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Hand Hygiene¹

¹ From the Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr, RI 1053, Indianapolis, IN 46202-5200. Received September 27, 2006; revision requested December 8; revision received December 20; accepted January 29, 2007; final version accepted March 20. Address correspondence to R.B.G. (e-mail: rbgunder{at}iupui.edu).

If dirt was trumps, what hands you would hold!

—Charles Lamb (1)

The U.S. Centers for Disease Control and Prevention (CDC) have cited hand washing as the single most effective way to prevent the transmission of disease (2). The CDC estimates that approximately 2 million nosocomial infections occur every year, and approximately 90 000 patients die as a result (3). Despite the attention this topic has received in the media (4), persuading physicians, nurses, technologists, and other health care workers to practice good hand hygiene is surprisingly difficult. In part, the problem lies with misperception. Most of us think we wash our hands more faithfully than we do. A sample of physicians at Royal Children's Hospital in Melbourne, Australia, reported that they washed their hands between 50% and 95% of the time. When they were observed without their knowledge, only 9% of physicians actually followed the recommended hand-washing protocol (5).

With 543 million radiologic examinations performed in the United States in 2003 (6), radiology departments have a great opportunity to control nosocomial infection by attending to hand washing. If our staff members perform poorly in this area, rates of infection will be unnecessarily high. Conversely, if we perform well, many patients will be spared the excess morbidity, mortality, longer hospitalizations, psychologic and social distress, and increased health care costs associated with preventable infections. To succeed at it, however, we must first understand it. This editorial discusses the role of hand hygiene in the history of medicine, its cultural significance, the epidemiologic case for its importance, and various strategies radiology department personnel can pursue in attempting to improve compliance with hand hygiene recommendations.

	HISTORY

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
The idea that health care personnel, and especially physicians, should wash their hands is not a new one. In the original version of the Hippocratic Oath, likely composed in the 4th century BC, the physician swears by Apollo the physician, Aesclepius, Hygieia, and Panacea to uphold the principles of the oath. In Greek mythology, Hygieia was the daughter of Aesclepius, the deity most closely associated with healing, and represented the goddess of cleanliness and sanitation. Although Aesclepius was responsible for healing the sick, it was primarily Hygieia who assisted in preventing illness and promoting health. She was adopted as Salus by the Romans, who worshipped her extensively. It is from Hygieia that we derive our terms hygiene and hygienic and from Salus that our word salutary is derived (7). Thus, the association between cleanliness and health has been recognized since ancient times.

The 12th century Spanish physician and Jewish scholar Rabbi Moses Maimonides, who lived from 1135 to 1204 and also was known as Rambam, was a champion of cleanliness. In the first of his 14-volume Mishnah Torah, a codification of Biblical and Talmudic law, he devotes an entire chapter to the principles of hygiene. In 1199, he also published his Treatise on Hygiene. He taught that physicians should "never fail to wash their hands after touching a sick person" (8). Describing his habits when making house calls, he states that after dismounting from his animal, he would wash his hands before going inside to see his patients. Although many physicians undoubtedly adopted Maimonides' advice, the lack of microbiologic and epidemiologic evidence to support these practices probably contributed to their eventual decline.

During the 1840s, Boston physician Oliver Wendell Holmes, father of the famous Supreme Court Justice, investigated the causes of childbed fever, now known to be caused by Streptococcus pyogenes, a major cause of maternal and infant mortality in the 19th century (9). Though Holmes lacked any notion of microbes and instead invoked what he called "an atmosphere of infection," he nonetheless argued forcibly that childbed fever was an infectious disease passed from patient to patient by physicians and nurses (9). He could not account for the mechanism of transmission but recommended that all physicians involved in performing autopsies on patients who died of childbed fever should "use thorough ablution, change every article of dress, and allow twenty-four or more hours to elapse before attending to any case of midwifery" (9).

Ignaz Semmelweis, an obstetrician at Vienna Lying-In Hospital, Vienna, Austria, in the 1840s, was the first to prove that hand washing could reduce the spread of disease. Semmelweis observed that the mortality rate was three times higher in the medical student delivery room than in the midwife delivery room (10). He suspected that this high mortality rate was because the medical students were coming straight from autopsies to deliver babies. He ordered the medical students and their instructors to wash their hands in chlorinated water, which caused the mortality rate to decrease below that of the midwife ward. Sadly, Semmelweis was not an effective advocate for his findings and ended up in a mental hospital, where he died of bacterial sepsis after performing an autopsy.

Semmelweis's findings were largely unknown during the 1870s in France, where physicians were still ridiculing the idea that they were the cause of disease and death. After all, in the absence of indoor plumbing, clean water was relatively difficult to come by. Moreover, contact with water was implicated in the development of diseases such as malaria and typhoid fever. In 1879, a lecturer at the Academy of Medicine in Paris denounced the view that diseases could be spread by the hands. An outraged member of the audience leapt up and shouted at the speaker, "What kills women with childbed fever is you doctors who carry deadly microbes from sick women to healthy ones!" (11). That audience member was none other than Louis Pasteur, who played an essential role in the development of the germ theory of disease and identified the microbe responsible for childbed fever. Even in 1910 in the United States, a group of 30 physicians reacted to a program to teach hygiene to child care providers in New York by circulating a petition protesting that "[i]t was ruining medical practice by keeping babies well" (12).

William Halsted, along with William Osler, William Welch, and Howard Kelly, was one of the leading faculty members of Johns Hopkins School of Medicine and its first chair of surgery. Although German physicians first described the use of gloves a century earlier and a patent for surgical gloves had been granted in 1878, Halsted is widely credited with popularizing hand hygiene throughout the surgical community, beginning in 1890 (13). Interestingly, infection control was not Halsted's primary objective. Instead, his operating room nurse, Caroline Hampton, had developed severe contact dermatitis from the antiseptics that were used to cleanse both surgical instruments and hands. Halsted asked the Goodyear Tire and Rubber Company to manufacture thin rubber gloves for use in the operating room (13). The gloves not only saved the skin of the future Mrs. Halsted but were so effective in protecting the skin that soon everyone was wearing them.

	CULTURE

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
In her book Purity and Danger, anthropologist Mary Douglas (14) argues that the concept of pollution and its symbols are absolutely necessary in any system of moral thought and practice. Some practices must fall within the bounds of the accepted, and others must be ruled outside of them. These may include permitted and forbidden foods, people and objects that may or must not be touched, and prescribed and proscribed patterns of speech. Such concepts help us to distinguish between the formed and the formless, the orderly and the chaotic, and life and death. Although many contemporary readers think first of hygiene, Douglas emphasizes that purity and danger are not primarily health-related concepts. Instead, "dirt is essentially disorder, existing in the eye of the beholder, and in chasing dirt we are not governed by anxiety to escape disease, but are positively reordering our environment, making it conform to an idea" (15).

	EPIDEMIOLOGY

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
As noted above, the U.S. CDC has described hand washing as "the single most important means of preventing the spread of infection" (2). How closely does our daily practice reflect this ringing endorsement? In an observational study at the University of Washington Veterans Administration Medical Center in Seattle, Wash, 40 physicians or trainees and 15 nurses were observed in the intensive care unit (ICU) (16). Sadly, physicians washed their hands only 28% of the time after contact with a patient (16). Nurses did better but still washed their hands only 43% of the time. In the same study, physicians and nurses were observed at a private hospital, where performance was even poorer. There, the physicians and nurses washed their hands only 14% and 28%, respectively, of the time (16).

The strong link between inadequate hand washing and infectious disease transmission has been demonstrated time and time again. Consider the investigation spawned by an outbreak of Malassezia pachydermatis, an organism associated with otitis in dogs, in the intensive care nursery at Dartmouth-Hitchcock Medical Center in Lebanon, NH (17). Investigators determined that the pathogen had been brought into the nursery on the hands of a health care worker who had been colonized by a pet dog. Thereafter, the organism was transmitted from patient to patient by health care workers' hands. After a rigorous program of hand hygiene was instituted, no further new cases arose, and the hands of nursing staff and attending physicians all tested negative for M pachydermatis (17).

In an observational study in Winnipeg, Manitoba, Canada (18), hand-washing practices and nosocomial infection rates were tracked before and after the commencement of an educational program designed to emphasize the importance of hand hygiene. Before the educational program was started, the nosocomial infection rate was greater than 30%. Afterward, the nosocomial infection rate decreased to 12%. Approximately 4 years later, the nosocomial infection rate was again increasing to about 33%. The educational program was repeated, and the infection rate decreased to 9%. There is, of course, an important difference between positive correlation and direct causation. Yet, after multiple alternative hospital and patient characteristics were analyzed to determine if they might have influenced the infection rate, the investigators determined that none could account for the difference in infection rates. The fact that nosocomial infection rates decreased dramatically each time after hand hygiene interventions were instituted strongly suggests that hand washing is the key causative factor (18).

Why do we fail to wash our hands as frequently as we know we should? Many factors are no doubt involved, but several fairly obvious ones deserve particular attention. First, as we have seen, we health care providers think that we wash our hands much more often than we actually do. Second, some of us providers think that we are too busy to wash our hands. Third, current medical technology and practices, such as the use of gloves, sometimes give us a false sense of security. Fourth, there is the "out of sight, out of mind" problem. Microbes are invisible, and it is usually not visually obvious to us that our hands are contaminated (19). This last problem may be especially important among visually oriented physicians, such as radiologists.

When we health care workers are asked why we do not lather up as frequently as we know we should, we offer a variety of justifications. These include the following: We are simply too busy to take time to wash our hands before and after every patient encounter. We frequently misperceive that there is no opportunity for transmission of microbes. We mistakenly suppose that hand washing is unnecessary because neither the patient nor we caregivers bear an infectious disease. We also complain that frequent hand washing takes an unacceptable toll on our skin. We cite the immediate need to tend to patients, which we suppose should come before hygiene. Two other frequently cited justifications are peer pressure from noncompliant colleagues and a lack of good role modeling by superiors (16,20).

	STRATEGIES FOR IMPROVEMENT

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
How can we achieve better hand hygiene compliance? In one prospective study (5) of efforts to educate a team of health care workers, hand-washing habits in an ICU at the Royal Children's Hospital in Melbourne, Australia, were observed during five time periods of 4–7 weeks each. During the first time period, the physicians did not know they were being observed. Prior to the second time period, the medical staff received written notice that hand-washing practices in the ICU were going to be observed. Prior to the third time period, the results were prominently displayed so that staff would be aware of how frequently or infrequently they were washing their hands. Data were updated weekly for each of the 4 weeks during this time period. During the fourth time period, observations and feedback were discontinued. Observations were then covertly recommenced during the fifth time period, 7 weeks after the latest hand hygiene data were given to the physicians.

The study results indicated that highest rates of hand washing were achieved when physicians were receiving feedback on the frequency of hand washing. Rates declined after feedback ceased, but initially a fourfold increase over baseline was retained. Unfortunately, hand-washing rates steadily declined each week thereafter, as staff thought they were no longer being observed and received no further feedback (5).

In another such study at the University of Iowa, Iowa City, Iowa (21), a special educational program on the use of each hand-cleansing agent available in the ICU was provided to nearly all staff members expected to have patient contact. This educational program included a videotaped demonstration, written instructions, and frequent presentations in the ICUs. Physicians received a written description about the study protocol before their ICU rotations, and a formal refresher program was provided midway through the project. Additionally, a monthly summary of the results of hand cultures and compliance was posted in each ICU in the middle of each month. Despite the extensive education and feedback, hand-washing rates were as low as 30% and were never higher than 48% for the duration of the study (21).

Several Boston hospitals heeded the advice of the CDC that doctors, nurses, and other health care workers needed to improve their hand-washing habits (19). Campaigns were launched to promote better hand hygiene. These campaigns included educational posters, observers watching for hand-washing practices, and incentives such as pizza parties and movie passes for groups of workers who improved their rates. Despite these programs, Brigham and Women's Hospital reached a compliance rate of only 80%—and it reached that level only while it offered free movie passes to the units that kept their rates high. According to one hospital official, rates decreased dramatically after the incentives were removed (22).

	HAND HYGIENE AGENTS

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
Myriad agents are available for hand hygiene, including plain soap, antiseptic soap and detergents, and alcohol-based rubs. Which is most effective? This is difficult to determine. Most studies among health care workers require that subjects wash their hands with the test agent for 30 seconds to 1 minute. Thus, results may be misleading, because most health care workers wash their hands for less than 30 seconds. Likewise, when antiseptic hand rubs are evaluated, it is sometimes recommended that 3 mL of the substance be used for 30 seconds and then repeated. Such protocols do not reflect how hand rubs are typically used by health care personnel (23).

Plain soaps act as detergents to remove dirt, soil, and various organic substances from the hands. They have minimal antimicrobial activity and may only remove loosely adherent hand flora. In two studies (24,25), washing with plain soap failed to remove pathogens from the hands of hospital personnel. In fact, in one study in Devon, England (26), a 17-fold increase in bacterial counts on the skin was documented when personnel washed with plain soap. Findings were similar to those of a study in Marseille, France, in which the researchers postulated that hand washing may increase bacterial counts by releasing bacteria that were previously hidden in fissures or behind rings (27). Furthermore, plain soaps can become contaminated with bacteria, which are then spread to the hands of other people who use the same bar or dispenser. Another French study showed that nonmedicated liquid soaps in a dispenser became contaminated with Serratia marcescens, which then contaminated the hands of health care workers (28).

Most alcohol-based antiseptics contain either a combination of several types of alcohol or limited amounts of other antimicrobial chemicals, such as triclosan. Alcohols are effective antimicrobial agents because they can denature proteins. This ability is accentuated when they are combined with water, and solutions containing 60%–95% alcohol are the most effective. Multiple studies have shown that alcohol can prevent the transfer of pathogens from health care workers' hands. In one Miami, Fla, study (23), washing with only plain soap and water allowed gram-negative bacilli to be transferred from heavily contaminated patient skin to a piece of urinary catheter in 92% of interactions. After using an antiseptic hand rub with an alcohol-based hand rinse, transfer occurred in only 17% of interactions (23). Likewise, in a Seattle, Wash, study, 88% of health care workers continued to have hand cultures positive for Clostridium difficile despite washing with a nondisinfectant soap; the rate decreased to 14% among those who washed with a soap containing 4% chlorhexidine gluconate (24).

Alcohol-based products are more effective for standard hand hygiene by health care workers than plain soap or even antimicrobial soaps. The October 25, 2002, Morbidity and Mortality Weekly Report summarizes multiple studies regarding the use of hand hygiene products (23). All but two of the studies in which alcohol-based solutions were compared with antimicrobial soaps or detergents showed that alcohol was better at reducing bacterial counts on hands than washing with soaps or detergents containing hexachlorophene, povidone-iodine, 4% chlorhexidine, or triclosan. Furthermore, alcohol-based products reduced the number of multidrug-resistant pathogens on the hands of health care workers better than soap and water (22).

	HAND WASHING TECHNIQUE

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
According to the Hand Hygiene Guidelines Fact Sheet of the CDC, when health care workers' hands are soiled, they should wash with soap and water (29). The generally accepted method for washing with soap and water includes wetting the hands with running water, applying a hand-washing agent, and thoroughly distributing it over the hands, fingers, and distal third of the forearms. The hands should be vigorously rubbed together for 10–15 seconds, covering all surfaces of the hands and fingers, before rinsing the hands with warm water and drying with a clean paper towel. The paper towel should then be used to turn off the faucet to avoid recontaminating the hands. Since it may be difficult to determine when 15 seconds have passed, it is often recommended that persons washing their hands scrub while singing the alphabet completely or singing "Happy Birthday" twice.

When the hands are not soiled, an alcohol-based rub should generally be used. The Hand Hygiene Guidelines Fact Sheet (29) recommends applying the rub to the palm of one hand and rubbing the hands together while being sure to cover all surfaces of the hands and fingers. The hands should be rubbed together until they are dry. The amount of alcohol-based rub that should be used is variable, depending on the type selected.

Frequent and repeated use of hand hygiene agents can cause a variety of dermatologic complaints, including a feeling of dryness or burning, erythema, scaling, fissuring, and the subjective sensation of roughness. As many as 85% of nurses in a study funded by 3M Health Care in St Paul, Minn, reported a history of signs or symptoms related to dermatitis. In the same study, approximately 25% of nurses met the criteria for dermatologic damage when their hands were examined stereomicroscopically by a trained technician (30). It is important to avoid such side effects of frequent hand washing, in part because they can reduce compliance and also because fissures and lesions on damaged hands are more susceptible to colonization by microorganisms, thereby fostering transmission.

Multiple steps can be taken to minimize skin irritation associated with hand hygiene. First, a hand-friendly hygiene agent should be readily available. Alcohol-based hand rubs containing emollients are better tolerated by health care personnel than plain soap or antimicrobial soap alone (27). Second, health care workers need to be reminded of the value of regular frequent use of hand-care products such as hand lotions or creams. In one study at the University of Wisconsin, Madison, Wis, scheduled use of an oil-containing lotion improved skin condition and led to a 50% increase in hand-washing frequency among health care personnel who initially suffered from long-standing hand irritation (31). Routine hand washing with soap and water after using an alcohol-based rub can lead to dermatitis and should be avoided.

	CONCLUSION

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 
Our mission as physicians is to protect our patients from harm. If we radiologists and other radiology department staff make a concerted effort to understand and apply these hand hygiene lessons, we can play an important role in reducing nosocomial infection and help to promote the health of both patients and health professionals throughout our institutions.

	FOOTNOTES

 
Authors stated no financial relationship to disclose.

	References

TOP INTRODUCTION HISTORY CULTURE EPIDEMIOLOGY STRATEGIES FOR IMPROVEMENT HAND HYGIENE AGENTS HAND WASHING TECHNIQUE CONCLUSION References

 

1. Lamb C. Life, letters, and writings of Charles Lamb. Vol 2. Manchester, NH: Ayer, 1995.
2. Why is handwashing important? Centers for Disease Control and Prevention Media Relations Web site. http://www.cdc.gov/od/oc/media/pressrel/r2k0306c.htm. Published March 6, 2000. Accessed September 8, 2006.
3. Healthcare-associated infections (HAIs). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/ncidod/dhqp/healthDis.html. Updated February 23, 2006. Accessed September 8, 2006.
4. Dubner SJ, Levitt SD. Selling soap. New York Times. http://www.nytimes.com/2006/09/24/magazine/24wwin_freak.html. Published September 24, 2006. Accessed December 16, 2006.
5. Tibballs J. Teaching hospital medical staff to hand wash. Med J Aust 1996;164:395–398.[Medline]
6. Estimated country level utilization, by modality, 2003. American College of Radiology Web site. http://apps2.acr.org/mcpr/pr/level_util.html. Accessed December 15, 2006.
7. Hygieia. Wikipedia. http://en.wikipedia.org/wiki/Hygieia. Accessed December 15, 2006.
8. Othersen MJ, Othersen HB Jr. A history of hand washing: seven hundred years at a snail's pace. Pharos Alpha Omega Alpha Honor Med Soc 1987;50:23–27. [Medline]
9. Holmes OW. The contagiousness of puerperal fever. N Engl Q J Med Surg 1843;1:503–530.
10. Nuland SB. The doctor's plague. New York, NY: Norton, 2003.
11. Vallery-Radot R. The life of Pasteur. Garden City, NY: Doubleday, 1928.
12. Case CL. Handwashing. Access Excellence at the National Health Museum Web site. http://www.accessexcellence.org/AE/AEC/CC/hand_background.html. Accessed May 29, 2006.
13. Miller JM. William Stewart Halsted and the use of the surgical rubber glove. Surgery 1982;92:541–543.[Medline]
14. Douglas M. Purity and danger: an analysis of the concepts of pollution and taboo. London, England: Routledge, 1984.
15. Douglas M. Purity and danger: an analysis of the concepts of pollution and taboo. London, England: Routledge, 2002.
16. Albert RK, Condie F. Hand-washing patterns in medical intensive care units. N Engl J Med 1981;304(24):1465–1466.[Medline]
17. Chang HJ, Miller HL, Watkins N, et al. An epidemic of Malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers' pet dogs. N Engl J Med 1998;338(11):706–711.[Abstract/Free Full Text]
18. Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Hand washing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control 1989;17(6):330–339.[CrossRef][Medline]
19. DeMarco P. Your life is in hospital workers' (clean) hands: washing hands can save patients' lives, but hospital workers still don't do it enough. The Boston Globe. July 13, 2004;E1.
20. Thompson BL, Dwyer DM. Hand washing and glove use in a long-term-care facility. Infect Control Hosp Epidemiol 1997;18(2):97–103.[Medline]
21. Doebbeling BN, Stanley GL, Sheetz CT, et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992;327(2):88–93.[Abstract]
22. Kihlstrom J. Hand washing by health care providers. Institute for the Study of Healthcare Organizations & Transactions Web site. http://www.institute-shot.com/hand_washing_by_health_care_providers.htm. Accessed October 7, 2007.
23. Boyce P. Guideline for hand hygiene in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51(16):1–44.[Medline]
24. Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol 1991;12:654–662. [Medline]
25. McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204–210. [Abstract]
26. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg (Lond) 1978;81:99–105. [Medline]
27. Winnefeld M, Richard MA, Drancourt M, Grob JJ. Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use. Br J Dermatol 2000;143:546–550.[CrossRef][Medline]
28. Sartor C, Jacomo V, Ducicier C, Tissot-Dupont H, Sambuc R, Drancourt M. Nosocomial Serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap. Infect Control Hosp Epidemiol 2000;21(3):196–199.[CrossRef][Medline]
29. Hand hygiene guidelines fact sheet. Centers for Disease Control and Prevention Media Relations Web site. http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm. Accessed September 26, 2006.
30. Larson E, Friedman C, Cohran J, Treston-Aurand J, Green S. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung 1997;26(5):404–412.[CrossRef][Medline]
31. McCormick RD, Buchman TL, Maki DG. Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers. Am J Infect Control 2000;28(4):302–310. [CrossRef][Medline]

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This Article Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Delaney, L. R. Articles by Gunderman, R. B. Search for Related Content PubMed PubMed Citation Articles by Delaney, L. R. Articles by Gunderman, R. B.