period, thereby improving end of life care. This would result in potentially significant savings of up to £17.5 million as a result of reduced home care costs; community nursing; out of ours access for GP and clinical services.For further information please refer to the costing template and costing report for this guideline on the NICE website.Costs correct at Nov. 2008Costs not updated for 2nd. edition
16 Costs and savingsRecommendations that may result in additional costs depending on local circumstances:Early diagnosis: improving access to MRI scanning servicesTreatment: increasing number of surgical proceduresRecommendations that may result in additional savings include preventing late crisis intervention or need for supportive careNOTES FOR PRESENTERS:For further information please refer to the costing template and costing report for this guideline on the NICE website.
17 Discussion How can cancer networks coordinate and audit the pathway? How do we ensure 24-hour availability of senior clinical advisers in centres treating patients with MSCC?How do we ensure 24-hour provision of the role of MSCC coordinator?How do we raise primary care awareness of significant symptoms?How can we improve timeliness of referral and imaging?What is the current provision of community-based rehabilitation and supportive care services and do we need to improve this?NOTES FOR PRESENTERS:These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
18 Find out more Visit www.nice.org.uk/CG75 for: the NICE guideline ‘Understanding NICE guidance’local patient information templateimplementation advicecosting report and templateaudit supportNOTES FOR PRESENTERS:You can download the guidance documents from the NICE website.The NICE guideline – all the recommendations.‘Understanding NICE guidance’ – information for patients and carers.The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.For printed copies of the ‘Understanding NICE guidance’, phone NICE publications on or and quote reference number N1720 (‘Understanding NICE guidance’).NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.Local patient information template which is locally adaptable, to highlight for vulnerable patients, early symptoms and the local routes to accessing speedy specialist care for MSCC.Implementation advice – on how to put the guidance into practice and national initiatives that support this locally.Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.Audit support – for monitoring local practice.
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