Study protocol of a prospective observational study on the impact of specialized nutritional care on the 3-month outcomes of patients at high risk of malnutrition admitted to a rehabilitation hospital

Abstract

Aim

Malnutrition is an often underestimated, worldwide, frequent problem with a high prevalence among inpatients, especially the elderly ones. Undernourished patients have an increased risk of comorbidities, complications and a decreased quality of life. Malnutrition is associated with longer hospital stay, increased care needs and costs for the National Health Service (NHS). We describe the protocol of a study conducted to evaluate the impact of specialized nutritional care on 3-month outcomes of patients at high risk of malnutrition at admission and to describe the actual nutritional practice in a rehabilitation setting.

Methods

In this single-center, prospective, observational study patients at high risk of malnutrition who received standard nutritional care (Group 1) were compared with patients at high risk of malnutrition who received a specialized nutritional care (Group 2). Three months after discharge (follow-up), patients of both groups were interviewed by telephone to collect data regarding number of hospital readmission, emergency department admission, general practitioner (GP) and outpatient visits, diagnostic tests, daily medication use and survival.

Conclusion

Our study could help to support clinical choices for personalized nutritional interventions to improve rehabilitation outcomes and to decrease the costs for the NHS. This protocol is registered at ClinicalTrials.gov (NCT07183098) under the title “A Prospective Observational Study on the Prevalence of Malnutrition and Clinical-Economic Aspects of the Impact of Specialized Nutritional care on the 3-month Outcomes of Patients at high Risk of malnutrition Admitted to a Rehabilitation Hospital”.

Keywords

malnutrition rehabilitation healthcare costs MUST dietitians

Introduction

Insufficient intake or uptake of nutrients compared with body needs can result in malnutrition, specifically undernutrition, which alters body composition and leads to decreased physical and cognitive function impairing clinical outcomes.¹

Disease-related malnutrition (DRM) with or without inflammation is the principal form of malnutrition in high-income countries¹ and is reported to be the most frequent comorbidity in diverse settings² especially in inpatients.³

DRM with inflammation is a catabolic condition in which the inflammatory status is among the etiologic mechanisms and muscle catabolism is maintained by a vicious circle between inflammation and malnutrition.¹ Notably, also central obesity in overweight/obese patients may be linked to malnutrition, due to its association with inflammation.¹ In DRM without inflammation alternative mechanisms such as dysphagia, reduced gastrointestinal (GI) uptake or neurologic disorders are etiologic mechanisms.

Advanced age contributes per se to undernutrition both through the inflammatory status in DRM with inflammation and through anorexia in DRM without inflammation.¹

Extensive evidence highlights the key role of protein-caloric malnutrition (PCM) in affecting patient's outcomes, such as wound and disease recovery, morbidity, length of hospital stay, functional and cognitive status, mortality, and healthcare costs.⁴

Patients are commonly already at nutritional risk upon hospital admission² and hospitalization per se is a major risk factor for further worsening of nutritional status.³

Throughout hospital stay, nutritional support has both a preventive role for patients at risk to be undernourished and is a treatment in overt undernourished patients.³

Nevertheless, nutritional care routines in hospital setting receive very poor attention due to different reasons such as the lack of time and knowledge of healthcare professionals and also the lack of a fast-acting effect on clinical outcomes of nutritional support.^3,5,6

Building on previous evidence from Project: Iatrogenic MAlnutrition in Italy (PIMAI) study which described the prevalence of nutritional risk in multidisciplinary hospitals in Italy^4,6,7 and collected data mainly from general medicine and general surgical wards, this paper describes the methodology of a study conducted at the rehabilitation Scientific Institute for Research, Hospitalization and Care, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Organizzazione Non Lucrativa di Utilità Sociale (ONLUS) of Florence, aiming to evaluate the impact of specialized nutritional care during hospitalization on 3-month outcomes of patients at high risk of malnutrition and to describe the actual nutritional practice in a rehabilitation setting.

Materials and methods

Study design and setting

We conducted a single-center, prospective, observational study to compare 3-month outcomes in patients at high risk of malnutrition based on the type of nutritional care received and to describe the actual nutritional practice in a rehabilitation hospital. Patients were recruited from a large rehabilitation hospital, the IRCCS Fondazione Don Carlo Gnocchi of Florence, where there is a Dietetic and Clinical Nutrition Service (DCNS) composed by physicians and dietitians. IRCCS Fondazione Don Carlo Gnocchi of Florence is a general rehabilitation and research hospital with 180 beds that admits over 3000 patients each year, primarily referred to by acute care hospitals. IRCCS Fondazione Don Carlo Gnocchi of Florence delivers rehabilitation programs with direct public health coverage. The rehabilitation program consists of a tailored exercise-based physiotherapy program of two one-hour sessions per day for 5 days a week, following a standardized protocol. Exercises are different for intensity and difficulty, according to the specific rehabilitation goals and the patient's clinical characteristics, and they are practiced under the therapist supervision.⁸

The study was performed between April 2018 and December 2022 and data were collected in 36 months with a discontinuation from March 2020 to November 2021 due to restrictions imposed by the COronaVIrus Disease-19 (COVID-19) pandemic.

In accordance with the European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines⁹ and with the internal protocol, at IRCCS Fondazione Don Carlo Gnocchi, nutritional risk of all patients admitted to the facility is routinely assessed using the validated Malnutrition Universal Screening Tool (MUST) tool¹⁰ within 24–48 h of hospitalization.

Patients of different age, not only geriatric patients, are referred to IRCCS Fondazione Don Carlo Gnocchi for rehabilitation therefore, malnutrition risk is assessed using Malnutrition Universal Screening Tool (MUST) which can be easily used in adults and in different settings.

According to the internal protocol, for patients with MUST score ≥ 2 (at high risk of malnutrition) the ward's attending medical team should activate the DCNS with an explicit request since the DCNS cannot autonomously initiate evaluation. However, in actual clinical practice not all patients with MUST score ≥ 2 are regularly referred to the DCNS.

Patients enrolled were therefore divided into two groups based on the type of nutritional care received.

Group 1 included patients with a MUST score ≥ 2 at admission who were not referred to the DCNS and received standard nutritional care.

Group 2 included patients with MUST score ≥ 2 at admission for whom the DCNS was actively consulted and who received specialized nutritional care.

Group assignment was not randomized as it reflected real-world clinical routines.

Three months after discharge, all enrolled patients of both groups were monitored through telephone by a structured follow-up interview.

The Ethics Committee of the IRCCS Fondazione Don Carlo Gnocchi ONLUS approved the study; approval number: Prot. N.16/2018/CE_FdG/FC/SA (5/4/2018); the study was carried out in adherence to the principles established by the Declaration of Helsinki. The number of ClinicalTrials.gov Identifier is NCT07183098.

Study population and enrolment

Inclusion criteria were MUST ≥ 2 and age ≥ 50 years. Exclusion criteria were age under 50 years; terminal illness with a prognosis < 6 months and /or with advanced or irreversible cachexia and end-stage renal disease (dialysis); patients already participating in a cardiac rehabilitation program at the time of enrollment and patients with severe acquired brain injuries. In this study were included patients admitted to neurological, pneumological, cardiological and orthopedic rehabilitation wards.

Patients with severe acquired brain injuries were excluded to ensure homogeneity in clinical progress during hospitalization, equivalent nutritional needs and care pathways, and to reduce confounding factors due to disease-specific prognosis or rehabilitation protocols.

Patients who met all the inclusion criteria and were considered eligible to participate in the study were asked to sign the written informed consent and were formally enrolled by the researchers of the DCNS. Patients or legal surrogates of all unconscious patients signed a written informed consent.

Outcome measures

The primary outcome was the rate of hospital readmission at three months post-discharge.

At three months post-discharge, as secondary outcomes were also evaluated: the number of emergency department admissions, GP and outpatient visits, diagnostic tests, daily medication use as a proxy for treatment burden and mortality rate.

Data collection

Data were prospectively collected by researchers of the DCNS from electronic and medical records using a standardized form and, then, entered into a dedicated, pseudonymized, password-protected database.

For all enrolled patients, at admission, the following variables were collected: age, sex, reason for hospital admission, nutritional risk and comorbidity burden assessed using the Charlson Comorbidity index (CCI).

At admission, nutritional risk was assessed using the MUST score. Nutritional diagnosis was performed according to the ESPEN 2015 criteria¹ and, from 2019, according to the Global Leadership Initiative on Malnutrition (GLIM) criteria.¹¹

The length of hospital stay, expressed in days, was calculated from admission to discharge.

Ninety days (three months) after discharge (follow-up), the following variables were collected: survival rate, number of emergency department admissions, hospital readmissions, GP visits and outpatient visits, diagnostic tests performed and daily medication use as a proxy for treatment burden.

Nutritional risk assessment

Nutritional screening is the first step in identifying patients at risk or potentially at risk of malnutrition.

In accord with the ESPEN guidelines,⁹ at IRCCS Fondazione Don Carlo Gnocchi, nutritional risk is routinely assessed using the MUST tool¹⁰ within 24–48 h after hospitalization. This tool is a five-step screening method, developed by the British Association for Parenteral and Enteral Nutrition (BAPEN) which can be used in adults, in different settings, by all care workers, with a sensitivity and specificity of 61% and 76%, respectively.^10,12 Step 1 includes the measure of height and weight to obtain body mass index (BMI) score; step 2 reports the percentage of unplanned weight loss and step 3 evaluates acute disease effect (whether the patient is acutely ill) and starvation (whether it is likely that there has not been any nutritional intake for more than 5 days). Each step from 1 to 3 is scored from 0 to a maximum of 2 points. Step 4 involves summing scores from previous steps to determine the overall risk of malnutrition and step 5 provides guidelines to develop a personalized and appropriate nutritional care plan. A total MUST score = 0 corresponds to a low nutritional risk, a total score = 1 a medium risk and a total score ≥ 2 indicates a high risk of malnutrition.¹⁰

MUST steps 1 and 2: Nutritional measurements

Body weight, expressed in Kg, is measured on a leveled platform scale (capacity 150 kg, graduation 0.1 Kg, SECA, Germany), with patients wearing light clothes. In bedridden patients, body weight is measured by a lifter (capacity 360 kg, graduation 0.2 Kg, Liko M230, Hillrom, Germany) and in patients unable to maintain an upright position a wheelchair platform scale is used (capacity 300 kg, graduation 100 g, MARSDEN, United Kingdom).

Body height, expressed in meters, is measured on a wall-mounted stadiometer (SECA, Germany), with patients standing barefoot, upright looking straight ahead, and holding their head in the Frankfurt-horizontal plane. For bedridden patients or those unable to stand upright, height is estimated by measuring the length of the left (preferably, when possible) forearm (ulna) between the elbow (olecranon process) and the midpoint of the styloid process (wrist's prominent bone)¹⁰.BMI is then calculated as [weight (Kg)]/ [height (m)]².

Data concerning history of recent (past 3–6 months) unintentional weight loss are obtained through medical records or patient/caregiver's anamnestic recall.

The unplanned weight loss, expressed as a percentage (%), is calculated using the following equation: [(past 3–6 months weight- current weight)/ past 3–6 months weight] x 100.

Malnutrition risk is reassessed at least once a week using the validated MUST screening tool.

Malnutrition diagnosis

At IRCCS Fondazione Don Carlo Gnocchi in accordance with a two-step model for nutritional status assessment, the first step of malnutrition risk screening is followed by the second step of malnutrition diagnosis and severity grading.¹¹

At least one phenotypic criterion and one etiologic criterion is required to confirm the diagnosis of malnutrition in accordance with the GLIM criteria.¹¹ Phenotypic criteria encompass unintentional weight loss, low BMI and reduced muscle mass; etiologic criteria encompass reduced food intake/assimilation and disease burden/inflammation. Phenotypic criteria alone are used to grade the severity of malnutrition, while etiologic criteria serve to guide proper nutritional intervention.¹¹

In the first months of the study, malnutrition diagnosis was performed according to the ESPEN 2015 criteria due to the fact that the study began in April 2018, prior to the publication of the GLIM criteria.¹ ESPEN 2015 criteria recommended two options to diagnose malnutrition: the first alternative required a low body mass index and the second alternative required unintentional weight loss in combination with both low body mass index and reduced muscle mass.¹

Patients who were enrolled before the release of the GLIM criteria were retrospectively re-evaluated according to the GLIM framework to ensure consistency in malnutrition classification and to standardize the results.

Description of ward's nutritional routines (standard nutritional care)

At IRCCS Fondazione Don Carlo Gnocchi in Florence the overall clinical management of patients by ward's staff includes also nutritional care.

At admission, the ward's nursing staff screens patients for nutritional risk using the validated MUST tool.

The attending ward's physician prescribes a nutritional plan based on the underlying disease, patient's current clinical needs and on-going treatments, in alignment with prior recommendations from the referring hospital and the institutional dietary protocols developed by the DCNS. IRCCS Fondazione Don Carlo Gnocchi's dietary protocols encompass unrestricted diets or therapeutic diets e.g., diets for patients suffering from renal failure. In case of dysphagia, patients are evaluated by a speech therapist and receive a texture-modified diet in accordance with internal protocols and evidence-based guidelines. In patients unable to be safely fed via the oral route, the ward's physician prescribes artificial nutrition. Nutritional care plans are adapted during hospitalization in response to changes in the patient's clinical needs. During hospitalization, the ward's attending physician prescribes laboratory analyses in accordance with the underlying disease, patient's current clinical needs and ongoing treatments. The decision to re-assess and monitor the patient's nutritional risk is guided by clinical judgment. Body weight is monitored periodically during the hospital stay, though not systematically.

Description of the dietetic and clinical nutrition service's nutritional routines (specialized nutritional care)

Patients referred to the DCNS receive a structured, evidence-based diagnostic and therapeutic support.

A dietitian of the DCNS, in a one-hour meeting, performs a detailed dietary assessment evaluating habitual oral intake during the period before the admission. Anamnestic data regarding nutritional status (e.g., weight history, food allergies/intolerances, physical activity) and metabolic status (e.g., history of dyslipidemia, diabetes, hypertension, cardiovascular diseases) are collected along with data regarding comorbid conditions.

DCNS's staff also collects data regarding prescribed drugs which may negatively affect nutritional status by drug-nutrient interaction or nutrition-related side effects.

In the absence of recent or sufficient laboratory data useful to fully evaluate the patient's nutritional status, the attending physicians of the DCNS prescribe a baseline set of relevant laboratory analyses if not yet prescribed by ward's physicians. These may include, but are not limited to: complete blood count, prealbumin, serum albumin, total protein levels, total cholesterol, iron panel, folate, B12 vitamin, 25-hydroxyvitamin D, thyroid-stimulating hormone (TSH), serum electrolytes and minerals (e.g., K, Mg, Ca, P), C-reactive protein (CRP) and 24-h urinary urea nitrogen (when indicated).

According to national and international guidelines, clinical and laboratory parameters are re-assessed periodically on the basis of the underlying disease, patient's current clinical needs and ongoing treatments.^13,14

Malnutrition diagnosis is performed using the GLIM criteria and according to the ESPEN 2015 criteria before 2019.^1,11 When direct measurement of height is not feasible, DCNS's dietitians estimate it using validated predictive equations based on segmental anthropometry as described above. Weight is monitored almost weekly according to clinical condition and nutritional problems, in order to systematically re-evaluate patient's nutritional risk and status.

Each patient referred to the DCNS receives a tailored nutritional plan to reach protein and caloric goals.

A dietitian of the DCNS calculates the daily individual caloric goal for each patient using the weight-adjusted Harris-Benedict equation and prescribes the documentation of oral intake for three consecutive days.

The Harris-Benedict equation calculates the Basal Metabolic Rate (BMR) and is used to predict daily resting energy requirements.¹³ Harris-Benedict equation is adjusted for sex, weight, height and age.¹³

BMR for men is calculated as follows: 66.5 + [(13.75 x current weight (Kg)] + [(5 x height (cm)] – [(6.75 x age (years)].

BMR for women is calculated as follows: 655 + [(9.563 x current weight (Kg)] + [(1.85 x height (cm)] – [(4.67 x age years)].¹³

In patients who can be safely oral fed, BMR is then adjusted for physical activity and disease.¹³

A daily protein intake (1.2–1.5 g/Kg body weight) and energy intake (30–35 Kcal/Kg body weight) is provided in accord with ESPEN guidelines.^15,16 For patients at nutritional risk with impaired kidney function a low amount of proteins is recommended whereas, in case of sepsis a higher amount of proteins is recommended

When reduced food intake is suspected, food intake is monitored for three consecutive days using a standardized assessment model which includes the estimation of dietary intake.¹⁰

In accordance with clinical national and international guidelines, the individualized nutritional plan includes oral nutrition adapted to all types of patients and clinical special needs, oral nutritional supplements (ONS) when dietary intake is insufficient to meet energy and protein requirements and artificial nutrition (enteral and parenteral nutrition) when oral intake remains inadequate or is not feasible.^13,14

It is important to reach at least 75% of calculated nutrition goals to reduce the risk of adverse outcomes and mortality.¹⁴ Patients with dysphagia receive a texture-modified diet in accordance with speech therapist prescriptions and national and international guidelines.^13,14

Patients referred to the DCNS are monitored regularly and systematically, daily or weekly according to the patient's clinical condition and nutritional problems, in order to re-evaluate the patient's nutritional risk and status. Each referred patient is regularly revaluated in a 30–40 min meeting from dietitians of the DCNS.

Sample size estimation

The sample size was estimated based on the expected difference in three months hospital readmission rates between group 1 and group 2. A readmission rate of 30% was assumed for group 1 (patients receiving standard nutritional care) and 12% for group 2 (patients receiving specialized nutritional care). To detect this difference with 80% power at two-sided significance level of 5%, a minimum of 158 patients (79 per group) was required. Accounting for a potential dropout rate of 10%, the final target sample size was 174 patients.

Discussion

This study was designed i) to evaluate the impact of a specialized nutritional support on clinical outcomes; ii) to estimate the treatment burden considered as a proxy of the economic impact on the NHS and iii) to describe the actual nutritional practice in a rehabilitation setting with the aim to design future effective educational interventions to increase the awareness of all the healthcare professionals on the importance of an early identification of patients at risk to be undernourished or already undernourished and to improve knowledge on the importance of a specialized nutritional support.

Disease-related malnutrition continues to be a significant problem in inpatients. A poor nutritional status, regardless of the underlying clinical condition, is a well-known risk factor for prolonged hospitalization and incidence of major complications, such as pressure ulcers, with a negative impact on healthcare costs, and it is an independent predictor of hospital readmission and mortality after discharge.^17,18

In contrast with many other diseases, a poor nutritional status is a preventable and, in many cases, reversible condition when recognized early and managed with a proper nutritional intervention.¹⁹

Prevalence of malnutrition differs significantly between studies due to numerous factors such as setting, underlying disease and screening methods.

Community setting shows the lowest percentage of malnutrition when compared to acute and subacute settings which have the highest prevalence of malnutrition.²⁰ Additionally, older and female patients have the highest percentage of malnutrition.²⁰

The high prevalence of hospital malnutrition has been attributed to different reasons such as lack of awareness, knowledge or skills among healthcare practitioners and scarce communication and collaboration among all involved stakeholders.¹⁷

Furthermore, the lack of a widely accepted gold standard to screen the risk of malnutrition in different populations and clinical settings is often one of the major limiting factors of performing screening and hinders the early identification of patients at high risk to be undernourished.¹⁹

In 2004, the Federation of Nutritional Italian Societies (FeSIN) designed a multicentric study to provide data on the prevalence of nutritional risk and disease-related malnutrition upon admission to 13 large multidisciplinary regional acute hospitals in Italy: the Project: Iatrogenic Malnutrition in Italy (PIMAI) study.^4,7

The PIMAI study was focused on acute patients from a broad range of specialties but most of them were from general medicine and surgery.

Evidence from PIMAI study showed a 28.6% prevalence of nutritional risk and a 30.7% prevalence of malnutrition, with marked differences among specialties and higher rates in medical wards.^4,7

The PIMAI study provided information also on nutritional care routines in Italy on the basis of diverse factors such as the attitude of the ward staff toward assessing the nutritional status, prescribing nutritional therapy and monitoring weight during the hospital stay.⁶ PIMAI study confirmed that in Italy, nutritional care routines are poor: only 38.2% of patients have their BMI calculated at admission and only 21.6% of patients have their weight monitored during hospitalization.⁶

Additionally, almost 80% of patients with overt malnutrition did not receive any nutritional support.⁶

In our rehabilitation hospital, one of the barriers most frequently reported by health professionals that prevents the nutritional screening of patients at admission and the monitoring during hospitalization is the lack of time.

The same barrier was highlighted in a previous study conducted on oncological patients.⁵ The results of our study could help to highlight that daily nutritional practice is a significant contributing factor to improving the health and quality of life of patients and caregivers and to reducing economic costs for patients and the NHS without being time-consuming for health professionals.

In 2003, ESPEN provided guidelines to assess the risk of malnutrition in different settings and recommended MUST as one of the validated screening tools which can be used in different care settings such as hospitals, outpatient clinics, general practice, nursing and care homes.^9,10

In accord with ESPEN guidelines, in our hospital nutritional risk is routinely assessed using MUST by nursing staff.

In a previous review focused on stroke patients, we reported that nutritional risk evaluated at admission by MUST has been frequently associated with numerous parameters such as infection rate, level of consciousness, disability at discharge, length of hospital stay and hospitalization costs.²¹

Previous evidence has showed that a large part of patients admitted to rehabilitation settings is undernourished or at high risk of becoming undernourished and hospitalization is an important risk factor to develop malnutrition.²²

In the actual clinical practice of IRCCS Fondazione Don Carlo Gnocchi of Florence not all patients with MUST score ≥ 2 are regularly referred to the DCNS. As previously shown by Spiro et al.,⁵ health professionals recognize the importance and the priority of a good nutritional practice but, sometimes, lack the proper education to identify patients at risk of malnutrition who may benefit from a specialized nutritional support. The results of our study could help to design nutritional education interventions and courses to improve nutritional practices also in rehabilitation hospitals without a DNCS or a nutrition team.

Evidence showed that decreased food intake is associated with increased in-hospital and 90-day mortality and complications.¹⁴

It is important to reach at least 75% of calculated nutrition goals to prevent weight and muscle mass loss that may cause decreased functionality¹⁴ and to significantly reduce the risk of mortality and adverse events.²³

A personalized nutritional support has been proven to be associated with higher energy and protein intake and a better nutritional status, with decreased rates of nonelective hospital readmissions and with significantly lower rates of mortality, particularly in patients with established malnutrition.²⁴

In our rehabilitation hospital, patients referred to the DCNS receive a specialized and tailored nutritional support.

This study was designed also with the aim to highlight the health and economic consequences of a specialized nutritional support not only for patients but also for the NHS and to raise awareness among Institutions and hospital medical directors.

A timely and proper evaluation of the nutritional status of inpatients at admission and during hospitalization is possible not only with an educated staff but also with an adequate number of specialized health professionals.

Conclusions

In conclusion, our study was designed to raise attention on the importance of a prompt evaluation of nutritional risk and a proper and specialized treatment of undernourished/at high risk of malnutrition patients to provide a high-quality nutritional care in rehabilitation. To our knowledge, previous evidence was focused on acute and post-acute clinical settings lacking data collected in rehabilitation settings.

Our study could help to support clinical choices for personalized nutritional interventions with the aim to improve rehabilitation outcomes and patients’ quality of life and to decrease the healthcare costs not only for patients and caregivers but also for the NHS. The protocol also emphasizes the role of specialized personnel and the importance of adequate specialized staffing to ensure a prompt and proper nutritional support.

Footnotes

Acknowledgments

The Authors would like to thank the Medical Director and the Rehabilitation Department Director of IRCCS Fondazione Don Gnocchi ONLUS of Florence.

ORCID iDs

Chiara Francesca Gheri

Alessandra Consales

Barbara Biffi

Giacomo Di Filippo

Sara Madiai

Maria Luisa Eliana Luisi

Ethics statement

This study was approved by the Ethics Committee of IRCCS Fondazione Don Carlo Gnocchi ONLUS (Ethics Code: N.16/2018/CE_FdG/FC/SA-5/4/2018) on April 05, 2018. All participants provided written informed consent prior to enrolment in the study. This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Author contributions

Chiara Francesca Gheri: Writing -original draft, Visualization. Lucio Lucchin: Conceptualization, Methodology. Alessandra Consales: Methodology, Investigation, Writing -review & editing. Barbara Biffi: Data curation, Project administration. Silvia Pancani: Formal analysis. Giacomo Di Filippo: Formal analysis. Sara Madiai: Resources. Miriam Cavaleri: Investigation. Rebecca Celoni: Investigation. Francesca Campani: Investigation, Methodology. Sofia Vidali: Methodology. Benedetta Giusti: Investigation. Claudio Macchi: Supervision. Maria Luisa E Luisi: Conceptualization, Funding acquisition, Validation.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Fondazione Ente Cassa di Risparmio di Firenze.

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

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