Anaesthesia 2012, 67, 1356–1363 doi:10.1111/anae.

12034

Original Article
Assessment of block height for satisfactory spinal anaesthesia for
caesarean section
1 1
R. Ousley, C. Egan, K. Dowling2 and A. M. Cyna3,4

1 Registrar, 3 Senior Consultant Anaesthetist, Department of Women’s Anaesthesia, 2 Statistician, Department of Public
Health, Women’s & Children’s Hospital, Adelaide, Australia
4 Clinical Senior Lecturer, University of Adelaide, Adelaide, SA, Australia

Summary
We investigated block heights that anaesthetists considered adequate for caesarean section to proceed under spinal
anaesthesia. During 3 months, 15 obstetric anaesthetists recorded block height to touch, pinprick or cold when spinal
anaesthesia was considered satisfactory for caesarean section to proceed. Median (IQR [range]) block height for touch,
pinprick, first cold and icy were: T10 (T7–T12 [T3–L1]); T5 (T4–T6 [C7–L1]); T5 (T4–T6 [C7–L1]); and T3 (T2–T4
[C7–L1]), respectively. Modalities were significantly correlated for: touch and cold, p = 0.0001; touch and icy,
p = 0.0007; touch and pinprick, p = 0.0018; cold and icy, p < 0.0001; cold and pinprick, p = 0.0001; icy and pinprick,
p < 0.0001. Pairwise comparisons showed differences between all modalities (p < 0.001) apart from pinprick and first
cold (p = 0.94). All women had satisfactory anaesthesia despite 76 (81%) having a block to touch below T6. Single
modality assessment of block height, particularly using touch, may erroneously indicate inadequate anaesthesia for
caesarean section.
. ..............................................................................................................................................................
Correspondence to: A. M. Cyna
Email: allan.cyna@health.sa.gov.au
Accepted: 9 September 2012

The assessment of block height following the adminis-
tration of a regional anaesthetic block for caesarean
section is said to be important for determining whether
there is satisfactory anaesthesia to allow surgery to
proceed and to practise to an appropriate standard [1].
Pain during caesarean section is one of the more
common reasons for a successful medicolegal claim [2].
However, assessments of block height rely on the
subjective experience and perceptions of the patient,
and the relationship between block height as assessed by
touch, pinprick or cold is variable [3, 4]. A number of
methods are used to assess block height [5] and some
workers have argued that the assessment of adequacy of
regional block with cold or sharp pinprick is at best
unhelpful, and at worst misleading, and that these
modalities should be abandoned in favour of touch.
Furthermore, it has been stated that, ‘If a block fails in
mid-surgery, even with cold or pinprick level at or above
T4, and there is no assessment indicating an adequate
level of block to touch preoperatively, then difficulties
for the anaesthetist lie ahead should litigation ensue’ [6].
Although this view was expressed in 2001 and based on
older data mostly obtained before the routine use of lipid
soluble opioids, other authorities have also stated that
‘we should be using touch rather than cold’ for testing
block height [1]. However, the reliance on touch alone
could lead to unnecessarily increasing the dose of local
anaesthetic injected during spinal anaesthesia, delaying

1356 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Ousley et al. | Block height for satisfactory spinal anaesthesia for caesarean section Anaesthesia 2012, 67, 1356–1363

the start of caesarean section, or even abandoning

perfectly adequate anaesthesia [7]. Modalities available
to assess block height include the NeurotipTM (Owen
Mumford, Oxford, UK), ethyl chloride spray and light
pressure with a finger to assess touch; an 18-G needle to
assess pinprick; and ethyl chloride spray, alcohol swab
and ice to assess temperature [5, 8–10]. There are
problems with some of these methods of assessment. For
example, the Neurotip may not be commonly available;
an 18-G cannula can cause trauma to the skin; and ethyl
chloride spray is relatively costly, unavailable in many
countries, and unfriendly to the environment. Ice, touch
and pinprick are commonly utilised methods of deter-
mining block height after spinal anaesthesia [5] perhaps
due in part to low cost, ready availability and clinicians’
familiarity.
Although various modalities have been tested in a
controlled way at various time intervals after injection of
intrathecal injectate [3, 9], there appears a paucity of
literature reporting the assessment of block height at the
time point when the anaesthetist considers that it is
satisfactory for the obstetrician to proceed with caesar-
ean section. We therefore aimed to investigate the block Figure 1 Diagram of dermatomes and table used to
height levels recorded by anaesthetists in our institution record the block height assessment for each modality
when spinal anaesthesia was assessed as clinically tested.
satisfactory for caesarean section to proceed.
between modalities of block, were deaf, or had a
Methods neurological disorder such as stroke. Information
The study was an observational study conducted in the regarding spinal anaesthesia was documented in, and
largest tertiary referral centre for maternity care in South later retrieved from, the patient’s anaesthetic chart,
Australia and ran from 22 September until 21 December including time of injection of drug; drug dose; spinal
2009. Following local human research ethics committee technique; time and block height when anaesthesia was
approval, anaesthetists were asked to use a modified considered satisfactory for surgery to proceed; and any
anaesthetic chart for recording assessments of block interventions recorded during surgery such as supple-
height when they considered that spinal anaesthesia was mentation or conversion to general anaesthesia.
adequate for caesarean section to proceed. This form Assessment of block height by the anaesthetist was
included a diagram of dermatomes and a table in which performed on both sides using touch, pinprick and cold
to record the block height for each modality tested in a standardised manner on each patient, using a
(Fig. 1). As such assessments were part of routine standardised explanation to patients. Ice was applied
anaesthetic care in our institution, the requirement for above the patient’s clavicle as a reference point and then
written patient consent was waived by our ethics applied to the L1 dermatome, asking the patient ‘Can
committee. you feel me touch you?’ If the woman stated that they
All women presenting for elective caesarean section could not feel anything, women were asked to report
under spinal anaesthesia were potentially eligible for when they first felt touch as the ice was moved
inclusion. Patients were excluded if they required an continuously cephalad in the mid-clavicular line. Once
interpreter, were unable to understand the distinction the patient stated at which dermatome level they were

Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 1357
Anaesthesia 2012, 67, 1356–1363 Ousley et al. | Block height for satisfactory spinal anaesthesia for caesarean section
able to feel touch, they were then asked to report when it
felt cold. Once patients stated that they could feel cold,
they were then asked to report when it felt icy cold
without change from the reference point. Pinprick was
assessed using an Interlink vial access cannula (BDTM,
North Ryde NSW, Australia; designed for needleless
access of rubber-topped vials) applied initially to the
patient’s clavicle. Then beginning at L1, the vial access
cannula was applied to the skin to successively more
cephalad dermatomes until the woman perceived the
sensation to be as sharp as that felt at the reference
point. The block heights for each modality were assessed
and recorded when the anaesthetist considered that the
woman had a satisfactory spinal anaesthesia block for
caesarean to proceed. Anaesthetists also recorded
whether the patient reported discomfort or needed an
analgesic ⁄ anaesthetic intervention at any time during
surgery, as well as the time and stage of the intervention.
Postoperatively, either in the recovery room or during
routine anaesthetic follow-up the next day, patients were
questioned in a standardised manner regarding whether
they were comfortable and satisfied with their anaesthe-
sia care during surgery and if they would have preferred
a general anaesthetic. Those patients missing assess-
ments before discharge from hospital were followed up
over the telephone at home.
The values analysed were the lower block height
level on the left or right sides for each modality for: first
sensation of touch; first sensation of cold; icy cold; and
pinprick when felt the same as the reference point. The
spinal segments from C7 or above to L2 were numbered
1–15 for data analysis. The Kruskal-Wallis test was used
to compare block levels between modalities, followed by
pairwise comparisons for significant differences. Fried-
man’s test was used to determine whether there were
differences between right and left heights of block.
Associations between the different modalities were
determined using Spearman’s correlations. Values of
p £ 0.05 were considered significant.
Results
Fifteen anaesthetists participated in the study: seven
consultants completed between one and 10 anaesthetic
charts each and eight registrars completed between one
and 11 charts each. Ninety-four women were included in
the study. All the anaesthetic charts had data suitable for
1358
analysis, although two patients’ records had missing data
for touch block height and three for pin prick. Indications
for surgery were previous caesarean section 57 women
(61%); breech or transverse presentation 10 women (11%);
previous vaginal trauma ⁄ surgery 4 (4%); twins 4 (4%);
pre-eclampsia 4 (4%); maternal request 3 (3%); intrauter-
ine growth restriction 2 (2%); placenta praevia 2 (2%);
postdates 2 (2%); and one each for macrosomia, fetal
abnormality, gestational diabetes and pelvic fracture. The
indications in two cases were unclear. The median (IQR
[range]) age of the women was 34 (28–37 [20–45]) years
and their booking weight was 77 (68–93 [48–130]) kg. The
majority of women spoke English as their primary
language and only 26 (28%) spoke it as a second language.
Spinal anaesthesia was with heavy bupivacaine 0.5%, with
a median (IQR [range]) dose of 2.2 (2.2–2.3 [2.0–2.6]) ml
with 15 (15–15 [10–20]) lg fentanyl and ⁄ or 125 (125–150
[100–150]) lg morphine. Eighty-seven women received
both fentanyl and morphine, four women received mor-
phine alone and three received fentanyl alone. The time
from injection to final assessment of adequate block height
was documented in 64 charts (68%). The mean (SD
[range]) time from injection to the decision to proceed was
9.5 (3.0 [5.0–20.0]) min.
Pairwise comparisons of block heights are shown in
Table 1 where differences were seen between all
modalities (p < 0.001) apart from pinprick and first cold
(p = 0.94). Modalities were significantly correlated for:
touch and cold, p = 0.0001; touch and icy, p = 0.0007;
touch and pinprick, p = 0.0018; cold and icy, p < 0.0001;
cold and pinprick, p = 0.0001; and icy and pinprick,
p < 0.0001. No significant differences were found
between the two sides for touch, p = 0.51; pinprick,
p = 0.56; cold, p = 0.11; and icy, p = 0.38. Overall, there
were significant differences in block level between
modalities (p < 0.001) with pairwise comparisons show-
ing differences between all modalities p < 0.001, apart
from pinprick and first cold p = 0.94 (Table 1).
Several women had blocks documented as lower
than T6 despite the anaesthetists’ assessment of the
block as adequate for surgery to proceed (Table 1). Ten
women reported no loss of sensation to touch (i.e.
recorded as below L1 bilaterally), and an additional
three women had no loss of sensation to touch
unilaterally. Of these 13 women, 11 (85%) had anaes-
thesia without needing any intervention, while two
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Ousley et al. | Block height for satisfactory spinal anaesthesia for caesarean section Anaesthesia 2012, 67, 1356–1363

Table 1 Block heights and number of patients assessed as having satisfactory anaesthesia for surgery to proceed in
whom block height was below T6, in 94 women undergoing caesarean section under spinal anaesthesia. Values are
median (IQR [range]).

Touch Pinprick First cold Icy cold

Block height T10 (T7–T12 [T3–L1])* à T5 (T4–T6 [C7–L1])*§– T5 (T4–T6 [C6–L1]) §** T3 (T2–T4 [C6–L1])à–**
Block height below T6 76 (81%)abc 15 (16%)ade 11 (12%)bdf 1 (1%)cef
Block height below T6 and 6 (6%) 3 (3%) 3 (3%) 1 (1%)
requiring intervention

*p < 0.001;  p = 0.001; àp = 0.001; §p = 0.94; –p = 0.001; **p < 0.001.

a
p < 0.001; bp = 0.001; cp = 0.001; dp = 0.3981; ep = 0.0003; fp < 0.0028.

Table 2 Patients requiring an intervention during caesarean section under spinal anaesthesia.

Level of block
Patient Touch Pinprick First cold Icy cold Comments

1 T10 T3 T3 T2 Discomfort due to loss of proprioception. Fentanyl 75 lg given

iv after the baby was born. Patient reported at postoperative
follow-up that she was satisfied and comfortable during
her anaesthetic
2 L1 L1 L1 L1 Previous failed spinal. Difficult to assess. Fentanyl 50 lg given
iv towards end of surgery. Patient reported being satisfied with,
and comfortable during, her anaesthetic at postanaesthesia follow-up
3 Below L1 T3 T3 C7 Fentanyl 50 lg given iv 30 min after first incision. Local anaesthetic
required to complete suturing. Patient reported that she was
satisfied with, and comfortable during, her anaesthetic at
post anaesthesia review
4 T9 T6 T7 T4 Complaints of headache and neck pain. Fentanyl given iv. Satisfied
and comfortable with anaesthetic
5 Below L1 T8 T7 T5 Slow onset of block despite free flowing CSF. Fentanyl 100 lg given
iv immediately before delivery and 20 min after delivery.
Not satisfied but stated on postoperative review that she was
comfortable during anaesthetic
6 T10 T8 T6 T4 Chest pain, no abdominal pain. Reassurance given. Satisfied and
comfortable with anaesthetic

CSF, cerebrospinal fluid; iv, intravenous.

(Patients 3 and 5 in Table 2) required an intervention.
Only 16 women had loss to touch at T6 or higher, with
76 (81%) maintaining a sensation of touch at this
dermatome. One woman stated that she felt all modal-
ities on testing despite having a profound motor block
of the lower limbs and a painless urinary catheter
insertion. She agreed that surgery could proceed
provided that general anaesthesia was immediately
available if required. Her surgery also proceeded
satisfactorily without the need for intervention. Six
women (6%) required an intervention for discomfort
(Table 2). Although two women were dissatisfied with
aspects of their birth experience, all had satisfactory
anaesthesia to complete their caesarean section surgery.
None of the women in our study required, or expressed
a desire for, general anaesthesia at any time. Follow-up
of women after surgery was obtained from 48 women
(51%) in the recovery room, 29 (31%) on the first
postoperative day, and 11 (12%) by phone call after
discharge. Six women were lost to follow-up postoper-
atively and could not be contacted after discharge.
However, all six were documented to have had an
uneventful anaesthetic without intervention during their
caesarean section.
Discussion
This is the first study to report modality assessments of
block height at the time point when spinal anaesthesia

Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 1359
Anaesthesia 2012, 67, 1356–1363 Ousley et al. | Block height for satisfactory spinal anaesthesia for caesarean section
was assessed by the anaesthetist as satisfactory for
surgery to proceed, rather than at various stipulated time
intervals after the administration of intrathecal injectate.
We have found a significant correlation of block
heights between modalities suggesting that all provide
potentially useful information about block height albeit
at different levels. We found a wide variation in the
assessments of block height between modalities and as
previously reported [9]; these were lower for touch than
for cold or pinprick, which in turn were lower than that
measured as icy without change from the reference point
(Table 1). More than three quarters of the women in our
study failed to have a block to touch that reached T6 at
the time anaesthesia was thought to be adequate to
commence surgery, and of these, only five (5%) required
an additional pharmacological intervention (Table 2).
None of these women, when questioned, reported that
they would have preferred conversion to a general
anaesthetic. While situations will always exist in which a
general anaesthetic is the most prudent management,
premature or unnecessary abandonment of an adequate
regional anaesthetic block, based on a single method of
assessment, may result in the mother’s being unable to
participate in the birth experience, and risks maternal
morbidity and even mortality. The inherent inaccuracy
of assessment of block height has been well documented
and considerable variation may exist between individual
anaesthetists [10–14]. The critical importance of com-
munication and the way anaesthetists question patients
about their block have been emphasised [12].
Our results suggest that the traditional belief that
there is one modality where a particular level of block
height ensures adequate anaesthesia in every patient, is an
unrealistic goal. Defining a dermatome level above which
anaesthesia is always satisfactory and below which it is
always inadequate denies the reality that patients’ reports
of their experiences are subjective and can be modulated
by suggestion and expectations both of the anaesthetist
and the patient [15]. It may be more helpful to assess
whether the progression of the block is behaving as would
be expected, with the modality of choice, and the way it is
tested, the one that is most familiar and provides most
reassurance to the anaesthetist.
Fewer than 10% of patients in our study required an
intervention during surgery and these were largely
unrelated to assessments of block height but due to
1360
symptoms such as anxiety, loss of sensation and chest
discomfort. Exactly why anaesthetists administered an
intervention is unknown as they were not specifically
questioned in this regard. Although it might be assumed
that this would be for pain, this may not necessarily have
been the case as all of these patients, when questioned
postoperatively, stated that they were comfortable dur-
ing their caesarean section, satisfied with their anaes-
thesia and would not have preferred general anaesthesia
(Table 2). Patients’ ability to communicate perceptions
accurately in the highly stressed setting of undergoing a
caesarean section under regional anaesthesia also needs
to be taken into account [16].
When last surveyed, the most common method of
assessing block height in the UK was the use of
temperature change [5], and anaesthetists more recently
have advocated its continued use [17]. In contrast to
strong opinions to the contrary [3, 4, 12], our study
findings suggest that height of block assessments to cold
may be reliable in most cases and appear much more
likely to avoid assessing an adequate block as one that is
unsatisfactory for surgery to proceed. Whilst some may
argue that ‘most’ isn’t enough, Russell’s own definition
of an adequate block height to touch for caesarean
section to start is when T6 is ‘either blocked to touch, or
expected to be blocked to touch before surgery had
reached the peritoneal cavity’ [3]. This definition relies
on the subjective expectation of the anaesthetist that a
level of T6 during surgery will be achieved during, rather
than reporting an assessment before, surgery. In
contrast, we have not used an ‘expectation’ component
in the assessment but the actual block level achieved
before commencing surgery. In addition, where other
researchers have assessed ‘normal touch’ against a
reference point before surgery, they report that a
number of patients required intervention despite a block
height to normal touch above T6 [12]. While a more
standardised assessment of block has been recom-
mended [1, 4, 18], the subjective influences that
inevitably occur when assessing block height will
remain. Interestingly, the wide variations seen in our
study are reflected in the findings of strong advocates for
the use of touch, where block levels have been found on
occasion to reveal up to eight dermatomes difference
when touch is compared with pinprick [3]. As previ-
ously stated, one patient reported feeling cold, pinprick
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Ousley et al. | Block height for satisfactory spinal anaesthesia for caesarean section
and touch at all levels despite having complete bilateral
lower limb block and a painless urinary catheter
insertion. On skin testing over the incision site, the
patient was unaware of pain and the patient reported
postoperatively that she was comfortable during, and
satisfied with, her anaesthesia, neither needing nor
desiring general anaesthesia at any stage.
There were some limitations of this study. First, the
height of some of the blocks was likely to have increased
by the time of first incision. However, it was clear that in
a minority of women, a block height of T6 to touch was
never going to be achieved despite clear evidence of
subsequent satisfactory anaesthesia during surgery. This
suggests that abandoning such adequate blocks would
expose women to the risks associated with general
anaesthesia in pregnancy. Use of the plastic spike of the
vial access cannula to assess pinprick is not a widely
described validated method of testing height of block.
However, this cannula is the standard way we assess
pinprick in our institution, and minimises the risk of
penetrating the patient’s skin with a metal needle.
Although we assessed pinprick and icy cold according to
a reference point, it may have also been useful to test at
what level the ice was first perceived as icy. The use of an
ice cube to assess touch and not a separate standardised
tool such as the Neurotip may be criticised, but we find
that our use of ice, to assess the first sensation of touch,
cold and icy cold, is an easy and inexpensive way for
most patients to communicate to the anaesthetist the
height of block, and reflects current practice within our
institution. Our height of block assessment using the
first sensation of touch rather than normal touch against
a reference point may be questioned, but the first
sensation of light touch is reported to be ‘the best
predictor of the likely efficacy of a spinal or epidural
block’ [12]. Interestingly, there seems to be ‘a close
association between the levels of block to touch assessed
by the ethyl chloride spray and the Neurotip’ and ‘in
normal clinical practice ethyl chloride spray touch
sensation can be considered equivalent to Neurotip
touch in predicting the likely adequacy of spinal
anaesthesia’[3]. It would be interesting to investigate
whether light touch with ice is similarly equivalent.
Unfortunately, the time from final testing to commenc-
ing surgery was not collected; although this would not
have affected our results or conclusions, it would be of
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2012, 67, 1356–1363
interest to collect this information in future research on
this topic. We did not ask anaesthetists to change their
usual practice and assess maximum block height, as
once there was a decision for surgery to proceed, further
assessments are rarely performed. Although anaesthe-
tists in this study used only a figure on the anaesthetic
chart as a guide for anatomical reference points, it has
been shown recently that even when dermatomes are
clearly marked by tape fixed to the midline of the
patient’s torso, individual anaesthetists show a wide
variation in their assessment of block height levels [18].
The study investigators collated data and transcribed it
onto a spreadsheet, which could potentially be a source
of bias. However, all data were checked by a second
investigator (RO ⁄ CE) to ensure that they were accu-
rately transcribed from the anaesthesia charts. The use
of multiple anaesthetist assessors, while potentially
reducing the likelihood of a standardised assessment,
has the advantage of being a more accurate reflection of
clinical practice, taking into account the variability in
assessments made by different practitioners. All five
patients administered a pharmacological intervention
during their surgery reported that they were comfortable
and satisfied with their anaesthesia when questioned
postoperatively about their experience (Table 2). This
suggests that the anaesthetist’s use of supplemental
analgesia may not always be because of pain or that any
pain experienced when managed satisfactorily will
subsequently lead to an experience that is remembered
postoperatively as being comfortable. Either way, the
need for intervention during surgery in our study does
not appear to have been of any significance to these
patients. Finally, our research ethics committee ap-
proved the study without the requirement for obtaining
written consent from patients. However, we recognise
on reflection that best practice would have been to
obtain written consent.
Further areas for research in this field might include
auditing current practice of anaesthetists in other
institutions within Australia and elsewhere. It would
also be useful to identify which modalities or combina-
tions are likely to provide the most clinically useful
information to anaesthetists, and how touch from a
continuous movement of an ice cube relates to a
Neurotip assessment or how continuous movement
relates to single-point placement. Also, it would be of
1361
Anaesthesia 2012, 67, 1356–1363 Ousley et al. | Block height for satisfactory spinal anaesthesia for caesarean section
interest to determine how the perception of first touch
to ice compares with perceived first touch and normal
touch by other methods. It is reported that the use of
the term ‘touch’ and how this particular sensory
modality is assessed may represent different meanings
to different clinicians and researchers [12]. Future
studies may also wish to investigate how the way
anaesthetists communicate with the patient affects her
responses about block height. A comparison of which
modality anaesthetists and patients found most reas-
suring in the assessment of their block, and other factors
apart from height of block that may affect the decision
to proceed with caesarean section following spinal
anaesthesia, would also be of interest. Outcomes such
as the use of an intervention during surgery may reflect
anaesthetists’ perceptions and expectations rather than
patient’s pain or distress. Future studies should consider
reporting why interventions were administered and
whether these were requested by the patient with and
without prompting. In addition, it would be useful to
know how the administration of an intervention related
to measures of pain experienced. Our study findings
suggest that height of block is only one, albeit impor-
tant, factor determining patient satisfaction and per-
ception of comfort.
In summary, our study has highlighted the large
variation and complexity that exists within this area.
Although the majority of assessments of block height are
straightforward, their subjective nature not infrequently
leaves the anaesthetist facing a multitude of clinical data
when assessing a balance of risks. We are not in any way
suggesting that clinicians should proceed in the absence
of a discernible or adequately assessed block. However,
all women in our study reported being comfortable and
satisfied with their anaesthesia despite over 80% having
a block to touch below T6 when anaesthesia was
considered adequate for surgery to proceed. Communi-
cating with the patient and checking at regular intervals
both before and throughout the operation may be more
important in mitigating patient dissatisfaction and any
potential for litigation than advocating one modality
over another. It is likely that some patients will find a
particular modality such as cold discrimination easier to
discern than touch or pinprick and vice versa. Therefore,
as long as the determination of block height has a
subjective component dependent on patients’ reports
1362
and the anaesthetist’s expectations [3], the debate
regarding the optimal technique to predict comfort
during caesarean section will remain [17]. Our study
findings suggest that cold and pinprick testing of block
height correlate well with touch and can provide useful
information during the assessment of adequacy of spinal
anaesthesia for caesarean section. A low level of block
height using any one modality alone, but particularly
using the first sensation of touch, may erroneously
indicate inadequate anaesthesia for caesarean in some
women.
Acknowledgements
We thank the anaesthetists and nursing staff at the
Women’s and Children’s Hospital in Adelaide for their
assistance.
Competing interests
No external funding and no competing interests
declared.
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