Assignment 1 Discussion Assignment

Assignment 1 Discussion Assignment

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, make sure you post your initial response to the Discussion Area by Week 2, Day 3.

To support your work, use your course and text readings and also use outside sources. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Complete your participation for this assignment by Week 2, Day 7.

Discussion Question

Click here to read the following article from the South University Online Library on the impact of disease on family members:

Golics, C. J., Basra, M. K. A., Finlay, A. Y., & Salek, S. (2013). The impact of disease on family members: A critical aspect of medical care. Journal of the Royal Society of Medicine, 106(10), 399–407.

After reviewing the article, which factor do you feel has the most impact on family members? Please support your response with examples from readings. What are some of the reasons it is important to include the support persons in the plan of care?

Citations should conform to APA guidelines. You may use this APA Citation Helper as a convenient reference for properly citing resources or connect to the APA Style website through the APA icon below.

http://web.a.ebscohost.com.libproxy.edmc.edu/ehost/pdfviewer/pdfviewer?vid=1&sid=b034420c-349b-48d0-988e-82c0d1b0629b%40sessionmgr4009

After reviewing the article, which factor do you feel has the most impact on family members? Please support your response with examples from readings. What are some of the reasons it is important to include the support persons in the plan of care?

The impact of disease on family members: a critical
aspect of medical care
Catherine Jane Golics1,2, Mohammad Khurshid Azam Basra2
, Andrew Yule Finlay2
and Sam Salek1
1
Centre for Socioeconomic Research, School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII
Avenue, Cardiff, CF10 3NB, UK
2
Department of Dermatology and Wound Healing, School of Medicine, Cardiff University, Cardiff, CF14 4XW, UK
Corresponding author: Catherine Jane Golics. Email: catherinegolics@hotmail.com
Summary
Most existing health-related quality of life research concerns
the impact of disease on patients. However, in several
medical specialties including dermatology, oncology, and
physical and mental disability, studies have been carried
out investigating the impact of disease on the lives of
families of patients. The aim of this paper is to review the
literature which relates to the impact of disease on family
members of patients. The OVIDSP Medline was selected as
the primary database, Searches were limited to sources
published in English. 158 papers were identified for
review. The definition of ‘‘family’’ varied across the literature,
and a broad definition was accepted in this review.
This review shows that a wide variety of aspects of family
members’ lives can be affected, including emotional, financial,
family relationships, education and work, leisure time,
and social activities. Many of these themes are linked to
one another, with themes including financial impact and
social impact being linked to emotional impact. Some positive
aspects were also identified from the literature,
including family relationships growing stronger. Several
instruments exist to measure the impact of illness
on the family, and most are disease or specialtyspecific.
The impact of disease on families of patients is
often unrecognised and underestimated. Taking into
account the quality of life of families as well as patients
can offer the clinician a unique insight into issues such
as family relationships and the effect of treatment
decisions on the patient’s close social group of partner
and family.
Introduction
Quality of life (QoL) of individuals is closely related
to the QoL of those around them, includingpartners
or parents1
. Therefore, any chronic illness carries the
potential to impact on the life of the family
Compared to parents of healthy children, parents of
children with chronic diseasereport lower selfdevelopment,
restrictions on their well-being and
emotional stability and lower levels of daily
functioning.2 Most studies on quality of life focus
on assessing the quality of life of patients. Family
quality of life has been explored in dermatology,3–9
oncology,10–21 and in the field of physical and mental
disability,22–28 but little is known about the impact
of disease on families of patients in many other
specialties. Several key review articles have been written
concerning the impact of illness on the quality
of life of the partner,1 the impact of cancer on
the family,14,19 the carer burden in mental health
illness,22 the impact of chronic childhood illness
on siblings,29 and the impact of chronic disease
in the elderly on the patient’s family.30 Family
members of patients are sometimes also carers,
but those who do not act as carers are often
still impacted. The aim of this paper is to review
the literature relating to the impact of disease on
all family members of patients, not just carers, and
identify common themes. Instruments used to assess
the quality of life of family members are also
reviewed.
Methods
The OVIDSP Medline was selected as the primary
database. This included the following resources:
Cardiff University Books and Journals,
PsycArticles, AMED (Allied and Complementary
Medicine), British Nursing Index 1985-present,
Embase 1947-present, HMIC (Health Management
Information Consortium), ICONDA 1976 to June
2011, Medline In Process, Medline 1947-present,
and PsycINFO 1806 to July Week 1 2011. A search
of the Compendium of Quality of Life Instruments
was also carried out.31,32 Searches were limited to
sources published in English.
The main search term ‘‘family quality of life’’ was
also substituted with ‘‘impact/effect on family’’, and
‘‘secondary impact’’, and these were combined with
‘‘disease’’ (Table 1). The term ‘‘partner’’ was also
! The Royal Society of Medicine 2013
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
Journal of the Royal Society of Medicine; 106(10) 399–407
DOI: 10.1177/0141076812472616
used. ‘‘Impact on family’’ was combined with several
common medical specialties. Each abstract identified
was read to determine the type of study and its relevance.
Where appropriate, the full paper was read in
detail. To be included, a source had to be an original
paper concerned with the impact of any illness or
disability on the family of patients. Two measures
of possible relevance to the impact of disease on
family members of patients were identified.
Results
Search results
In total, 1517 abstracts were screened, and 158 were
identified for review of the full paper. Of these, 63
articles highlighted at least one aspect which was
not covered in other articles. Articles were rejected
if, after fully reading them, their content was already
covered by other articles. No sources were identified
when combining the search term ‘‘impact on family’’
with several major medical specialties and only 13
sources were identified using the term ‘‘impact of disease
on family’’ (Table 1). Several sources were
rejected for use of the term ‘‘family’’ in an irrelevant
context, for example articles about genetics.
The majority of articles reviewed concerned family
members of patients of one medical specialty or specific
disease, and were often limited to one particular
family member, for example partners. No information
was found regarding the more general impact
of disease on families of patients over more than
one specialty. However, many of the studies revealed
similar ways that family members of patients were
impacted by disease. In this review, only original articles
were included.Table 2 summarises the studies
which included a control group.
Definition of Family
The term ‘‘family’’ is difficult to define. The mid 20th
century concept of family, with heterosexual parents
and offspring living under the same roof is now
seldom used, and many authors now consciously
use a wider definition of family. The dynamics
between family members are constantly evolving
and there is evidence of many diverse family types
in modern western European society33. Poston
et al.34 define family as ‘‘people who think of themselves
as part of the family, whether by blood or marriage
or not, and who support and care for each other
on a regular basis’’, and this definition is thought to
acknowledge the diverse social arrangements that
may constitute a family.35 In other studies, the
terms ‘‘family’’, ‘‘informal carer’’, and ‘‘carer’’ are
used interchangeably.20,36 For this review, we have
taken a broad view of the term family and accepted
each authors interpretation as valid. Where studies
refer to carers, it was ensured that this related to
family carers.
Key impact areas
Most chronic diseases have similar effects on family
members including psychological and emotional
functioning, disruption of leisure activities, effect on
Table 1. Results of key search terms.
Key search term(s) used
Number of
references
retrieved
Family quality of life 193
Impact on family 2493
Impact of disease on family 13
Effect on family 1349
Effect of disease on family 3
Family þ disease 388
Family scale 491
Family measurement 113
Impact on family þ surgery 0
Impact on family þ medicine 12
Impact on family þ dermatology 0
Impact on family þ psychiatry 0
Impact on family þ respiratory 0
Impact on family þ cardiology 0
Impact on family þ renal 0
Impact on family þ gynaecology 0
Impact on family þ paediatrics 0
Impact on family þ urology 0
Impact on family þ gastroenterology 0
Impact on family þ disability 0
Greater patient 2946
Secondary impact 165
Impact on partner 113
Chronic disease þ family 38
400 Journal of the Royal Society of Medicine 106(10)
interpersonal relationships, and financial resources
(Figure 1). However there may be some aspects
which attain dominance in one particular disease as
compared to other diseases. Several common themes
were identified from the studies reviewed. Leisure and
social impact were reported separately in much of the
literature, and hence are reported as separate themes.
Further examples of less common themes mentioned
are summarised in Table 3.
Emotional impact
Family members suffer greatly from the emotional
effects of living with, and caring for, a relative with
a disease, with the impact of some diseases being felt
by every member of the family.37 Emotional impact
was the most common topic discussed in the literature.
The psychological distress felt by family members
often results from their feelings of helplessness
and lack of control.3,38 Many different emotions are
mentioned by family members; guilt, anger, worry,
upset, frustration, embarrassment, despair, loss,
relief. Each emotion affects family members in different
ways and to different extents, often depending on
the disease severity of the patient,39,40 and the period
of time that has passed since the diagnosis.13
Female partners of cancer patients had higher psychological
distress than male partners.12 However, no
significant difference was seen between genders when
measuring overall quality of life of relatives.
There may be gender differences in responses to caregiving,16,19,41,42
although there was no difference in
the well-being of partners of rheumatoid arthritis
patients, based on the gender of the patient.43 It is
not just the parents and partners who are affected
emotionally by a relative’s disease.29 For example,
siblings of children with pervasive developmental disorder
suffered from ‘‘significant adjustment problems’’
compared to a control group.24
Financial impact
One of the greatest burdens on family members of
patients is the financial cost to the family.44 This
can include treatment costs, transport to appointments,
the cost of hiring a carer, and adapting their
home environment. In a Canadian study,45 families
spent on average C$624 per month on care or support
for the patient with an intellectual disability; many
described not having any money left at the end of
the month. In a similar USA study, the financial
impact on families caring for patients with dementia
varied from US$3630 to US$17700 depending on the
severity of the patient’s dementia.46
The financial strains felt by family members of
patients often lead to stress and worry. Family members
of dermatology patients increase their working
hours in order to support their family financially, and
many need state benefits to cover the extra costs
which may lead to compromises for other family
Table 2. Summary of studies that included a control group.
Reference number Family member group Control Summary
2 Parents of children diagnosed
with cancer, diabetes
or epilepsy.
Parents of healthy
children.
Parents of children diagnosed with cancer, diabetes
or epilepsy reported significantly lower
quality of life compared with healthy controls.
However they were also more satisfied with
their family situation compared with healthy
controls.
9 Families of children with
atopic dermatitis.
Families of healthy
children.
Families of children with atopic dermatitis have a
lower family function level than families of
healthy controls.
12 Male and female partners
of cancer patients.
Healthy couples. Female cancer patients and female partners of
patients perceived more psychological distress
and a lower quality of life than women in
healthy couples. Psychological distress and
quality of life did not differ between male
partners of patients and their healthy controls.
51 Family members of overactive
bladder (OAB)
patients.
Family members of
healthy individuals.
The OAB-FIM discriminated between OAB and
control family members. OAB family members
demonstrated significant impact on quality of
life of relatives.
There may be gender differences in responses to caregiving,16,19,41,42
although there was no difference in
the well-being of partners of rheumatoid arthritis
patients, based on the gender of the patient.43 It is
not just the parents and partners who are affected
emotionally by a relative’s disease.29 For example,
siblings of children with pervasive developmental disorder
suffered from ‘‘significant adjustment problems’’
compared to a control group.24
Financial impact
One of the greatest burdens on family members of
patients is the financial cost to the family.44 This
can include treatment costs, transport to appointments,
the cost of hiring a carer, and adapting their
home environment. In a Canadian study,45 families
spent on average C$624 per month on care or support
for the patient with an intellectual disability; many
described not having any money left at the end of
the month. In a similar USA study, the financial
impact on families caring for patients with dementia
varied from US$3630 to US$17700 depending on the
severity of the patient’s dementia.46
The financial strains felt by family members of
patients often lead to stress and worry. Family members
of dermatology patients increase their working
hours in order to support their family financially, and
many need state benefits to cover the extra costs
which may lead to compromises for other family
Table 2. Summary of studies that included a control group.
Reference number Family member group Control Summary
2 Parents of children diagnosed
with cancer, diabetes
or epilepsy.
Parents of healthy
children.
Parents of children diagnosed with cancer, diabetes
or epilepsy reported significantly lower
quality of life compared with healthy controls.
However they were also more satisfied with
their family situation compared with healthy
controls.
9 Families of children with
atopic dermatitis.
Families of healthy
children.
Families of children with atopic dermatitis have a
lower family function level than families of
healthy controls.
12 Male and female partners
of cancer patients.
Healthy couples. Female cancer patients and female partners of
patients perceived more psychological distress
and a lower quality of life than women in
healthy couples. Psychological distress and
quality of life did not differ between male
partners of patients and their healthy controls.
51 Family members of overactive
bladder (OAB)
patients.
Family members of
healthy individuals.
The OAB-FIM discriminated between OAB and
control family members. OAB family members
demonstrated significant impact on quality of
life.
Golics et al. 401
members.3 When caring for a child with cerebral
palsy, providing even the basic necessities put financial
pressure on the parents,47 and accessing funding
was also challenging, which again increased stress
and emotional effects. The difficulties involved in
accessing funding are greater in low income families,
who often receive minimal support and face greater
problems with social functioning and relationships.48
Impact on family relationships
Family members of patients experience a negative
effect on their family relationships, both between
the relative and the patient, and between other members
of the family as a result of the patient’s illness.
Poor family relationships do not bode well for
chronic disease management regardless of the disease
and often family members find relationships difficult
as they do not know how to emotionally support each
other.49 Family members of patients with multiple
sclerosis reported negative effects on their relationships
with each other, resulting in arguments, tension,
and a lack of understanding of each other’s feelings.37
In particular, relatives struggle to deal with patients
whose beliefs, outlook, and behaviour have altered as
a consequence of their disease. There was little time
for relationships between other members of the
family. For example, Golics et al.50 found that 38%
of adolescents with dermatological conditions felt
that their family relationships had been affected as
a result of their condition.
Table 3. Examples of other ways disease impacts on the lives
of family members.
Affecting sleep2,4,6,9,21,48,58,62,67
Concerns about medical treatment2,4,62,68
Altered food choices2,6,69
Using religion, spiritual and cultural beliefs to
cope2,11,13,46,59
Feeling obliged to give care41
Concerns about receiving information about the disease
and understanding13,21,37,62
Needing support from others15,46,70
Limited freedom48
Worrying about death of the patient17,21,62
Figure 1. A man whose chronic disease is affecting the lives of his family.
402 Journal of the Royal Society of Medicine 106(10)
Partners of patients experience a negative effect on
their sex lives as a result of the patient’s disease,often
as a result of the patient’s symptoms51 or not having
time to spend together as a couple due to another
family member’s illness.3 It can lead to friction
between couples, and in some cases can lead to the
breakdown of relationships, or partners seeking
sexual encounters outside the relationship.3,6
However, in some families relationships can grow
stronger,52 as the family members work together to
help each other and become more closely knit. In
families with a child with an intellectual disability,
the majority were taking the initiative to maintain
good family relations, and engaging in family activities
to encourage this.45 An increase in family closeness
was also found in families of cancer survivors;
one husband of a survivor said ‘‘I look at life differently
after that. I feel much closer to her.’’15
Education and work
Living with, or caring for, a relative with a disease
can have a large impact on the education and careers
of family members. This could include disruption of
school work in siblings or children of the patients, or
the employment of adults being affected and the
burden of care placed upon them. Some families of
children with disabilities45 felt that some of their
family members would not be able to attend work
or school in the near future. One family member is
quoted: ‘‘The unpredictable natures of our children’s
health and lives does not often fit with a typical, progressive
work profile’’.45 In eight of the 34 families
studied, one or both parents had given up an education
or career to care for their child with a disability.
40% of family members of dermatology patients felt
that their employment was affected by their family
member’s skin condition.3 Reasons included needing
to look after the patient, attendinghospital appointments,
and emotional effects affecting work. Looking
after a patient with cancer can also have a huge
impact on a family member’s work on a day-to-day
basis.20 Family member carers were reporting late for
work, missing work, spending time at work talking
on the telephone to their relative and some left work
due to their carer responsibilities.
Leisure time
An important part of family QoL is family members
being able to participate in the hobbies they enjoy.34
The barriers that prevent families from taking advantage
of leisure opportunities45 link into other domains
of family quality of life, including lack of time due to
the responsibilities of care, limited finance, and lack
of support available. However, encouragingly, it has
been shown that when family members do take the
initiative to plan leisure activities, they usually work
out positively, despite the restrictions due to the relative’s
illness, and families show high satisfaction with
this achievement.45
Family members also find difficulty in taking
family holidays, often depending on the disease
state of their relative. Problems with finding suitable
accommodation can make holiday planning ‘‘awkward’’.47
Relatives of patients with skin diseases
described limitations of holiday planning, for example
not wanting to swim together at the beach or their
relative having to wear certain types of clothes.4
Social impact
The burden on family members caring for a person
with a disease has a drastic effect on their social
lives.3,4,34,47 Mothers caring for disabled children
felt that their lives were so different from their friends
and felt that they could only contribute to depressing
conversations, and therefore lost friends as a result.47
Other family members described friends ‘‘drifting
away’’, as they do not understand the family
situation.37
A large number of individuals with a relative suffering
from a skin disease complained of social disruption.4
Conditions which result in visible signs of
disease (for example basal cell carcinoma on the face
or chronic obstructive pulmonary disease requiring
oxygen therapy) may have a greater effect on the
social lives of patients and their relatives, for fear of
strangers’ reactions to their visible condition.
Mothers of adolescent patients suffering from severe
chronic pain reported more restrictions in their social
life than mothers of children with less severe chronic
pain and the authors suggest that this could be directly
related to the illness.53
Instruments to measure family quality of life
Several studies have lead to the development of
instruments designed to measure the impact of disease
on families of patients.3,26,54,55 However, these
instruments are mostly disease or specialty specific,
and can therefore only be used to assess the quality
of life of the family of a particular group of patients.
The Family Dermatology Life Quality
Index(FDLQI) is a ten-item questionnaire designed
to measure the quality of life of family members of
dermatology patients.56 This validated instrument
contains items such as ‘‘Over the last month how
much emotional distress have you experienced due
to your relative/partner’s skin disease (e.g. worry,
Golics et al. 403
Table 4. A summary of the characteristics of family quality of life measures.
Name of
measure Population
Number
of items Coverage
Completion
time Origin
Mode of
administration
Frame of
reference Languages Scale Other
Impact-on-Family
Scale26
Parents of children
with
chronic
illness
24 Four dimensions (factors):
Financial,
Social, Personal
strain and Mastery
10 minutes Family member
interviews
Self-administered
or interviewer-administered
if low
reading level
‘‘at the present
time’’
English and
Spanish
Likert A revised 15-item
version was
created in 2003
which should be
used as replacement
of the
earlier
instrument.
Beach Center
Family Quality
of Life Scale54
Family members
of children
with a
disability
25 Five domains: Family
interaction,
Parenting,
Emotional wellbeing,
Physical/
material well-being
and Disabilityrelated
supports
15 minutes Family member
interviews
and focus
groups
Selfadministration
Current e.g. ‘‘how satisfied
am I
that…?’’
English, Spanish
and Chinese
Likert The scale was later
tested in
families of nondisabled
children
and proved
to have psychometric
validity.
Family Quality of
Life Survey28
Main caregivers
of people
with intellectual
or
developmental
disabilities
9 parts,
total of
49
items,
many
include
multiple
parts
Covers 9 areas of
family life: health,
financial well-being,
family relationships,
support from
others, support
from services, influence
of values, careers,
leisure and
recreation, and
community
integration
60 minutes Previous
research,
expert
opinion
Self-administration
or
administration
by a
researcher
Questions
relate to the
present and
the future
Has been
translated
into 16 languages
including
English,
French and
German
5-point scales
and a variety
of response
categories
The measure was
updated in 2006
and a version to
include families
without disability
has also been
produced
Family Strain
Questionnaire55
Caregivers of
patients
with any
disease
44 Five factors: emotional
burden, problems in
social involvement,
need for knowledge
about the disease,
satisfaction with
family relationships,
and thoughts about
death
20 minutes Developed
from a
stressappraisalcoping
model
Semi-structured
interview by
clinical psychologist
or
healthcare
professional
and self-administered
questionnaire
Present.
Phrases
such as
‘‘during this
period’’ and
‘‘at this
moment’’
are used
English Dichotomous In 2010, the Family
Strain
QuestionnaireShort
Form was
developed,
which contains
30 items and
can be completed
in 5
minutes.
depression, embarrassment, frustration)?’’. The
Impact of Pediatric Epilepsy Scale,57 is designed to
measure the impact of childhood epilepsy on the
patient and their family. Using this measure, the
severity of seizures correlated directly with the quality
of life of the patient and their family.57 This correlation
with disease severity was also found in atopic
dermatitis58 using the Dermatitis Family Impact
Questionnaire.9 Further examples of disease-specific
measures include the Psoriasis Family Index,59 the
Overactive Bladder Family Impact Measure,51 and
the Quality of Life in Life Threatening Illness –
Family Carer Version,11 which is designed to be
used with carers of palliative oncology patients to
assist the development and delivery of the most effective
services to these carers. Many of the existing
instruments to measure family quality of life have
been designed for use in families of patients with
cancer,21,60 and mental health illness.22
The Impact-on-Family Scale measures the impact
of childhood chronic illness on the family.26
Similarly, the extensively tested Beach Centre
Family Quality of Life scale,54 was evaluated in
families of children with disabilities. The questions
in this measure fall under five main categories:
family interaction, parenting, emotional well-being,
physical/emotional well-being, and disability-related
support. The Family Quality of Life Survey is
another example of a measure designed for use in
family members of patients with or without an intellectual
disability.28 This survey is designed to assess
the aspects of family quality of life that are important
to a family and whether these aspects are being
adhered to.
The Caregiver Quality of Life Index,61 is a fouritem
visual analogue scaled measure assessing the
quality of life of primary carers of hospice patients,
but not specifically family members. The Family
Strain Questionnaire,55 is designed for use by ‘‘principal
caregivers’’ and not family members.
Furthermore, the measure assesses the burdens or
problems and needs of carers of patients and not
the overall quality of life. Most of these generic measures
demonstrated good evidence of validity and reliability
testing. The properties of these generic
measures are summarised in Table 4. No measure
was found which can be used to assess and compare
the impact of any disease on family members of
patients.
Discussion
There is a wide range of information about the
impact of disease on family members of patients. It
is unknown whether the results of disease-specific
studies are applicable to a more general population,
or whether family members are affected in similar
ways across every medical specialty. For example,
the family quality of life domains suggested by
Poston et al.34 result from a study with family members
of disabled children. Kazak,62 discusses the lack
of ‘‘reliable and valid family outcome measures’’ and
the negative effects of family outcome studies of one
disease or clinical area, including the lack of communication
between medical specialties and obscuring
commonalities across different disease areas.
Although many studies conclude that a more
family-centred approach to care,13,37,63,64 and further
education of professionals is needed,35 no generic
measure exists to assess the impact of a variety of
diseases on family members of patients.
The impact of disease on families of patients is
often unrecognised and underestimated. Comparing
contrasting information from families of patients
with a variety of diseases could uncover new domains
of quality of life unique to family members, which,
with appropriate support in place, could result in a
higher standard of patient and family care. Taking
into account the quality of life of families as well as
patients can offer the clinician a unique insight into
issues such as family relationships and the effect of
treatment decisions on the patients’ close social group
of partner and family.3
There are some limitations of this review. The
review was not a systematic review. Carrying out a
systematic review would have lead to a substantial
reduction in the number of articles to be reviewed,
therefore influencing the intended comprehensive
nature of the review. Many of the articles reviewed
were written several decades ago, as there is not a
large volume of modern literature looking specifically
at impact on the family. The use of restricted search
databases was also identified as a limitation.
In conclusion, in order to understand the needs of
family members of patients and be able to offer
appropriate support, we first need to understand the
ways in which their lives are affected. This review has
highlighted the need for a multi-specialty study investigating
the issues faced by families of patients, how
these differ between diseases, and exploring the
common themes and ideas.
Declarations
Competing interests: AYF and MKAB are joint copyright
owners of the Family Dermatology Life Quality Index. AYF is a
joint copyright owner of the Psoriasis Family Impact questionnaire
and the Dermatitis Family Impact questionnaire. SS is copyright
owner of the Compendium of Quality of Life Instruments. CJG
has no competing interests.
Golics et al. 405
Funding: The PhD funding of CJG comes from departmental
funds within Cardiff University School of Medicine and School
of Pharmacy and Pharmaceutical Sciences, Cardiff University.
Ethical approval: Not applicable
Guarantor: CJG
Contributorship: CJG carried out the literature review and
wrote the first draft of the manuscript. The other authors contributed
equally to extensive revision of the manuscript.
Acknowledgements: None
Provenance: Submitted; peer-reviewed by David Seamark
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