Emergency Medicine

Predictive value of the Trauma Rating Index in Age, Glasgow Coma Scale, Respiratory rate and Systolic blood pressure score (TRIAGES) and Revised Trauma Score (RTS) for the short-term mortality of patients with isolated traumatic brain injury: A retrospective study

a b s t r a c t

Background: Ensuring rapid and precise Mortality prediction in patients with Traumatic brain injury at the emergency department (ED) is paramount in patient triage and enhancing their outcomes. We aimed to estimate and compare the Predictive power of the Trauma Rating Index in Age, Glasgow Coma Scale, Respiratory rate, and Systolic blood pressure score (TRIAGES) and Revised Trauma Score for 24-h in-hospital mortality in patients with isolated TBI.

Methods: We conducted a retrospective single-center study analyzing clinical data from 1156 patients with isolated acute TBI treated in the ED of the Affiliated Hospital of Nantong University from January 1, 2020, to December 31, 2020. We calculated each patient’s TRIAGES and RTS scores and estimated their predictive value for short-term mortality using receiver operating characteristic curves.

Results: 87 patients (7.53%) died within 24 h of admission. The non-survival group had higher TRIAGES and lower RTS than the survival group. Compared to non-survivors, survivors exhibited higher Glasgow Coma Scale scores (GCS) with a median score of 15 (12, 15) compared to a median score of 4.0 (3.0, 6.0). The crude and adjusted odds ratios (ORs) for TRIAGES were 1.79, 95% CI (1.62 to 1.98) and 1.79, 95% CI (1.60 to 2.00), respectively. The crude and adjusted ORs for RTS were 0.39, 95% CI (0.33 to 0.45) and 0.40, 95% CI (0.34 to 0.47), respectively. The area under the ROC (AUROC) curve of TRIAGES, RTS, and GCS was 0.865 (0.844 to 0.884), 0.863 (0.842 to 0.882), and 0.869 (0.830 to 0.909), respectively. The optimal cut-off values for predicting 24-h in-hospital mor- tality were 3 for TRIAGES, 6.08 for RTS, and 8 for GCS. The subgroup analysis showed a higher AUROC in TRIAGES (0.845) compared to GCS (0.836) and RTS (0.829) among patients aged 65 and above, although the difference was not statistically significant.

Conclusions: TRIAGES and RTS have shown promising efficacy in predicting 24-h in-hospital mortality in patients

with isolated TBI, with comparable performance to GCS. However, improving the comprehensiveness of assess- ment does not necessarily translate into an overall increase in Predictive ability.

(C) 2023

  1. Introduction

traumatic brain injury is a significant source of health loss and disability worldwide, which is usually referred to as a “silent epidemic” because complications of TBI, such as cognitive, sensory, or emotional impairment, may not be readily apparent [1,2]. With the loss of human potential associated with TBI, many survivors are left with

* Corresponding authors at: Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong City 226001, Jiangsu Province, China.

E-mail addresses: [email protected] (Y. Shen), [email protected] (Z. Huang).

1 These authors contributed to this study equally.

severe disabilities that create a considerable socioEconomic burden. Globally, the annual incidence of TBI is estimated to be between 27 and 69 million [3,4]. In China, TBI is the primary cause of traumatic death and death in adults under the age of 40 [5,6].

Patients with TBI at high risk of death should be promptly triaged to a trauma center for resuscitation [7]. Therefore, accurate assessment of short-term mortality risk in patients with TBI is essential. The ideal pre- hospital triage tool for trauma should be simple to use and accurately distinguish between patients with severe and minor injuries. Despite its widespread use, the Glasgow Coma Score has limitations. Al- ternative scoring systems may offer additional benefits in predicting outcomes and guiding Treatment decisions for patients with TBI.

https://doi.org/10.1016/j.ajem.2023.06.030

0735-6757/(C) 2023

trauma scores in early trauma care typically include several predictors, such as age, mechanism of injury, and physiologic status; these scores include the Revised Trauma Score (RTS) and mechanism, GCS, age, and arterial pressure (MGAP) score [8].

RTS is intended for prehospital trauma triage, including the variables respiratory rate (RR), systolic blood pressure (SBP), and GCS. Several studies have evaluated the performance of RTS as a classification and Prediction tool in the emergency department (ED). However, limited research has been conducted on the predictive value of RTS for early mortality in patients with Traumatic brain injury . TRIAGES, a novel trauma score that includes age, SBP, RR, and GCS as a bedside assessment tool, is more effective than RTS in predicting in-hospital mortality among trauma patients. RTS and TRIAGES incorporate GCS to provide a concise and comprehensive assessment of the patient’s condition. Therefore, we hypothesize that they are not inferior to GCS in predicting prognosis within the TBI population.

We conducted a retrospective analysis of medical records to evaluate and compare the Predictive performance of TRIAGES and RTS in predicting 24-h mortality in patients with isolated TBI. Our study was motivated by the lack of evidence in the existing medical literature regarding whether TRIAGES and RTS are superior to GCS in predicting short-term prognosis in patients with isolated TBI.

  1. Methods
    1. Study design and setting

We conducted a retrospective single-center study that analyzed clinical data from 1156 patients with isolated acute traumatic brain in- jury (TBI) in the ED of the Affiliated Hospital of Nantong University from January 1, 2020, to December 31, 2020, to estimate the predictive value of TRIAGES and RTS for short-term mortality in patients with isolated TBI. Our hospital is a government-operated tertiary comprehensive

Healthcare facility that has been in operation for over 110 years. Located in Eastern China, it is a crucial medical hub that serves over 40,000 trauma patients annually. Equipped with a state-of-the-art Trauma Center, it offers resuscitation rooms, emergency Operating rooms, and emergency intensive care units. We received approval from the re- search ethics committee of the Affiliated Hospital of Nantong University (Approval No.: 2021-K084-01), which waived the need for consent from study participants for this research project.

    1. Definition and population selection criteria

TBI was defined as a patient with a clear history of trauma and a final diagnosis of acute injury on a CT scan and clinical symptoms. To assess the severity of TBI, we used the widely recognized Glasgow Coma Scale (GCS), whICH Scores patients based on their level of consciousness, with 13 to 15 considered mild, 9 to 12 considered moderate, and 8 or less considered severe. To ensure the integrity of our study, we applied the following exclusion criteria: patients under 18 years of age, patients who died on arrival, patients with incomplete data (such as missing RR, SPO2, or GCS), and patients with polytrauma. A detailed description of our exclusion criteria can be found in Fig. 1.

    1. Data collection and endpoint

All characteristics were obtained from medical records at admission to the ED and verified for consistency by one of the study authors (TC). An electronic hospital information system (DoCare Emergency Clinical Information System, Medical-system Co., Ltd., Suzhou, China) was used to collect clinical data. This system allowed attending nurses and doctors to record patient data promptly and input it directly into the information system. By using this approach, we were able to obtain re- liable and consistent clinical data for our analysis. All attending nurses and doctors were certified in emergency department specialties and

Image of Fig. 1

Fig. 1. Flow chart of patient enrollment.

Trauma Rating Index in Age, GCS, Respiratory rate and Systolic blood pressure score (TRIAGES).

Variables

Score

1

0

1

2

3

4

5

6

Age, years

Respiratory rate, breaths/min

>28

16-54

12-27

55-74

4-11

75+

0-3

Systolic blood

pressure, mmHg

>200

100-199

80-99

50-79

0-49

Glasgow Coma Scale

15

14

12-13

8-11

5-7

4

3

possessed a minimum of three years of experience in ED. The gathered data comprised the age and gender of patients, the mechanism of injury, their HR, SBP, RR, SPO2, and GCS, as well as their history of anticoagulant use and hypertension. These patients were monitored continuously during their hospitalization, and their progress was documented.

The primary endpoint was 24-h in-hospital mortality. The TRIAGES and RTS were calculated for each subject based on the relevant measured variables in the medical records. The medical records and computed scores were reserved in the database for further statistical analysis. This study focused on short-term prognosis; therefore, long- term follow-up on the patient’s survival status was not conducted.

    1. TRIAGES

TRIAGES is a relatively new Prognostic prediction score for pre- screening triage of emergency trauma patients. TRIAGES is calculated based on the following four variables: age, GCS, respiratory rate, and systolic blood pressure [9]. Table 1 shows the corresponding scores for each variable, ranging from 0 to 14.

    1. RTS

RTS contains three variables: SBP, RR, and GCS. The scores range from 0 to 12, with lower scores corresponding to higher injury severity (Table 2). GCS, SBP, and RR were divided into one of five categories from 0 to 4. RTS was multiplied by a weighting factor of 0.9368 for GCS, 0.7326 for SBP, and 0.2908 for RR. In contrast to TRIAGES, a lower RTS score indicates a worse patient status.

    1. Statistical analysis

Continuous variables were summarized with medians (IQR). Non- parametric methods were used regardless of the distributions to provide robust comparisons. The Mann-Whitney U test tested differ- ences for continuous measurements. The categorical variables were expressed as frequency and percentage and compared using the chi-squared or Fisher’s exact test.

The logistic regression analysis based on survival and non-survival and the area under receiver operating characteristic curves (AUROCs) analysis framework were used to investigate the predictive value of TRIAGES and RTS for 24-h mortality. Gender, age (except TRIAGES), SPO2, anticoagulant use, and hypertension were added to the multivar- iable model to adjust the variable OR value. Subgroup analyses were performed to evaluate the predictive ability of various scores in patients

Table 2

Revised Trauma Score (RTS).

Variables

Score

0

1

2

3

4

Glasgow Coma Scale

3

4-5

6-8

9-12

13-15

Systolic blood pressure, mmHg

0

1-49

50-75

76-89

>89

Respiratory rate, breaths/min

0

1-5

6-9

>29

10-29

stratified by age. The main objective was to determine the AUROC for each score in every subgroup.

A P value of less than 0.05 indicated statistical significance; all tests were two-tailed. All the analyses were performed with the statistical software packages R (http://www.R-project.org, The R Foundation) and Free Statistics software (version 1.7.1). Reporting of this study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.

  1. Results
    1. Baseline and clinical characteristics

A total of 1156 patients were included in the analysis. All patients arrived by ground ambulance. 87 patients (7.53%) died within 24 h of admission. No significant differences between the survival and non- survival group except for the gender composition (P = 0.028) and baseline GCS (P < 0.001). The non-survival group had higher TRIAGES and lower RTS than the survival group. (P < 0.001 for both) (Table 3).

    1. Association between the TRIAGES and RTS and 24-h mortality

The associations between the TRIAGES score and RTS score and mor- tality are presented in Table 4. The crude and adjusted ORs for TRIAGES were 1.79, 95% CI (1.62 to 1.98) and 1.79, 95% CI (1.60 to 2.00), respec-

tively. The crude and adjusted ORs for RTS were 0.39, 95% CI (0.33 to 0.45) and 0.40, 95% CI (0.34 to 0.47), respectively.

    1. Predictive performance of the TRIAGES and RTS in 24-h mortality

The AUROCs for TRIAGES, RTS, and GCS were 0.865 (0.844 to 0.884),

0.863 (0.842 to 0.882), and 0.869 (0.830 to 0.909), respectively (Fig. 2). No statistically significant differences were observed in the AUROC of the TRIAGES, RTS, and GCS (Table S1). The optimal cut-off values for predicting 24-h in-hospital mortality were 3 for TRIAGES, 6.08 for RTS, and 8 for GCS. The optimal cut-off values and their corresponding sensi- tivity, specificity, positive predictive value, and negative predictive value are shown in Table 5.

    1. Subgroup analysis

We conducted a subgroup analysis to investigate the predictive performance of various scores in two distinct age groups (Fig. 3 and Fig. S2). In patients younger than 65 years, the AUROC values for TRIAGES, RTS, and GCS are 0.872 (0.850 to 0.901), 0.897 (0.872 to

0.919), and 0.919 (0.874 to 0.920), respectively. In patients aged over 65 years, the AUROC values for TRIAGES, RTS, and GCS are 0.845 (0.809 to 0.876), 0.829 (0.792 to 0.862), and 0.836 (0.799 to 0.868), respec-

tively. No statistical differences were observed between these scores.

  1. Discussion

Our analysis indicated that TRIAGES and RTS performed equally well as GCS in predicting 24-h mortality among patients with isolated TBI, as

Table 3

Clinical characteristics of survival and non-survival groups.

Variables

Survival

Non-survival

P value

n = 1069

n = 87

Age, years

61.0 (51.0, 70.0)

63.0 (49.5, 72.0)

0.383

Gender, n (%)

0.028

Female

390 (36.5)

21 (24.1)

Male

679 (63.5)

66 (75.9)

Hypertension, n (%)

471 (44.1)

34 (39.1)

0.368

Anticoagulant use, n (%)

146 (13.7)

8 (9.2)

0.239

Heart rate, beats/min

81.0 (71.0, 93.0)

82.0 (67.5, 107.0)

0.224

Respiratory rate, breaths/min

20.0 (16.0, 21.0)

19.0 (15.5, 21.0)

0.240

Systolic blood pressure, mmHg

142.0 (122.0, 162.0)

137.0 (99.0, 169.5)

0.196

Pulse oxygen saturation, %

98.0 (95.0, 98.0)

96.0 (90.0, 96.0)

<0.001

Injury mechanism, n (%)

0.285

Penetrating

12 (1.1)

2 (2.3)

Closed

1057 (98.9)

85 (97.7)

Glasgow Coma Scale

15.0 (12.0, 15.0)

4.0 (3.0, 6.0)

<0.001

Severity, n (%)

<0.001

Mild

784 (73.3)

12 (13.8)

Moderate

99 (9.3)

4 (4.6)

Severe

186 (17.4)

71 (81.6)

SCORE

TRIAGES

2.0 (1.0, 4.0)

7.0 (5.0, 8.0)

<0.001

RTS

7.8 (6.9, 7.8)

5.0 (4.1, 6.0)

<0.001

The data are expressed as the medians (IQR) or number (%) of patients. Comparisons between groups were performed using Mann-Whitney U tests for continuous variables and ?2 tests for categorical data. TRIAGES, Trauma Rating Index in Age, Glasgow coma scale, Respiratory rate and Systolic blood pres- sure; RTS, Revised Trauma Score.

evidenced by their comparable AUROC. This finding has potential clinical implications, as timely and accurate classification of patients can significantly impact their prognosis. By utilizing early warning scores, healthcare providers can better understand patients’ conditions and make prompt and well-informed decisions regarding their care.

GCS is traditionally the most commonly used risk-scoring tool for patients with TBI [10]. Because it is a widely used assessment for neuro- logical status, many other trauma scores, including TRIAGES and RTS, also incorporate the GCS into their algorithms. Our study also demon- strated the significant predictive power of GCS, with a slightly higher AUROC than TRIAGES and RTS, although without statistical significance. This finding suggests that GCS plays a substantial role in TRIAGES and RTS scoring systems. Despite incorporating factors other than GCS, the predictive performance of these two scores did not exhibit significant improvements. GCS is a crucial factor in predicting the prognosis of patients with TBI and should be prioritized in triage assessments. How- ever, it is limited due to several confounding factors, such as pharmaco- logic sedation and paralysis, endotracheal intubation, and poisoning [11,12]. The development of an alternative scoring system, the full pic- ture of unresponsiveness (FOUR) score, has been undertaken to avoid these problems, primarily by including a brainstem examination [13,14]. However, performing it may challenge non-neurologists, as it can be more complex than other assessments [15]. Other outcome prediction models derived from large datasets, incorporating multiple predictors, have been developed and have undergone external valida- tion [16-19]. Nevertheless, such prediction models often need Imaging results, making it challenging to carry out prompt evaluations and susceptible to disruption from self-fulfilling prophecies. Because

Table 4

Logistic regression model with 24-h mortality.

Score

Crude OR (95% CI)

Adjusted OR (95% CI)

TRIAGES

1.79 (1.62-1.98)

1.79 (1.60-2.00)

RTS

0.39 (0.33-0.45)

0.40 (0.34-0.47)

Adjustment variables: gender, age, pulse oxygen saturation, history of anticoagulant use, and history of hypertension.

OR, odds ratio; CI, confidence interval; TRIAGES, Trauma Rating Index in Age, Glasgow coma scale, Respiratory rate and Systolic blood pressure; RTS, Revised Trauma Score.

building a novel prediction model necessitates a sizable dataset, utiliz- ing established trauma scores may represent a viable alternative.

RTS is a widely used rapid trauma score because the three variables incorporated can be obtained quickly at the bedside, especially in EDs with monitoring equipment, and is an accepted predictor of mortality in trauma populations. Using RTS in early trauma care can assist emer- gency physicians in making prompt decisions by accurate estimation [20-22]. Research has also highlighted the correlation between RTS

Image of Fig. 2

Fig. 2. Receiver operating characteristic (ROC) curve of 24-h mortality prediction. The red line is the ROC curve for TRIAGES, the blue line is the ROC curve for RTS, and the green line is the ROC curve for GCS. The brown line is the reference line. TRIAGES, Trauma Rating Index in Age, Glasgow coma scale, Respiratory rate and Systolic blood pressure; RTS, Revised Trauma Score; GCS, Glasgow coma scale.

Table 5

Predictive value of TRIAGES and RTS for 24-h mortality.

Score

AUROC (95%CI)

Cutoff value

Sensitivity

Specificity

PPV

NPV

TRIAGES

0.865 (0.844-0.884)

3

93.1%

73.7%

22.4%

99.2%

RTS

0.863 (0.842-0.882)

6.08

82.8%

82.3%

27.6%

98.3%

GCS

0.869 (0.830-0.909)

8

81.6%

82.6%

27.6%

98.2%

The cutoff value was obtained by ROC curve analysis. AUROC, area under the receiver operating characteristic curve; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; TRIAGES, Trauma Rating Index in Age, Glasgow coma scale, Respiratory rate and Systolic blood pressure; RTS, Revised Trauma Score; GCS, Glasgow coma scale.

and in-hospital mortality rates for elderly patients with TBI [23]. Similarly, our study has found that RTS is a reliable and accurate predic- tor of 24-h in-hospital mortality in patients with isolated TBI. However, some scholars have argued that the application of RTS may be limited in bedside or ED settings, as its complex and intricate classification system may challenge its effective implementation [20,24]. The weighting factors utilized in the RTS have been considered potentially obsolete [25,26]. In addition, it may be challenging to determine RTS scoring parameters at the bedside because of the requirement to differentiate between 0 and 1 to 49 mmHg for SBP and between 0 and 1 to 5 breaths/min for RR. Conversely, TRIAGES is a more modern trauma scoring system that surmounts these restrictions by removing the dif- ferentiation between SBP and RR values close to 0 and obviating the need for weighting factors with decimal points [9].

TRIAGES incorporates an additional variable, age, compared to RTS. TBI has a higher mortality rate in older adults, regardless of the severity of the head injury [27]. A recent study in France found that mortality rates among TBI patients increased with age, ranging from 15% in the 15-24 age group to 71% in those aged 85 years and older [28]. Also, IMPACT and CRASH prediction models identified age as a significant variable affecting the prognosis of patients with TBI [17]. Our study ob- served a trend of slightly older patients in the non-survival group than in the survival group. However, we did not detect a statistical difference. It may be attributed to the small sample size of our dataset, particularly the limited number of deaths.

TRIAGES considers the level of consciousness and respiratory and hemodynamic status, which is especially relevant in the elderly group due to Multiple comorbidities and age-related physiological changes. In contrast, the GCS score may not adequately reflect the complexity of clinical presentations in elderly patients. Previous studies have dem- onstrated that GCS may not be a reliable predictor of prognosis in el- derly individuals due to their increased risk of subdural hematomas and slower Neurological deterioration, which can lead to uncertain out- comes [29,30]. The elderly population also experiences more significant

brain atrophy and has more intracranial space, which increases their susceptibility to Intracranial bleeding [29]. Elderly patients with similar levels of Intracranial injury severity tend to present with higher GCS scores [30]. Hence, despite experiencing minor trauma and possessing a higher GCS score upon arrival at the ED, elderly individuals with TBI were considered assigned to a higher classification [31]. The subgroup analysis of our study revealed a higher AUROC in TRIAGES than GCS and RTS in patients above 65, although there was no statistical signifi- cance. This suggests that TRIAGES may be able to provide a more comprehensive assessment and improve triage decision accuracy. However, further studies with larger sample sizes are needed to confirm these results and determine the optimal score for triaging elderly patients.

TRIAGES was constructed differently from RTS because it was based on the U-shaped relationship between RR and SBP, which more accurately reflects the clinical pathophysiology of trauma [9]. Fuller G et al. demonstrated a U-shaped correlation between SBP and the prog- nosis of patients with TBI [32]. Our study also observed a U-shaped correlation between RR and SBP, associated with short-term mortality (Fig. S1). These findings suggest that using more thorough and nuanced scoring systems, such as TRIAGES, may be necessary to accurately predict the short-term prognosis of patients with isolated TBI. However, we did not find evidence indicating that TRIAGES enhanced the predic- tive performance of GCS in evaluating patients with isolated TBI. In ad- dition to the potential impact of sample size, the categorization of GCS in RTS and TRIAGES may result in a significant loss of information. Further efforts should be made to develop prognostic models incorporating ad- ditional factors without sacrificing continuous GCS scores.

Further, TRIAGES exhibited a higher sensitivity (93.1%) than RTS (82.8%) and GCS (81.6%) when using the optimal threshold in the pres- ent study. The improved sensitivity may be attributed to incorporating the patient’s age, more physiologically consistent scoring criteria, and the increased emphasis on GCS within the TRIAGES model, particularly those with low GCS values. While the AUROCs were similar between the

Image of Fig. 3

Fig. 3. Forest plot of subgroup analysis stratified by age. The primary outcome was the area under the receiver operating characteristic curve for each score in each subgroup. The squares represent the point estimate of the AUC for each score, and the horizontal lines represent the 95% confidence interval. TRIAGES, Trauma Rating Index in Age, Glasgow coma scale, Respi- ratory rate and Systolic blood pressure; RTS, Revised Trauma Score; GCS, Glasgow coma scale; AUROC, the area under the receiver operating characteristic curve; CI, confidence interval.

three scoring systems, the increased sensitivity of TRIAGES may be particularly important in detecting early adverse prognoses in patients with TBI. Underdiagnosing such cases could lead to delayed or inappro- priate treatment, resulting in poorer outcomes. Therefore, despite the potential for increased healthcare resource utilization, TRIAGES may be more suitable for clinical use than RTS and GCS in identifying patients with TBI at risk for adverse outcomes.

  1. Strengths and limitations

To the best of our knowledge, our research represented the first in- vestigation into the Predictive capacity of TRIAGES in the short-term prognosis of patients with isolated TBI. Although previous research has examined the utility of other scoring systems, such as RTS and GCS, our study provides novel insights into the potential use of TRIAGES for TBI prognosis. Furthermore, our subgroup analysis uncov- ered, for the first time, a potential advantage of TRIAGES in the elderly population. However, we must admit that our study has several limita- tions. First, as it was not a prospective study, some variables were not recorded, such as EMS transport time, level of EMS transport, the spe- cific mechanism of injury, and surgery after admission. The lack of these variables may have introduced bias into our analysis, and as such, we acknowledge that caution should be exercised when interpret- ing our findings. Well-prepared prospective studies could better cap- ture these variables and minimize potential bias effects. Second, although experienced nurses and physicians registered our medical re- cords, implementing a rigorous quality control scheme is essential to ensure the accuracy and reliability of the data. Moving forward, we will consider additional measures to enhance the accuracy and reliabil- ity of our data, such as applying double checks and conducting regular data audits to minimize the risk of errors. Finally, the sample size in our study was limited, which may have impacted our ability to draw ro- bust conclusions. The scarcity of abnormal RR and SBP values may pose challenges in evaluating the predictive value of TRIAGES/RTS in compar- ison to GCS. Although we observed several trends and associations be- tween variables, our findings should be cautiously interpreted and validated in more extensive studies. Subsequent investigations should aim to augment the sample size to enhance the statistical power of our analysis.

  1. Conclusion

The TRIAGES and RTS scoring systems have shown promising efficacy in predicting 24-h in-hospital mortality in patients with isolated TBI, with predictive performance comparable to, but not exceeding, the GCS. Al- though TRIAGES seems to have a more thorough evaluation, higher sen- sitivity, more straightforward computations, and better performance in elderly patients, additional research is required to ascertain whether it can outperform GCS as a triage tool for patients with isolated TBI.

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.06.030.

Ethics approval and consent to participate

This research project was approved by the research ethics commit- tee of the Affiliated Hospital of Nantong University (approval no.: 2021?K084?01), waiving the need for consent from study participants.

Financial disclosure statement

There are no financial conflicts of interest to disclose.

Funding

This research was supported by funding from the Nantong Munici- pal Health Commission Mandatory Subject Surface Project (No:

MS2022010) and the Nantong Municipal Science and Technology Pro- ject (No.MS12021020).

CRediT authorship contribution statement

Daishan Jiang: Writing – original draft, Software, Methodology, For- mal analysis, Conceptualization. Tianxi Chen: Validation, Resources, In- vestigation, Data curation. Xiaoyu Yuan: Writing – review & editing. Yanbo Shen: Writing – review & editing, Supervision. Zhongwei Huang: Supervision, Project administration.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declaration of Competing Interest

There are no competing interests to disclose.

Acknowledgments

Not applicable.

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