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Abstract

Sex-based differences in rib fracture presentation and recovery may influence surgical stabilization of rib fractures (SSRF) outcomes. Greater chest wall muscle mass in males may necessitate higher-energy trauma to cause rib fractures, increasing the risk of respiratory complications. Objective: We compared the rates of SSRF in male and female blunt trauma patients (BTPs) with rib fractures, hypothesizing that males would undergo SSRF at a higher rate and experience increased respiratory complications following SSRF. Methods: TQIP (2017-2022) was queried for adult BTPs with multiple rib fractures and/or flail segment. Male SSRF BTPs were compared to female SSRF BTPs. Multivariable logistic regression analysis was performed to determine if sex was associated with an increased risk of respiratory complications [unplanned intubation, acute respiratory distress syndrome (ARDS), and ventilator-associated pneumonia (VAP)]. Results: The rate of SSRF in males was 3.1% and 2.3% in females (P < .001). From 20 487 SSRF patients, 15 086 (74%) were male. Both groups had similar median injury severity scores (ISS) of 17; however, males had higher rates of severe thoracic injury (34.7% vs 31.1%, P < .001). Males had higher rates of overall respiratory complications (13.0% vs 10.3%) including ARDS (1.9% vs 1.3%), VAP (3.9% vs 2.4%), and unplanned intubation (7.8% vs 6.8%) (all P < .05). On multivariable analysis, males had an increased risk of respiratory complications (OR 1.37, CI 1.24-1.52, P < .001) and mortality (OR 1.33, CI 1.07-1.65, P = .01). Conclusion: Despite comparable ISS, males more frequently underwent SSRF and had increased risk of respiratory complications and mortality post-operatively. These disparities may reflect underlying anatomical/physiological factors.

Keywords

chest wall muscle mass respiratory complication sex-based differences SSRF surgical stabilization of rib fractures

Background

Thoracic injuries remain a major burden in trauma care, contributing significantly to morbidity and mortality worldwide.^1,2 Rib fractures are the most common consequence of blunt thoracic trauma, often resulting in severe pain, respiratory compromise, and prolonged hospitalization.³ Historically, rib fractures have been managed nonoperatively and primarily with a multimodal pain regimen.^3-5 However, over the past decade, surgical stabilization of rib fractures (SSRF) has become a vital addition to the trauma surgeon’s armamentarium, particularly for managing patients with severely displaced fractures that compromise respiratory function. Studies have demonstrated that SSRF can reduce pain, improve respiratory function, shorten hospital and intensive care unit (ICU) length of stays (LOS), and lower mortality rates.^3,6-11

Sex-based physiological differences may influence outcomes following SSRF.^12,13 Prior research has established that anatomical and biomechanical variations between males and females affect injury patterns and recovery trajectories across various trauma populations.^13-17 Males generally have greater skeletal muscle mass and soft tissue density, particularly in the upper body, which may provide some degree of protection against fractures but also necessitate greater force to cause fractures.^12,13,18 These distinctions raise questions about how the patterns and severity of rib fractures (ie, displacement) present differently in males vs females and whether these differences impact the decision to pursue SSRF and outcomes following surgical intervention.

A prior study from the United Kingdom suggested that males sustain rib fractures more frequently and are more likely to undergo SSRF than females.¹⁹ This may be attributed to the higher-energy trauma mechanisms typically associated with male patients, leading to more severe chest injuries. Additionally, the physiological consequences of high-energy trauma, including increased pulmonary complications, may vary between sexes, further influencing SSRF outcomes.²⁰ However, despite the growing adoption of SSRF, sex-based differences in postoperative outcomes remain poorly defined.

The aim of this study is to compare SSRF rates between male and female blunt trauma patients (BTPs) with rib fractures and examine the potential differences in postoperative respiratory complications. We hypothesized that male patients would not only undergo SSRF at a higher rate but also experience increased respiratory complications following SSRF, compared to female patients.

Methods

This study was approved by our Institutional Review Board and a waiver of informed consent was granted as it utilizes a national deidentified database. The 2017-2022 Trauma Quality Improvement Program database (TQIP) was queried for adult BTPs 18 years of age or older. BTPs with multiple rib fractures (≥3) and/or flail segment were identified. The following patients were excluded: patients who were transferred from another facility, those sustaining penetrating trauma, patients dead on arrival, and those discharged ≤48 h from admission. This research adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and a complete checklist is available as Supplemental Digital Content (SDC Appendix 1).

Male and female patients undergoing SSRF were compared. The primary outcome was respiratory complications, defined by unplanned intubation, acute respiratory distress syndrome (ARDS), and ventilator-associated pneumonia (VAP). Secondary outcomes included hospital and ICU LOS, ventilator days, and mortality. Additional outcomes measured included in-hospital complications, and emergency surgery (defined by admission to the operating room within 2 h of arrival).

Demographic variables collected included age, vitals on arrival, alcohol and drug screens, and comorbidities including cerebrovascular accident (CVA), dementia, functional dependency, congestive heart failure, chronic obstructive pulmonary disease (COPD), and diabetes. Additional data on smoking, alcohol, substance, and drug use were also collected. The injury profile included the mechanisms of injury [motor vehicle collision (MVC), fall, motorcycle collision, pedestrian struck, and bicycle crashes], injury severity score (ISS), and severe injuries of the head, thorax, and abdomen. Severe injuries were defined by an Abbreviated Injury Score (AIS) grade 3 or higher for the body region. Additionally, specific injuries to the brain, lungs [pneumothorax, hemothorax, hemopneumothorax, and not otherwise specified (NOS)], thorax including flail chest, diaphragm, and abdomen (liver, spleen, kidneys, intestines, and bladder) were also collected.

Bivariate analyses were performed utilizing the Mann-Whitney U test to compare continuous variables and Pearson’s chi-squared analysis to compare categorical variables. Continuous and categorical variables were reported as medians with an interquartile range and frequencies, respectively. Multivariable logistic regression models were also used to evaluate the associated risk of death and respiratory complications between males and females after controlling for known predictors of mortality and respiratory complications that are available in the TQIP database. These variables were chosen by consensus among authors after review of the literature and included age ≥65, ISS, hypotension (SBP <90 mmHg), tachycardia (>120 beats/min), functional dependency, dementia, diabetes, smoking, alcohol use disorder, and substance use disorder.^21-23 To further control for differences in demographics and injury profile between male and female patients, an additional multivariable logistic regression analysis for respiratory complications and mortality was performed, in which all variables with a P-value < .10 on univariable analysis were included as covariates.

Additionally, two planned subgroup analyses of patients with severe thoracic injury (AIS ≥3) and flail segment were performed. All P-values were two-sided, with a statistical significance set at P < .05. All analyses were performed utilizing IBM SPSS Statistics for Windows (Version 29, IBM Corp., Armonk, NY).

Results

Demographics and Comorbidities for Male vs Female BTPs With Rib Fractures Undergoing SSRF

Among BTPs with rib fractures, SSRF was performed in 3.1% of males and 2.3% of females (P < .001). Of the 20 487 SSRF patients, 15 086 (73.6%) were male. Males were younger with a median age of 57 compared to females with a median age of 60 (P < .001). Male patients had higher rates of smoking (27.0% vs 22.1%, P < .001), but lower rates of COPD (7.1% vs 9.1%, P < .001), compared to females (Table 1).

Table 1.

Demographics for Male vs Female Blunt Trauma Patients With Rib Fractures Undergoing SSRF

Characteristic	Female	Male	P-Value
Characteristic	(n = 5401)	(n = 15 086)	P-Value
Age, year, median (IQR)	60 (45, 72)	57 (46, 66)	<0.001
Comorbidities, n (%)
Cerebrovascular accident	84 (1.6%)	237 (1.6%)	0.945
Dementia	125 (2.3%)	152 (1.0%)	<0.001
Mental personality disorder	835 (15.7%)	1289 (8.7%)	<0.001
Functionally dependent	305 (5.7%)	379 (2.5%)	<0.001
Angina pectoris	11 (0.2%)	28 (0.2%)	0.791
Myocardial infarction	25 (0.5%)	98 (0.7%)	0.129
Congestive heart failure	123 (2.3%)	354 (2.4%)	0.782
COPD	483 (9.1%)	1058 (7.1%)	<0.001
End stage renal disease	32 (0.6%)	117 (0.8%)	0.176
Diabetes	813 (15.3%)	2336 (15.7%)	0.474
Hypertension	2100 (39.3%)	5622 (37.6%)	0.032
Smoking	1177 (22.1%)	4027 (27.0%)	<0.001
Alcohol use disorder	280 (5.3%)	1605 (10.8%)	<0.001
Substance use disorder	395 (7.4%)	1351 (9.1%)	<0.001
Steroid use	59 (1.1%)	123 (0.8%)	0.061
Alcohol screen positive	776 (22.8%)	3109 (29.8%)	<0.001
Drug screen positive	974 (41.3%)	3199 (43.8%)	0.032
Vitals on arrival, n (%)
Hypotensive (SBP <90 mmHg)	392 (7.4%)	1004 (6.8%)	0.112
Tachycardia (HR >120/min)	660 (12.5%)	1892 (12.7%)	0.629
Tachypnea (RR >22/min)	1921 (36.8%)	5908 (40.3%)	<0.001

SSRF, surgical stabilization of rib fracture; IQR, interquartile range; COPD, chronic obstructive pulmonary disease; SBP, systolic blood pressure; HR, heart rate; RR, respiratory rate. Bold values indicate statistical significance.

Injury Profile for Male vs Female BTPs With Rib Fractures Undergoing SSRF

Male patients had higher rates of motorcycle collisions (20.5% vs 5.1%, P < .001), and bicycle accidents (5.7% vs 1.9%, P < .001), but lower rates of MVCs (34.1% vs 50.2%, P < .001), falls (28.9% vs 31.0%, P = .003), and pedestrian struck (6.4% vs 9.1%, P < .001), compared to females. Both groups had a similar median ISS of 17; however, males had higher rates of severe (AIS ≥3) thoracic injury (34.7% vs 31.1%) and specifically lung injuries (92.5% vs 88.7%) including hemopneumothorax (44.5% vs 38.5%), lung NOS (53.7% vs 48.0%), and flail chest (44.2% vs 40.5%) (all P < .001) (Table 2).

Table 2.

Injury Profile for Male vs Female Blunt Trauma Patients With Rib Fractures Undergoing SSRF

	Female	Male	P-Value
Characteristic	(n = 5401)	(n = 15 086)	P-Value
Mechanism of injury, n (%)
Motor vehicle collision	2712 (50.2%)	5149 (34.1%)	<0.001
Any fall	1676 (31.0%)	4361 (28.9%)	0.003
Motorcycle collision	278 (5.1%)	3100 (20.5%)	<0.001
Pedestrian struck	493 (9.1%)	968 (6.4%)	<0.001
Bicycle accident	105 (1.9%)	865 (5.7%)	<0.001
ISS, median (IQR)	17 (13, 26)	17 (13, 26)	<0.001
AIS (grade ≥3), n (%)
Head	257 (4.8%)	812 (5.4%)	0.077
Thorax	1678 (31.1%)	5233 (34.7%)	<0.001
Abdomen	453 (8.4%)	1067 (7.1%)	0.002
Injuries, n (%)
Brain	770 (14.3%)	2324 (15.4%)	0.043
Cervical cord	35 (0.6%)	117 (0.8%)	0.349
Spinal cord	90 (1.7%)	287 (1.9%)	0.268
Heart	113 (2.1%)	391 (2.6%)	0.042
Lung	4791 (88.7%)	13 948 (92.5%)	<0.001
Pneumothorax	2112 (39.1%)	5720 (37.9%)	0.123
Hemothorax	915 (16.9%)	2690 (17.8%)	0.141
Hemopneumothorax	2079 (38.5%)	6708 (44.5%)	<0.001
NOS	2595 (48.0%)	8096 (53.7%)	<0.001
Flail segment	2187 (40.5%)	6668 (44.2%)	<0.001
Diaphragm	222 (4.1%)	552 (3.7%)	0.135
Liver	773 (14.3%)	1560 (10.3%)	<0.001
Spleen	780 (14.4%)	2092 (13.9%)	0.297
Kidney	252 (4.7%)	827 (5.5%)	0.021
Stomach	17 (0.3%)	35 (0.2%)	0.30
Small intestine	71 (1.3%)	154 (1.0%)	0.075
Colon	64 (1.2%)	175 (1.2%)	0.883
Rectum	1 (0%)	5 (0%)	0.590
Bladder	49 (0.9%)	76 (0.5%)	0.001
Spine fracture	2286 (42.3%)	5833 (38.7%)	<0.001
Pelvis fracture	953 (17.6%)	2061 (13.7%)	<0.001
Upper extremity fracture	921 (17.1%)	2110 (14.0%)	<0.001
Lower extremity fracture	1092 (20.2%)	2376 (15.7%)	<0.001

SSRF, surgical stabilization of rib fracture; ISS, injury severity score; IQR, interquartile range; AIS, abbreviated injury scale; NOS, not otherwise specified. Bold values indicate statistical significance.

Clinical Outcomes for Male vs Female BTPs With Rib Fractures Undergoing SSRF

Males had increased overall hospital complications (25.7% vs 22.0%, P < .001) as well as increased respiratory complications (13.0% vs 10.3%, P < .001), including ARDS (1.9% vs 1.3%, P = .002), VAP (3.9% vs 2.4%, P < .001), and unplanned intubation (7.8% vs 6.8%, P = .014). Mortality rates were similar between cohorts (male: 2.6% vs female: 2.3%, P = .31) (Table 3).

Table 3.

Clinical Outcomes of Male vs Female Blunt Trauma Patients With Rib Fractures Undergoing SSRF

Characteristic	Female	Male	P-Value
Characteristic	(n = 5401)	(n = 15 086)	P-Value
Hospital LOS, days, median (IQR)	12 (9, 18)	12 (8, 18)	0.191
ICU LOS, days, median (IQR)	7 (4, 12)	7 (4, 13)	0.022
Ventilator, days, median (IQR)	7 (3, 13)	7 (3,13)	0.542
Any complication, n (%)	1187 (22.0%)	3874 (25.7%)	<0.001
Cerebrovascular accident	42 (0.8%)	130 (0.9%)	0.568
Cardiac arrest	70 (1.3%)	346 (2.3%)	<0.001
Myocardial infarction	15 (0.3%)	56 (0.4%)	0.319
Any respiratory complication	554 (10.3%)	1964 (13.0%)	<0.001
ARDS	69 (1.3%)	291 (1.9%)	0.002
Pulmonary embolism	75 (1.4%)	270 (1.8%)	0.051
VAP	130 (2.4%)	594 (3.9%)	<0.001
Unplanned intubation	364 (6.8%)	1173 (7.8%)	0.014
Acute kidney injury	81 (1.5%)	411 (2.7%)	<0.001
Sepsis	65 (1.2%)	266 (1.8%)	0.005
Superficial incision SSI	25 (0.5%)	86 (0.6%)	0.361
Deep SSI	19 (0.4%)	68 (0.5%)	0.340
Organ space SSI	17 (0.3%)	52 (0.3%)	0.749
Deep vein thrombosis	145 (2.7%)	534 (3.5%)	0.003
CAUTI	55 (1.0%)	78 (0.5%)	<0.001
CLABSI	10 (0.2%)	29 (0.2%)	0.992
Unplanned return to OR	195 (3.7%)	643 (4.3%)	0.038
Emergent OR, n (%)	654 (12.1%)	1603 (10.6%)	0.003
Mortality, n (%)	126 (2.3%)	390 (2.6%)	0.310

SSRF, surgical stabilization of rib fracture; LOS, length of stay; IQR, interquartile range; ICU, intensive care unit; ARDS, acute respiratory distress syndrome; VAP, ventilator-associated pneumonia; SSI, surgical site infection; CS, compartment syndrome; CAUTI, catheter associated urinary tract infection; CLABSI, central line associated blood stream infection; OR, operating room. Bold values indicate statistical significance.

On multivariable logistic regression analysis, male patients had an increased associated risk of respiratory complications (OR 1.37, CI 1.24-1.52, P < .001) and mortality (OR 1.33, CI 1.07-1.65, P = .01). The increased risk of respiratory complications remained significant in subgroup analyses of patients with severe thoracic injury (OR 1.34, CI 1.20-1.49, P < .001) and flail chest (OR 1.23, CI 1.06-1.42, P < .001) (Table 4).

Table 4.

Multivariable Logistic Regression Analysis for Risk of Respiratory Complications and Mortality in Male vs Female Blunt Trauma Patients With Rib Fractures Undergoing SSRF

Predictors^b	OR	CI	P-Value
All respiratory complications^a	1.37	1.24-1.52	<0.001
Severe thoracic injury (AIS ≥3)	1.34	1.20-1.49	<0.001
Flail segment	1.23	1.06-1.42	<0.001
Mortality	1.33	1.07-1.65	0.01

^aIncluding unplanned intubation, ventilator-associated pneumonia, and acute respiratory distress syndrome.

^bControlling for age ≥65, injury severity score, hypotension on arrival, tachycardia on arrival, functional dependency, dementia, diabetes, smoking, alcohol use disorder, and substance use disorder.

Reference group: female patients. Bold values indicate statistical significance.

In an additional multivariable logistic regression model that accounted for a broader array of potential confounders, including thoracic injury severity, hemopneumothorax, and flail chest, male patients continued to have an increased associated risk of respiratory complications (OR 1.36, CI 1.22-1.51, P < .001). The association between male sex and mortality was slightly stronger in this expanded model (OR 1.42, CI 1.13-1.77, P = .002) (Table 5).

Table 5.

Expanded Multivariable Logistic Regression Analysis for Risk of Respiratory Complications and Mortality in Male vs Female Blunt Trauma Patients With Rib Fractures Undergoing SSRF

Predictors^b	OR	CI	P-Value
All respiratory complications^a	1.36	1.22-1.51	<0.001
Mortality	1.42	1.13-1.77	0.002

^aIncluding unplanned intubation, ventilator-associated pneumonia, and acute respiratory distress syndrome.

^bControlling for age ≥65, injury severity score, hypertension, tachypnea on arrival, functional dependency, mental/personality disorder, chronic obstructive pulmonary disease, dementia, smoking, alcohol use disorder, substance use disorder, chronic steroid use, severe head and thoracic injury, traumatic brain injury, cardiac injury, hemopneumothorax, lung injury not otherwise specified, flail chest, injury to the liver, kidney, small intestine, and bladder, and fractures of the spine, pelvis, upper extremity, and lower extremity.

Reference group: female patients.

Discussion

Over the past decade, SSRF has become an increasingly adopted intervention for managing severe chest wall injuries.²⁴ In this national analysis spanning 6 years, we found that while male and female BTPs with rib fractures had comparable injury severity scores, males more often sustained severe thoracic injuries and underwent SSRF. Additionally, male sex was independently associated with a higher risk of respiratory complications following SSRF, a finding that remained significant in subgroup analyses of patients with severe thoracic injuries and flail chest. Notably, males also had a higher associated risk of death following SSRF. These associations persisted, with similar or slightly stronger effect sizes, even after additional adjustment for a broader array of demographic and injury-related covariates in an expanded multivariable model.

Males in our study were more likely to sustain severe thoracic injuries and undergo SSRF. This finding is consistent with prior research demonstrating a predominance of male patients in thoracic trauma cases. A multicenter study by Benhamed et al. found that nearly 70% of patients with severe thoracic trauma were male,²⁵ while Bayer et al²⁶ similarly reported that over 70% of patients with thoracic injuries were male, with a mean ISS >16. Additional studies have confirmed these trends, showing a higher ISS in male patients with chest trauma.^27-29 We found that this pattern extends to SSRF utilization, a finding echoed in multiple studies.^8,20,30 One explanation for the disparities between males and females lies in anatomical and biomechanical differences. While males have greater chest wall muscle mass (up to 40% more) and denser skeletal structures, these protective factors necessitate higher-energy trauma to cause fractures, often leading to more severe injuries requiring surgical stabilization.¹⁹ This aligns with our findings, as males in our study were more frequently involved in high-energy mechanisms such as motorcycle collisions, whereas females had higher rates of falls and motor vehicle collisions.^31-33 Motorcycle collisions are known to generate greater impact forces compared to motor vehicle collisions.³⁴

The number of ribs fractured and severity of displacement of ribs are well-established predictors of respiratory complications in thoracic trauma patients undergoing SSRF.^2,35 Given that male patients in our study sustained more severe thoracic injuries, this may partially explain their higher incidence of postoperative respiratory complications. However, the risk of respiratory complications persisted in subgroup analyses of patients with flail chest and severe thoracic injuries. Beyond injury severity, lifestyle factors such as smoking may further contribute to poorer respiratory outcomes in male SSRF patients as males more often smoked in our cohort, which aligns with national data showing that smoking prevalence is greater in males.³⁶ Smoking is associated with impaired pulmonary function, chronic inflammation, delayed wound healing, and increased mucus production, all of which heighten the risk of pulmonary complications.^37,38 Additionally, biological differences in immune response and pulmonary physiology may contribute to sex-based disparities in respiratory outcomes. Estrogen has been shown to exert protective effects on lung function and immune modulation, potentially reducing susceptibility to inflammatory lung injury and/or infection in female trauma patients.^39,40 Conversely, males have been observed to exhibit higher levels of systemic inflammation and oxidative stress following trauma, which may predispose them to worse pulmonary outcomes after major surgery.^39,40 These mechanisms could further explain why males in our study had significantly higher rates of ARDS, VAP, and unplanned intubation following SSRF. Future translational research appears warranted to see if this disparity can be mitigated.

While SSRF may be effective in reducing overall mortality among patients with rib fractures,⁷ the impact varies by sex. A national analysis performed by Taghavi et al. identified male sex as a risk factor for increased mortality in SSRF patients.⁴¹ Similarly, our study corroborates these findings, with male patients exhibiting a higher mortality risk even when controlling for age, vitals, injury profile and comorbidities. The reasons for this are likely multifactorial but may be partially explained by the variance in severity of injuries, and pre-existing health conditions.^12,25,36

The limitations of this study include those inherent to retrospective database studies, such as selection and reporting bias. Pertinent variables missing from the TQIP database include precise timing of SSRF procedures and baseline pulmonary function data. In addition, potential unaddressed confounders include procedural details (ie, the number of ribs fixed, intrathoracic vs extrathoracic plating, tube thoracostomy placement, and analgesia strategies), number of displaced ribs, the experience of those performing the procedure, and post-discharge data/outcomes. In addition, the study lacks data related to social determinants of health and patient centric outcomes. Finally, the distinction between male and female patients may be an oversimplification and ignores potential physiological variations (ie, hormonal and inflammatory markers) beyond binary classifications, which could influence both the management strategies and outcomes. Despite these limitations, the results of this study are strengthened by the large number of patients and trauma centers included, which provides increased generalizability of the findings compared to prior studies.

Conclusion

This national analysis demonstrates sex-based differences in SSRF utilization and outcomes following blunt thoracic trauma. Despite comparable injury severity scores, male patients underwent SSRF more frequently and experienced higher rates of respiratory complications and mortality post-operatively. These disparities may be influenced by anatomical, physiological, and/or lifestyle factors, though the precise mechanisms remain unclear. Future research should focus on identifying sex-specific risk factors and optimizing perioperative management strategies to improve SSRF outcomes across all patients.

Footnotes

Author Note

This work was presented at: Chest Wall Injury Society (CWIS) 2025 Annual Meeting, Atlanta, Georgia.

ORCID iDs

Negaar Aryan

Jiabao Nie

Author Contributions

N.A.: literature search, study design, data interpretation, writing—original draft, and critical revisions. S.D.S.: study design, data interpretation, and critical revisions. J.N.: study design, data interpretation, and critical revisions. M.D.: study design, data interpretation, and critical revisions. M.L.: study design, data interpretation, and critical revisions. J.N.: study design, data interpretation, and critical revisions. A.G.: study design, data collection, data interpretation, and critical revisions.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

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

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Sex-Based Differences in Surgical Stabilization Outcomes for Rib Fractures in Blunt Trauma Patients

Abstract

Keywords

Background

Methods

Results

Demographics and Comorbidities for Male vs Female BTPs With Rib Fractures Undergoing SSRF

Injury Profile for Male vs Female BTPs With Rib Fractures Undergoing SSRF

Clinical Outcomes for Male vs Female BTPs With Rib Fractures Undergoing SSRF

Discussion

Conclusion

Footnotes

Author Note

ORCID iDs

Author Contributions

Funding

Declaration of Conflicting Interests

References