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Impact of morbid obesity on postoperative outcomes in reverse total shoulder arthroplasty: A national inpatient sample analysis
⁎Corresponding author: Aruni Areti. aruni.areti@bcm.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Reverse total shoulder arthroplasty (rTSA) is a widely used procedure for rotator cuff arthropathy, with indications expanding to include fractures, osteoarthritis, and revision arthroplasty. Obesity poses significant challenges in arthroplasty, yet the impact of morbid obesity (BMI ≥40 kg/m2) on rTSA outcomes remains underexplored. This study examines the association between morbid obesity and perioperative outcomes in rTSA patients using a large database.
We conducted a retrospective cohort study using the National Inpatient Sample (NIS) database from 2016 to 2019. Patients aged ≥18 years who underwent rTSA were stratified into morbidly obese (Morbid-Obesity (+)) and non-morbidly obese (Control) cohorts. Outcomes analyzed included demographic factors, length of stay (LOS), discharge disposition, and postoperative complications. Statistical analyses were performed using chi-squared tests, independent t-tests, and multivariate logistic regression to assess associations.
The study included 4850 Morbid-Obesity (+) patients and 55,075 Control patients. The Morbid-Obesity (+) cohort was younger (mean age: 67.74 vs. 71.67 years; p < 0.001) and more likely to be from minority groups, particularly Black patients (7.71 % vs. 3.94 %; p < 0.001). They had significantly longer LOS (mean: 2.23 vs. 1.87 days; p < 0.001) and higher rates of discharge to non-routine facilities. Major complications were more common in the Morbid-Obesity (+) cohort, including periprosthetic dislocation (2.60 % vs. 1.59 %; OR 1.65, p < 0.001), deep vein thrombosis (0.17 % vs. 0.07 %; OR 2.27, p = 0.03), blood loss anemia (11.61 % vs. 10.12 %; OR 1.17, p < 0.001), and acute renal failure (3.53 % vs. 2.11 %; OR 1.69, p < 0.001).
Morbid obesity is associated with higher complication rates, prolonged hospital stays, and increased non-routine discharge rates in rTSA patients. These findings underscore the need for tailored preoperative planning and postoperative management in this high-risk population.
Keywords
Morbid obesity
Reverse total shoulder arthroplasty
Complications
Length of stay
1 Introduction
Reverse total shoulder arthroplasty (rTSA) is the gold standard treatment for rotator cuff arthropathy, accounting for approximately 50 % of all shoulder arthroplasty procedures.1 Its indications have expanded to include revision arthroplasty, fractures, glenoid insufficiencies, and primary osteoarthritis in elderly patients without rotator cuff insufficiency.1 The use of rTSA has grown significantly over time; for instance, the population-adjusted incidence of primary rTSA increased from 7.3 cases per 100,000 persons (22,835 procedures) in 2012 to 19.3 cases per 100,000 (62,705 procedures) in 2017.2 This growing utility has triggered research that has identified a variety of complications associated with rTSA, such as periprosthetic dislocation or periprosthetic fractures.3,4
Obesity is increasingly prevalent and is linked to comorbidities such as cardiovascular disease, diabetes, and metabolic syndrome, as well as higher complication rates following arthroplasty.4 In total knee and hip arthroplasty, obesity contributes to challenges like incorrect implant positioning, component failure, infection, and postoperative complications.5 Similarly, obesity poses unique difficulties in rTSA, including limited glenoid exposure due to the soft tissue envelope and challenges in arm positioning caused by the size of the arm and torso.4
Preoperative planning is crucial for addressing the potential challenges posed by obesity in rTSA. Although previous research has identified complications associated with obesity in arthroplasty, no study has specifically investigated the impact of morbid obesity, body mass index (BMI) ≥ 40 kg/m2, on rTSA outcomes.4 To fill this gap, our study leverages a large national database to explore this relationship. We hypothesize that morbid obesity will be associated with higher rates of periprosthetic complications and longer hospital stays amongst rTSA patients.
2 Methods
2.1 Database description
The National Inpatient Sample (NIS) is part of the Healthcare Cost and Utilization Project (HCUP) and is maintained by the Agency for Healthcare Research and Quality (AHRQ). It is the largest publicly available inpatient database in the United States, capturing data from over 7 million hospital stays each year. This database includes detailed patient demographics, length of stay (LOS), hospital expenditures, discharge status, payment sources, comorbidities, and perioperative complications. The NIS adheres to the Health Insurance Portability and Accountability Act (HIPAA) and is certified to the ISO 27001:2013 standard, ensuring the protection and privacy of healthcare data.
2.2 Data acquisition
This study was deemed Institutional Review Board exempt as it involved a secondary analysis of de-identified data, which complies with the de-identification standard defined in Section 164.514(a) of the HIPAA Privacy Rule. The analysis used data from the National Inpatient Sample (NIS) for the period 2016–2019. Data collection and classification were based on the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) detailed in Appendix A.
The inclusion criteria included all patients aged 18 years or older who underwent rTSA. Patients were stratified into two cohorts: those classified as morbidly obese (Morbidly-Obese (+)) and non-morbidly obese patients (Control group). Demographic factors analyzed included age, sex, race (White, Black or African American, Asian, Pacific Islander, and Other), ethnicity (Hispanic vs. non-Hispanic), minority vs. non-minority status, tobacco-related diagnoses, diabetes (both with and without complications), and admission characteristics (elective vs. non-elective).
Postoperative complications were analyzed and included systemic issues such as postoperative anemia, acute renal failure (ARF), deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), pneumonia, and blood transfusion. Local complications included periprosthetic infections (PPIs), prosthetic dislocations, periprosthetic mechanical complications, periprosthetic fractures, and wound dehiscence. Post-hospitalization dispositions were categorized as routine discharge, short-term hospital stays, discharge to alternative facilities, home healthcare (HHC), and patients leaving against medical advice (LAMA), as well as in-hospital mortality. Hospital metrics included length of stay (LOS) and total charges.
2.3 Data analyses
All statistical analyses were conducted using SPSS version 29.0 (IBM; Armonk, NY, USA). Univariate analyses evaluated differences between the Morbid-Obesity (+) and Control groups. For categorical variables, such as race, sex, admission type, and disposition outcomes, chi-squared tests were used to compare proportions. Fisher's exact test was applied for variables with an expected cell count of less than 5. Odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated to quantify the association between morbid obesity status and specific postoperative complications, including periprosthetic dislocation, DVT, pulmonary embolism, and acute renal failure. A p-value of ≤0.05 was considered statistically significant for all categorical analyses. For numerical variables, including total charges, LOS, and age at admission, independent sample t-tests were used to compare means between the two groups. Levene's test for equality of variances was conducted to assess whether the variances for these variables were equal across groups. For significant findings, effect sizes were calculated using Cohen's d, Hedges' correction, and Glass's delta to evaluate the magnitude of the differences.
3 Results
Among patients undergoing rTSA, 4850 were identified as Morbid Obesity (+), and 55,075 were included in the Control group. Table 1 summarizes the demographic and admission characteristics of these groups.
| Variable | Morbid-Obesity (+) (4850) | Control Group (55,075) | P value | |
| Age >60 | 4164 (85.85 %) | 50,494 (91.68 %) | <0.001∗ | |
| Age Categorical | ||||
| <60 | 686 (14.15 %) | 4581 (8.32 %) | <0.001∗ | |
| 60–69 | 2063 (42.55 %) | 16,435 (29.84 %) | <0.001∗ | |
| 70–79 | 1848 (38.12 %) | 23,958 (43.50 %) | <0.001∗ | |
| 80–89 | 249 (5.13 %) | 9550 (17.34 %) | <0.001∗ | |
| >90 | 4 (0.08 %) | 551 (1.00 %) | <0.001∗ | |
| Sex (Proportion of Women) | 3472 (71.60 %) | 32,820 (59.56 %) | <0.001∗ | |
| Tobacco-Related Disorder | 546 (11.26 %) | 9098 (16.51 %) | <0.001∗ | |
| Diabetes With Complications | 19 (0.39 %) | 99 (0.18 %) | <0.001∗ | |
| Diabetes Without Complications | 1069 (22.04 %) | 7588 (13.78 %) | <0.001∗ | |
| Race | ||||
| White | 4004 (82.58 %) | 46,938 (85.23 %) | <0.001∗ | |
| Black | 374 (7.71 %) | 2168 (3.94 %) | <0.001∗ | |
| Hispanic | 183 (3.77 %) | 2482 (4.51 %) | <0.001∗ | |
| Asian | 19 (0.39 %) | 322 (0.58 %) | <0.001∗ | |
| Pacific Islander | 22 (0.45 %) | 184 (0.33 %) | <0.001∗ | |
| Other | 58 (1.20 %) | 824 (1.50 %) | <0.001∗ | |
| Minority | ||||
| Non-Minority | 4004 (82.58 %) | 46,938 (85.23 %) | <0.001∗ | |
| Minority | 656 (13.52 %) | 5980 (10.86 %) | <0.001∗ | |
| Elective Admission | 4501 (92.80 %) | 50,903 (92.41 %) | 0.329 | |
| Non-Elective Admisison | 341 (7.0 %) | 4083 (7.4 %) | 0.329 | |
| Disposition of patient | ||||
| Routine | 2921 (60.22 %) | 36,429 (66.18 %) | <0.001∗ | |
| Short-term hospital | 11 (0.23 %) | 95 (0.17 %) | <0.001∗ | |
| Another type of facility | 897 (18.49 %) | 7269 (13.21 %) | <0.001∗ | |
| Home Health Care (HHC) | 1016 (20.96 %) | 11,197 (20.34 %) | <0.001∗ | |
| Against medical advice (AMA) | 1 (0.02 %) | 40 (0.07 %) | <0.001∗ | |
| Died | 4 (0.08 %) | 35 (0.06 %) | <0.001∗ | |
The Control group had a significantly higher proportion of patients over the age of 60 compared to the Morbid-Obesity (+) group (91.68 % vs. 85.85 %, p < 0.001). Age distribution analysis revealed significant differences across categories. The Morbid-Obesity (+) group had a higher proportion of patients in younger age categories (<60: 14.15 % vs. 8.32 %, 60–69: 42.55 % vs. 29.84 %; p < 0.001), whereas the Control group had significantly higher proportions in older age categories (70–79: 43.50 % vs. 38.12 %, 80–89: 17.34 % vs. 5.13 %, >90: 1.00 % vs. 0.08 %; p < 0.001). Diabetes was significantly more prevalent in the Morbid-Obesity (+) group, with higher rates of diabetes without complications (22.04 % vs. 13.78 %, p < 0.001) and diabetes with complications (0.39 % vs. 0.18 %, p < 0.001). Racial differences were also notable. The Morbid-Obesity (+) group had significantly higher proportions of Black (7.71 % vs. 3.94 %, p < 0.001) and Pacific Islander patients (0.45 % vs. 0.33 %, p < 0.001). In contrast, the Control group had higher proportions of White (85.23 % vs. 82.58 %, p < 0.001), Hispanic (4.51 % vs. 3.77 %, p < 0.001), Asian (0.58 % vs. 0.39 %, p < 0.001), and Other race patients (1.50 % vs. 1.20 %, p < 0.001). Minorities overall were significantly more represented in the Morbid-Obesity (+) group (13.52 % vs. 10.86 %, p < 0.001). Disposition outcomes showed significant differences between the groups. Morbid-Obesity (+) patients had higher rates of discharge to short-term hospitals (0.23 % vs. 0.17 %), another type of facility (18.49 % vs. 13.21 %), and home health care (HHC) (20.96 % vs. 20.34 %; all p < 0.001). Mortality rates were also slightly higher in the Morbid-Obesity (+) group (0.08 % vs. 0.06 %; p < 0.001). Elective versus non-elective admissions did not significantly differ between the groups (p = 0.329).
Postoperative complications among rTSA patients with and without morbid obesity are summarized in Table 2. Periprosthetic dislocation was significantly higher in the Morbid-Obesity (+) group (2.60 %) compared to the Control group (1.59 %) (OR = 1.65 [95 % CI: 1.37–1.99], p < 0.001). Deep vein thrombosis (DVT) was also more frequent in the Morbid-Obesity (+) group (0.17 %) compared to the Control group (0.07 %) (OR = 2.27 [95 % CI: 0.26–4.86], p = 0.03). Patients in the Morbid-Obesity (+) group had a significantly higher rate of blood loss anemia (11.61 %) compared to the Control group (10.12 %) (OR = 1.17 [95 % CI: 0.80–1.28], p < 0.001). Additionally, acute renal failure occurred more often in the Morbid-Obesity (+) group (3.53 %) than in the Control group (2.11 %) (OR = 1.69 [95 % CI: 1.03–2.00], p < 0.001).
| Postoperative Variables | Morbid-Obesity (+) (4850) | Control Group (55,075) | Odds Ratio (CU/NCU Group) | Odds Ratio 95 % Confidence Interval | P value |
| Wound dehiscence | ∗∗∗ | 18 (0.03 %) | 0.63 | (0.08–4.72) | 0.65 |
| Periprosthetic infection | 33 (0.68 %) | 312 (0.57 %) | 1.2 | (0.84–1.72) | 0.32 |
| Superficial SSI | 0 (0.00 %) | ∗∗∗ (0.01 %) | 0.92 | (0.61–1.24) | 0.51 |
| Periprosthetic mechanical complication | 58 (1.20 %) | 694 (1.26 %) | 0.95 | (0.82–1.24) | 0.7 |
| Periprosthetic dislocation | 126 (2.60 %) | 874 (1.59 %) | 1.65 | (1.37–1.99) | <0.001∗ |
| Periprosthetic fracture | 14 (0.29 %) | 119 (0.22 %) | 1.34 | (0.77–2.32) | 0.3 |
| DVT | ∗∗∗ | 40 (0.07 %) | 2.27 | (0.26–4.86) | 0.03∗ |
| Pulmonary embolism | ∗∗∗ | 66 (0.12 %) | 1.55 | (0.36–3.11) | 0.21 |
| Blood transfusion | 82 (1.69 %) | 1095 (1.99 %) | 0.85 | (0.94–1.06) | 0.15 |
| Pneumonia | 24 (0.50 %) | 203 (0.37 %) | 1.34 | (0.52–2.05) | 0.17 |
| Blood loss anemia | 563 (11.61 %) | 5573 (10.12 %) | 1.17 | (0.80–1.28) | <0.001∗ |
| Myocardial infarction | ∗∗∗ | 25 (0.05 %) | 1.81 | (0.24–5.22) | 0.26 |
| Acute renal failure | 171 (3.53 %) | 1163 (2.11 %) | 1.69 | (1.03–2.00) | <0.001∗ |
| Died during hospitalization | ∗∗∗ | 35 (0.06 %) | 1.3 | (0.31–3.65) | 0.62 |
Table 3 present the analysis of total charges, length of stay, and age at admission between the Morbid-Obesity (+) and Control cohorts.
| Variables | Mean | Std. Deviation | P value | |
| Total charges | ||||
| Morbid Obesity | 80,688.12 | 50,469.36 | 0.137 | |
| Control | 79,599.79 | 48,630.69 | ||
| Length of stay | ||||
| Morbid Obesity | 2.23 | 3.253 | <0.001∗ | |
| Control | 1.87 | 1.887 | ||
| Age in years at admission | ||||
| Morbid Obesity | 67.74 | 7.674 | <0.001∗ | |
| Control | 71.67 | 8.642 | ||
The mean length of stay was 2.23 days (SD: 3.253) for the Morbid-Obesity (+) group and 1.87 days (SD: 1.887) for the Control group (Table 3). The mean difference of 0.361 days (95 % CI: 0.301–0.421) was significant, with two-sided p < 0.001 (Table 3).
The mean age at admission for the Morbid-Obesity (+) group was 67.74 years (SD: 7.674) compared to 71.67 years (SD: 8.642) for the Control group (Table 3). The mean difference of −3.93 years (95 % CI: 4.181 to −3.678) was significant with two-sided p < 0.001 (Table 3).
The mean total charges for the Morbid-Obesity (+) group were $80,688.12 (SD: $50,469.36), compared to $79,599.79 (SD: $48,630.69) for the Control group (Table 3). The mean difference was $1088.33 (95 % CI: 347.327 to 2523.987), with a two-sided p = 0.137 (Table 3).
4 Discussion
The use of rTSA has been steadily increasing, yet its outcomes in morbidly obese patients, who represent a high-risk surgical population, remain unclear.1,12 Our study addresses this gap by leveraging a large national database to evaluate outcomes and postoperative care in morbidly obese patients undergoing rTSA.
Our study found that morbidly obese patients undergoing rTSA were found to have significantly greater lengths of stay. Several studies have demonstrated this association across different types of arthroplasty. Hanly et al. reported that morbidly obese patients experienced prolonged hospital stays following total hip arthroplasty, while Crawford et al. also observed an increased likelihood of overnight stays after outpatient arthroplasty in this cohort.6,7 Similarly, Griffin et al. and Garcia et al. found that morbidly obese patients undergoing aTSA had a significantly extended length of stay (eLOS) compared to non-obese patients.8,9 The outcomes of rTSA in obese patients remain underexplored, with existing studies yielding inconsistent results. Berman et al., in a systematic review, identified obesity as a factor associated with prolonged hospital stays.10 In contrast, Pappou et al., in a case-control study of 21 morbidly obese patients, reported no significant difference in hospital stay duration.11 Similarly, Beck et al., in a cohort of 17 obese patients, found no significant differences in hospitalization length between obese and non-obese patients undergoing rTSA.12 However, these studies are limited by small sample sizes, reducing their statistical power. Despite these limitations, Pappou et al. and Berman et al. reported higher rates of discharge to rehabilitation facilities rather than home in obese patients, and Beck et al. noted a higher complication rate in this population.10–12 These findings align with our results, which showcased significantly higher rates of routine discharge among our control group, whereas the Morbid-Obesity (+) group showed increased rates of discharge to short-term hospitals, other care facilities, or home healthcare services, as well as higher mortality rates. These results underscore the increased postoperative complexity and heightened care needs for morbidly obese patients undergoing reverse total shoulder arthroplasty, including longer hospital stays and a greater likelihood of discharge to rehabilitation facilities.
Across most surgeries, studies have thoroughly established that eLOS and non-home discharge (NHD) are typically associated with increased rates of medical complications, surgical site infections, readmissions, and mortality.13–15 Our study identified that a significant contributor to increased eLOS and NHD is the increased incidence of complications, specifically periprosthetic dislocation, deep vein thrombosis, blood loss anemia, and acute renal failure.
Theodoulou et al.’s systematic review and meta-analysis identified that obese patients had increased odds of dislocation following rTSA.16 Additionally, Gupta et al. reported that patients with a BMI exceeding 35 kg/m2 had a significantly higher overall dislocation rate compared to those with lower BMI.17 This may be due to increased BMI causing heightened soft tissue impingement and altered shoulder joint biomechanics, which can compromise prosthesis stability. For example, Elkins et al. highlighted that thigh soft tissue impingement lowered the resistance to dislocation for BMIs of 40 or greater in THA patients.18 Morbidly obese patients experience physiological changes, including elevated levels of procoagulant factors, impaired fibrinolysis, and increased inflammation, placing them in a prothrombotic state and heightening their risk for thromboembolic events, such as DVT.19 This risk is further heightened by prolonged immobility associated with extended hospital stays, which are common among morbidly obese patients undergoing rTSA—a trend further observed in our Morbid-Obesity (+) cohort.20 DVT may result from prolonged surgical times, as Swindell et al. showed in aTSA patients, linking longer surgeries to higher postoperative complications, including DVT.21 Pappou et al. and Wiater et al. also reported longer surgical times for obese patients.11,33 Although not focused solely on rTSA, Cogan et al. specifically demonstrated that obese patients undergoing either aTSA or rTSA had increased odds of developing deep vein thrombosis (DVT) and pulmonary embolism within 90 days postoperatively.22
Our study highlighted the increased risk of blood loss anemia in the Morbid-Obesity (+) cohort, an association often overlooked but supported by prior research. Pappou et al. reported that morbidly obese patients undergoing rTSA experienced greater intraoperative blood loss than non-obese patients, averaging 40 mL more.11 Similarly, Gupta et al. found that patients with a BMI over 35 kg/m2 had significantly higher intraoperative blood loss and an increased incidence of acute blood loss anemia requiring transfusion than those with lower BMI.17 Diabetes mellitus is well-known to cause microvascular complications, ultimately leading to increased blood loss.23 This relationship was evident in our study, as the Morbid-Obesity (+) cohort exhibited a significantly higher prevalence of both diabetes with and without complications, along with a marked increase in blood loss anemia. These outcomes stem from pathological changes in the microvasculature: Barrett et al., in their statement from the Endocrine Society, emphasize how diabetes-induced microvascular damage increases vascular fragility and bleeding risk, a finding supported by Fadini et al., who highlight the role of altered angiogenesis in these complications.23,24
The Morbid-Obesity (+) cohort was also significantly associated with acute renal failure, consistent with findings by Mayfield et al., who reported that patients with a BMI over 35 kg/m2 undergoing rTSA or aTSA had a significantly higher risk of developing acute renal failure.1 This may be linked to the increased prevalence of blood loss anemia and diabetes mellitus, both with and without complications, identified in our study. These factors have been established in prior research as mediators of acute renal failure. Acute blood loss anemia can impair oxygen delivery to the kidneys, resulting in ischemic injury and acute kidney injury (AKI), as demonstrated by Choi et al. in their retrospective study on THA patients.25 Xie et al. found that diabetes significantly increases the risk of AKI following total joint arthroplasty, likely due to microvascular damage that impairs renal perfusion and heightens susceptibility to AKI.26 This risk is further compounded by the chronic inflammatory state in diabetes, which promotes endothelial dysfunction and exacerbates the impairment of renal blood flow.
The complexity of postoperative care for morbidly obese patients undergoing rTSA is multifactorial, with several interrelated variables contributing to increased risks. Morbid obesity has long been associated with diabetes, which predisposes patients to complications such as blood loss anemia. Both blood loss anemia and diabetes can exacerbate the risk of acute renal failure. Additionally, complications like blood loss anemia or prosthetic dislocation can prolong the LOS, further heightening the risk of DVT. This complexity is further highlighted by our finding that a significantly greater portion of these morbidly obese patients undergoing rTSA are from minority communities, particularly black populations. These groups have been shown in previous studies to face higher rates of obesity and diabetes, placing them at an even greater risk for the complications observed in our study.27,28 More specifically, Best et al. found that Black patients undergoing rTSA had increased odds of complications, including acute renal failure, compared to White patients.2 These findings underscore the need for further research into the social determinants of health and the systemic barriers to equitable healthcare that contribute to the higher prevalence of obesity and diabetes in these populations.
4.1 Limitations
This retrospective study has several limitations, primarily stemming from the use of the NIS database. The NIS does not provide follow-up data beyond the index hospitalization, limiting the assessment of long-term outcomes and potentially biasing the understanding of disease progression and treatment efficacy.29,30 Additionally, the NIS captures hospitalization events rather than unique patients, which can lead to misinterpretation if repeat admissions are not properly accounted for.29 Coding and data accuracy biases are also a concern, as miscoding and inaccuracies in administrative data can introduce significant bias, particularly when nonspecific secondary diagnosis codes are used to infer in-hospital events.31 Furthermore, the NIS lacks data on key confounding variables, such as outpatient care, follow-up visits, and long-term management, as well as patients' income, education level, and employment status. Income is particularly significant, as Khlopas et al. illustrated that individuals from lower socioeconomic backgrounds tend to have poorer functional outcomes following rTSA.32 Additionally, some of the studies included did not isolate rTSA cases, instead combining them with aTSA, which may have skewed the results and complicated the attribution of complications specifically to rTSA.1,22
5 Conclusion
In conclusion, morbidly obese patients undergoing rTSA face complex postoperative care needs, often resulting in prolonged hospital stays. This population is frequently characterized by younger age, minority status, particularly Black communities, and a high prevalence of diabetes mellitus. These factors contribute to the medical complications identified in our study, including periprosthetic dislocation, deep vein thrombosis, blood loss anemia, and acute renal failure. Although obesity is not a contraindication to rTSA, our findings provide valuable information for clinicians and patients to make informed decisions about surgical interventions while highlighting the challenges these patients may face after surgery.
CRediT authorship contribution statement
Aruni Areti: Formal analysis, Visualization, Project administration, Writing – original draft. Benjamin Montanez: Writing – review & editing. Vinayak Perake: Investigation, Methodology, Writing – review & editing. Senthil Sambandam: Data curation, Software, Supervision.
Declaration of patient consent
Not applicable.
Ethical approval and patient consent
Not applicable.
Data availability statement
Data is available upon request from Dr. Senthil Sambandam.
Funding
This research did not receive any specific grant from public, commercial, or not-for-profit funding agencies.
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