A Survey of Pharmacy Students’ Satisfaction with a Basic Life Support Course and an Exploration of Factors Related to Awareness Change Before and After the Course

Summary

The model core curriculum for pharmacy education and professional standards for pharmacists established by the Japan Pharmaceutical Association aim to inculcate knowledge and skills on basic life support (BLS) and ensure that pharmacy students are well equipped with knowledge on BLS. In this study, pharmacy students were enrolled in the PUSH course, a BLS training course for citizens, and a questionnaire survey was conducted before and after the course to evaluate the change in students awareness about BLS and overall satisfaction with the course. The participants enrolled for the course were fourth-year students from the School of Pharmacy, Hyogo Medical University, who consented to participate in the study. A total of ninety-nine participants were included in this study. After the completion of the course, the participants displayed greater confidence, preparedness, and willingness to teach BLS, and decreased anxiety about BLS. Factor analysis revealed four factors based on the questionnaire answers before the course, while three factors were extracted based on the answers after the course. Lack of confidence in BLS, extracted as one of the factors before the course was inverted and gave rise to a new factor. Some participants displayed increased awareness about BLS after completion of the PUSH course. Hierarchical cluster analysis before and after the course divided respondents into three groups. The results showed that lesser number of participants displayed anxiety over BLS after the course. The results also indicated high levels of satisfaction among the participants after the completion of the PUSH course.

INTRODUCTION

In Japan, approximately 79000 sudden cardiac deaths are reported annually, most of which are due to ventricular fibrillation.¹⁾ According to the “2022 Edition: Current Status of Emergency and Rescue Services” released by the Fire and Disaster Management Agency attached to the Ministry of Internal Affairs and Communications, the number of emergency calls received in 2020 was 5935694. Out of the total number of cases of cardiogenic cardiopulmonary arrest witnessed by citizens, bystanders provided cardiopulmonary resuscitation (CPR) to 14974 (58.1%) patients who were sick and wounded, while 10816 (41.9%) sick and wounded patients did not receive CPR.²⁾ A total of 2273 (16.2%) sick and wounded patients for whom citizens provided CPR survived after one month and 1530 (10.2%) returned to society one month after the incident. However, only 882 (8.2%) sick and wounded patients who were not provided CPR by citizens survived after one month and 412 (3.8%) patients returned to society one month after the incident. Therefore, it was established that CPR by citizens led to a 1.9-fold increase in one-month survival rate and 2.7-fold increase in one-month social reintegration rate.²⁾ Furthermore, the number of sick and wounded patients who were defibrillated by citizens was 1092, and 581 (53.2%) of them survived after one month and 479 (43.9%) returned to society one month after the incident. The fact that the survival rate decreased by 10% for each minute of delay from the start of the cardiac arrest to administration of electric shock, and that the national average time required for emergency medical teams to arrive at the scene was approximately 8.9 min in 2020 suggests that CPR and defibrillation by citizens for sick and wounded patients with cardiogenic cardiopulmonary arrest can improve the survival rate and social reintegration rate.^2,3)

One of the learning objectives of the model core curriculum for pharmacy education in Japan is “being able to explain and perform basic life support procedures (cardiopulmonary resuscitation, injury response, etc.) using a simulator.”⁴⁾ In addition, the knowledge, skills, and attributes that a pharmacist should possess to respond to emergencies as described by the professional standards for pharmacists established by the Japan Pharmaceutical Association are as follows: 1) to be able to outline the basic knowledge needed to respond to a cardiopulmonary arrest situation, 2) to be able to assess a cardiopulmonary arrest situation, and 3) to be able to adequately operate an automated external defibrillator (AED).⁵⁾ Therefore, it is essential that pharmacists and pharmacy students are well equipped with knowledge on basic life support (BLS). Previous studies on the importance of BLS education in first-year pharmacy students reported the effectiveness of introducing feedback devices into BLS training programs using simulators,⁶⁾ which ensures that the compression skills learnt using a station that combines training with video instruction and audio feedback are not inferior to training in the presence of an instructor.⁷⁾ These studies also showed that students were more engaged in confirming responsiveness, assessing breathing, assessing pulse rate, performing adequate ventilation, and performing CPR in peer-led BLS training sessions than in instructor-led BLS programs.⁸⁾

BLS educational courses traditionally offered in Japan include those offered by the fire department and the Japanese Red Cross Society; however, these courses take anywhere between 3 h to half a day to complete. On the other hand, the 45-min chest compression-only CPR training called the PUSH course, which is a BLS training course for citizens, can be easily integrated into the higher education system in Japan, where most classes are 90 min long.^9,10) In addition, while conventional BLS training courses use one simulator for several people, the PUSH course uses a simplified cardiopulmonary resuscitation training tool, known as the “APPA-Kun Light®” (Alexon, Osaka), and individual training kits are allotted to each participant. Therefore, each participant in the PUSH course spent more time performing chest compressions, and a higher percentage of participants continued to improve their resuscitation skills one year after the course as compared to participants who enrolled in conventional courses.¹⁰⁾

In this study, we enrolled pharmacy students in the PUSH course, and questionnaire surveys before and after the course were used to explore and stratify factors related to changes in students confidence, preparedness, anxiety, and willingness to teach BLS, as well levels of satisfaction with the PUSH course.

MATERIALS AND METHODS

The participants in this study were fourth-year students from the School of Pharmacy, Hyogo Medical University, who consented to participate in the study.

PUSH course was mainly composed consists of performing chest compressions and using an AED.¹¹⁾ Participants were divided into three classes of approximately 40 students each, and each PUSH course was conducted for one hour per session containing the time of answering the questionnaire before and after the course. The subject was informed that BLS training would be provided, but no details were explained to participants before the course was conducted. Instruction was provided by three in-school teachers and one hospital pharmacist invited from outside the university.

A web-based questionnaire using Google Forms was used in this study. A QR code to access the questionnaire form was displayed on the screen before and after the PUSH course, and participants were asked to access and respond to the form on their own wearable devices. In addition, a random ID number was assigned to each participant, and the participant was asked to enter this ID number before answering the questionnaire, to link the data from each participant before and after the course and prevent duplicates. The questionnaire was designed using the Japan Cabinet Office’s 2017 Public Opinion Survey on First Aid and previous studies on psychological analysis of pharmacy students as references.^12,13) Questions in the survey included whether or not the participant had ever called for an ambulance before the course and the reason for the call and 21 questions regarding confidence, readiness, anxiety, and willingness to teach BLS before and after the course (graded on a 5-point scale). The post-course questionnaire included nine questions regarding satisfaction with the PUSH course (graded on a 10-point scale) (Fig. 1).

Fig. 1. Survey Questionnaire

Answers to each of the questions were tabulated, and the distribution of the answers before and after the course was tested using Fisher’s exact test, with statistical significance set at 0.05. In addition, an exploratory factor analysis based on the data from the questionnaires was conducted to explore the factors that influenced the psychological state of the students regarding their confidence, preparedness, anxiety, and willingness to teach BLS. Factor analysis was performed using the maximum likelihood method, diagonal element=squared multiple correlation (SMC) method, and quartimin rotation, based on an eigenvalue of one or more from the scree plot and a cumulative contribution ratio of 70% or more. Questions with commonality less than 0.16 were considered highly unique and excluded from the factor analysis, and questions with factor loadings less than 0.4 were also excluded. We also confirmed the internal consistency of each factor using Cronbach’s alpha coefficients.¹³⁾ For questions with negative factor loading, Cronbach’s alpha coefficient was calculated after inverting the data. A Cronbach’s alpha coefficient of 0.8 or higher indicated internal consistency.¹³⁾ Hierarchical cluster analysis was performed based on the factor scores obtained from factor analysis. The Ward method was used in cluster analysis, and clustering was performed upon confirmation with three analysts.^14,15)

This study was conducted in compliance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects and was approved by the Ethical Review Committee of Hyogo University of Health Sciences (Approval no: 20004-2) and by the President of Hyogo Medical University. Participation in the study was voluntary and the purpose of the study was made clear to the participants at the start of the web questionnaire. Answers to the questionnaire were kept anonymous so that individuals could not be identified. After it was made clear to the participants that their answers would be anonymous because it was a no-name questionnaire and that the transmission of data could not be canceled, a section for consent to use the results for research was included in the questionnaire, and only data from participants who agreed to this was included in the analysis.

RESULTS

Out of the 117 participants who enrolled in the course, 116 (99.1%) responded to the pre-course questionnaire and 115 (98.3%) responded to the post-course questionnaire. A total of 99 (84.6%) participants who consented to participate in the study and have their data published and whose pre- and post-course answers were complete, were included in the study analysis. When asked if they had ever called an ambulance before the course, 34 (34.3%) participants responded yes and 65 (65.7%) participants responded no. The reasons cited by the participants for calling an ambulance were as follows: 20 (58.8%) because they were in no condition to move on their own, 11 (32.4%) because they thought their life was in danger, 10 (29.4%) because they did not know whether their symptoms were mild or severe, 5 (14.7%) because it was nighttime or they were on a holiday and the nearest hospital was not open, 8 (23.5%) because it was a traffic accident, 5 (14.7%) because they thought it would be faster to reach hospital by ambulance, 0 (0.0%) because they did not know which hospital to go to, 1 (2.9%) because they did not have transportation to reach the hospital, and 2 (5.9%) because of other reasons.

Table 1 shows the simple tabulation of answers to questions regarding confidence, preparedness, anxiety, and willingness to teach BLS (Q3–Q23). The distribution of answers was tested using Fisher’s exact test, and the results showed that there was a significant increase in confidence, preparedness, and willingness to teach BLS, and a significant decrease in anxiety after the course compared to before the course, except for Q10, Q17, and Q18.

Table 1. Simple Tabulation of the Questionnaire Q3 to Q23

Question	Answer (n=99)							Answer (n=99)							p-Value
	Pre							Post
		1	2	3	4	5			1	2	3	4	5
Q3	Disagree	10	29	38	17	5	Agree	Disagree	0	1	4	48	46	Agree	<0.001
Q4	Disagree	18	43	25	12	1	Agree	Disagree	3	10	27	33	26	Agree	<0.001
Q5	Disagree	9	19	32	30	9	Agree	Disagree	0	1	2	32	64	Agree	<0.001
Q6	Disagree	1	10	11	27	50	Agree	Disagree	11	30	24	19	15	Agree	<0.001
Q7	Disagree	2	4	10	30	53	Agree	Disagree	16	28	26	21	8	Agree	<0.001
Q8	Disagree	5	4	17	28	45	Agree	Disagree	38	30	16	8	7	Agree	<0.001
Q9	Disagree	5	24	20	34	16	Agree	Disagree	15	26	31	19	8	Agree	0.006
Q10	Disagree	20	27	26	16	10	Agree	Disagree	23	20	30	20	6	Agree	0.570
Q11	Disagree	9	24	24	22	20	Agree	Disagree	22	43	15	15	4	Agree	<0.001
Q12	Disagree	6	16	34	29	14	Agree	Disagree	25	34	22	12	6	Agree	<0.001
Q13	Disagree	3	8	25	39	24	Agree	Disagree	19	43	24	7	6	Agree	<0.001
Q14	Disagree	1	8	19	32	39	Agree	Disagree	14	44	29	6	6	Agree	<0.001
Q15	Disagree	1	11	10	38	39	Agree	Disagree	13	37	25	16	8	Agree	<0.001
Q16	Disagree	4	15	34	30	16	Agree	Disagree	1	2	21	37	38	Agree	<0.001
Q17	Disagree	0	3	11	47	38	Agree	Disagree	0	0	12	35	52	Agree	0.066
Q18	Disagree	0	2	14	37	46	Agree	Disagree	0	0	8	33	58	Agree	0.152
Q19	Disagree	2	14	34	33	16	Agree	Disagree	0	1	27	31	40	Agree	<0.001
Q20	Disagree	3	11	35	35	15	Agree	Disagree	0	2	26	32	39	Agree	<0.001
Q21	Disagree	7	14	42	23	13	Agree	Disagree	0	6	23	43	27	Agree	<0.001
Q22	Disagree	7	13	42	25	12	Agree	Disagree	1	6	23	41	28	Agree	<0.001
Q23	Disagree	13	31	34	14	7	Agree	Disagree	2	13	39	24	21	Agree	<0.001

Fisher’s exact test

Table 2 shows the results of the factor analysis based on the answers to Q3–Q23 before the course. Four factors with eigenvalues greater than one were extracted, with a cumulative contribution rate of 79.6%. No question had a commonality of less than 0.16; therefore, the answers to all questions were subjected to factor analysis. Factors were defined as follows: Pre-Factor 1: anxiety for BLS, Pre-Factor 2: willingness to be an instructor, Pre-Factor 3: willingness to improve one’s own BLS abilities, and Pre-Factor 4: willingness to develop their BLS skills with others. Cronbach’s alpha coefficients calculated based on the answers to these questions for each factor were calculated to be: Pre-Factor 1=0.904, Pre-Factor 2=0.938, Pre-Factor 3=0.943, and Pre-Factor 4=0.959.

Table 2. Results of Factor Analysis in Pre Questionnaire

Question	Pre-Factor 1	Pre-Factor 2	Pre-Factor 3	Pre-Factor 4
Q7	0.750	−0.072	0.010	−0.091
Q13	0.728	−0.107	−0.002	0.260
Q15	0.698	−0.095	0.108	0.139
Q14	0.688	−0.047	−0.003	0.157
Q8	0.605	−0.080	0.008	0.048
Q12	0.603	−0.084	0.091	0.288
Q6	0.582	0.152	0.213	0.018
Q11	0.567	0.070	−0.173	0.229
Q21	0.046	1.017	0.049	−0.111
Q22	0.054	0.958	0.018	−0.024
Q23	−0.079	0.684	−0.037	0.115
Q17	0.006	−0.048	0.985	0.010
Q18	0.037	0.119	0.886	−0.048
Q3	−0.773	−0.041	0.123	0.083
Q20	−0.292	0.437	0.220	0.540
Q19	−0.332	0.462	0.175	0.507
Q4	−0.638	0.069	0.066	0.177
Q5	−0.678	−0.038	0.026	0.103
Cronbach’s alpha coefficients	0.904	0.938	0.943	0.959
Contribution rate	28.93	23.37	16.85	10.39
Commulative contribution rate	28.93	52.30	69.16	79.55
Eigenvalues	7.26	4.20	1.54	1.22

Pre-Factor 1: anxiety for BLS, Pre-Factor 2: willingness to be an instructor, Pre-Factor 3: willingness to improve one’s own BLS abilities, and Pre-Factor 4: willingness to develop their BLS skills with others.

Hierarchical cluster analysis was performed using the factor scores calculated from the factor analysis based on data collected before the course (Fig. 2). The participants were classified into three groups: A–C. The mean and standard deviation values of the factor scores for each group were calculated and are presented in Table 3. Group A comprised of 28 participants (28.3%) and was the group with the lowest factor scores for Pre-Factors 1, 2, and 3. Group B comprised of 50 participants (50.5%) and was the group with the highest factor scores for Pre-Factors 1 and 4. Group C comprised of 21 participants (21.2%), was a group with a low factor score for Pre-Factor 1 and high factor scores for Pre-Factors 2 and 3.

Fig. 2. Results of Cluster Analysis Using Pre Questionnaire Data

Table 3. Factor Scores of A to C Group

Cluster	Number	Rate(%)	Pre-Factor 1	Pre-Factor 2	Pre-Factor 3	Pre-Factor 4
A	28	28.3	0.03±0.70	−0.74±0.78	−0.67±0.96	−1.04±0.58
B	50	50.5	0.46±0.69	−0.08±0.80	0.00±0.87	0.58±0.70
C	21	21.2	−1.13±0.92	1.17±0.55	0.90±0.36	0.00±0.61

Pre-Factor 1: anxiety for BLS, Pre-Factor 2: willingness to be an instructor, Pre-Factor 3: willingness to improve one’s own BLS abilities, and Pre-Factor 4: willingness to develop their BLS skills with others.

Table 4 shows the results of the factor analysis based on the answers to Q3–Q23 after the course. Three factors with eigenvalues greater than one were extracted, with a cumulative contribution rate of 91.6%. No question had a commonality of less than 0.16; therefore, the answers to all questions were subjected to factor analysis. Factors were defined as follows: Post-Factor 1: anxiety about BLS, Post-Factor 2: active involvement in BLS and willingness to improve BLS skills; Post-Factor 3: willingness to be an instructor and develop their BLS skills with others. Cronbach’s alpha coefficients calculated based on the answers to these questions for each factor were calculated to be: Post-Factor 1=0.936, Post-Factor 2=0.926, and Post-Factor 3=0.948.

Table 4. Results of Factor Analysis in Post Questionnaire

Question	Post-Factor 1	Post-Factor 2	Post-Factor 3
Q14	0.956	−0.080	0.125
Q13	0.917	−0.059	0.124
Q15	0.898	0.060	−0.004
Q12	0.838	−0.144	0.138
Q7	0.736	0.095	−0.171
Q9	0.732	0.045	0.013
Q11	0.703	−0.094	−0.021
Q6	0.612	−0.019	−0.016
Q10	0.560	0.042	−0.217
Q8	0.555	0.004	−0.125
Q18	0.132	0.998	0.000
Q17	−0.021	0.915	−0.047
Q16	−0.109	0.672	0.086
Q5	−0.074	0.668	0.026
Q3	−0.038	0.637	0.071
Q21	−0.052	−0.028	0.967
Q22	−0.086	0.038	0.931
Q23	−0.046	0.141	0.629
Q20	0.009	0.415	0.597
Q19	0.064	0.445	0.584
Cronbach’s alpha coefficients	0.936	0.926	0.948
Contribution rate	35.18	32.40	30.26
Commulative contribution rate	28.93	61.33	91.59
Eigenvalues	9.73	3.66	1.42

Post-Factor 1: anxiety about BLS, Post-Factor 2: active involvement in BLS and willingness to improve BLS skills; Post-Factor 3: willingness to be an instructor and develop their BLS skills with others.

Hierarchical cluster analysis was performed using the factor scores calculated from the factor analysis based on data collected after the course (Fig. 3). The participants were classified into three groups, D–F. The mean and standard deviation values of the factor scores for each group were calculated and are presented in Table 5. Group D comprised of 24 (24.2%) participants, with a high factor score for Post-Factor 1 and low factor scores for Post-Factors 2 and 3. Group E comprised of 52 (52.5%) participants, with a slightly higher factor score for Post-Factor 1 and slightly lower factor score for Post-Factor 2. Group F comprised of 23 (23.2%) participants who had a low factor score for Post-Factor 1 and high factor scores for Post-Factors 2 and 3.

Fig. 3. Results of Cluster Analysis Using Post Questionnaire Data

Table 5. Factor Scores of D to F Group

Cluster	Number	Rate(%)	Post-Factor 1	Post-Factor 2	Post-Factor 3
D	24	24.2	0.49±0.69	−1.30±0.68	−1.18±0.60
E	52	52.5	0.16±1.00	−0.20±0.66	0.03±0.68
F	23	23.2	−0.88±0.56	0.90±0.08	1.17±0.06

Post-Factor 1: anxiety about BLS, Post-Factor 2: active involvement in BLS and willingness to improve BLS skills; Post-Factor 3: willingness to be an instructor and develop their BLS skills with others.

Table 6 shows the simple tabulation of the answers to the PUSH course satisfaction questions. A ceiling effect was observed for all questions, indicating high levels of satisfaction with the PUSH course among the enrolled pharmacy students.

Table 6. Simple Tabulation of the Questionnaire Post Q1 to Q2

Question	Answer (n=99)
		1	2	3	4	5	6	7	8	9	10
Post Q1	Dissatisfaction	0	0	0	0	1	1	1	17	26	53	Satisfaction
Post Q2-1	Dissatisfaction	0	0	0	0	0	3	2	19	17	58	Satisfaction
Post Q2-2	Dissatisfaction	0	0	0	1	1	2	5	19	22	49	Satisfaction
Post Q2-3	Dissatisfaction	0	0	1	0	0	0	4	18	20	56	Satisfaction
Post Q2-4	Dissatisfaction	0	0	0	0	1	1	5	18	19	55	Satisfaction
Post Q2-5	Dissatisfaction	0	0	1	1	1	3	3	13	19	58	Satisfaction
Post Q2-6	Dissatisfaction	0	0	0	1	1	1	1	17	23	55	Satisfaction
Post Q2-7	Dissatisfaction	0	0	0	0	2	2	8	11	18	58	Satisfaction
Post Q2-8	Dissatisfaction	0	0	0	2	1	2	2	10	25	57	Satisfaction

DISCUSSION

In this study, pharmacy students were enrolled in the PUSH course as part of the BLS training strategy. Changes in BLS awareness before and after the course, factor analysis, and hierarchical cluster analysis were used to stratify the students and determine their satisfaction with the course.

The consent acquisition rate in this study was 84.6%, which is comparable to a previously reported pharmaceutical education study based on a questionnaire survey of Japanese pharmacy students.^16,17) Among the participants, 34 (34.3%) had requested an ambulance, which was similar to an internet survey of the Japanese general public conducted by Nakazawa et al.¹⁸⁾ Simple tabulation of the answers to questions regarding confidence, preparedness, anxiety, and willingness to teach BLS before and after the course revealed that the PUSH course increased confidence, preparedness, and willingness to teach BLS, and reduced anxiety about BLS in the participants, except for questions Q10, Q17, and Q18. Therefore, it is suggested that the PUSH course, a BLS course for citizens, is an adequate BLS educational strategy for pharmacy students. Factor analysis based on the answers to the pre- and post-course questionnaires extracted four factors before the course and three factors after the course. Cronbach’s alpha coefficients for each of the extracted factors was high, suggesting that the results from this study have a degree of reliability. Pre-Factor 1 and Post-Factor 1 were defined as “Anxiety about BLS” both before and after the course, but the questions that composed the factor were different between before and after the course. Before the course, the factor loadings for Q3–Q5 were negative, indicating anxiety about BLS among the participants and the lack of confidence in their ability to perform BLS accurately in situations when it is needed. However, after the course, Pre-Factor 3 and a part of Pre-Factor 1 are theorized to have inverted to form Post-Factor 2. This suggests that the PUSH course reduced anxiety regarding BLS and increased confidence and readiness in the participants. A similar trend was observed in the hierarchical cluster analysis before and after the course. Before the course, group B comprised of 50 participants who were highly anxious about BLS. However, after the course, the number of participants in group D who were highly anxious about BLS reduced to 24. Group D also had low factor scores for Post-Factor 2 and Post-Factor 3 and may be considered a group in which the educational effectiveness of the PUSH course was low, and the participants in these groups may require other strategies to improve their confidence and reduce anxiety about BLS. Although participants in group C initially had low anxiety about BLS and were willing to become BLS instructors, and improve their own BLS skills, they were not willing to develop their BLS skills with others. However, participants in group F, with similar tendencies as group C, were highly willing to develop their BLS skills with others. The probable reason for this may be that the participants learned through the course that in a situation where BLS is necessary, they cannot save the patient without help from others. This caused a change in their perspective about BLS and highlighted the importance of collaboration with others in a situation where BLS is necessary.

Questions related to satisfaction with the PUSH course confirmed high levels of satisfaction across all questions. Since conventional BLS courses require anywhere between 3 h to half a day to complete, adjustments like timetable changes need to be made to allow integration of such courses into the higher education system, where classes are often 90 min long. The results of this study suggest that the PUSH course could be applied to pharmacy education.

Iwami, one of the PUSH course developers, suggested since sudden cardiac deaths are so frequent, pharmacists are more likely to encounter situations involving sudden cardiac arrest or similar situations in healthcare facilities, pharmacies, and schools. Therefore, it is essential that practicing pharmacists across different medical institutions are well equipped with knowledge on BLS to prevent sudden cardiac deaths.¹⁹⁾ Akatsuka, who is a paramedic, also noted that people seek help in pharmacies and drugstores when they feel unwell, because citizens recognize pharmacists as healthcare professionals and trust them.¹⁹⁾ There is a growing need for BLS education and awareness among pharmacists, and the PUSH course is a useful strategy to integrate BLS education into the pharmacy education system.

The limitations of this study include the limited number of participants included in the analysis (n=99); the fact that since the analysis was based on the results from questionnaires before and after the course, long-term changes in perspective about BLS could not be studied; and the fact that it is difficult to extrapolate the results in a single university to other pharmaceutical institutions because results may vary across different universities.

In this study, pharmacy students were enrolled in the PUSH course as part of the BLS training strategy, and its change in improving BLS awareness was examined. The results showed that some participants became more aware about BLS after the PUSH course, and the participants showed high levels of satisfaction with the course, suggesting that the PUSH course, a BLS course for citizens, can be integrated into the pharmacy education system in Japan.

Acknowledgements

The Hyogo University of Health Sciences Research Grant partially supported this research.

Conflict of Interest

The authors declare no conflict of interest.

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