Application value of real-time shear wave elastography in the diagnosis and efficacy evaluation of venous thrombosis

Abstract

BACKGROUND:

OBJECTIVE:

To investigate the application of real-time shear wave elastography (SWE) in diagnosing lower-limb deep vein thrombosis (DVT).

METHODS:

A total of 91 patients with DVT were selected and divided into three groups: acute phase ( $n=$ 29), subacute phase ( $n=$ 30) and chronic phase ( $n=$ 32). The Young’s modulus of the patients was measured using real-time SWE. The diagnostic efficacy of Young’s modulus was evaluated by ROC curves. The hardness differences in Young’s modulus across different parts of the same thrombus (head, body and tail) were measured using SWE.

RESULTS:

Before treatment, significant differences were observed in Young’s modulus among patients with DVT ( $P<$ 0.001). Following anticoagulant therapy, catheter-directed thrombolysis and systemic thrombolysis, significant differences were noted in Young’s modulus among patients at the same stage but receiving different treatments (acute phase: $P=$ 0.003; subacute phase: $P=$ 0.014; chronic phase: $P=$ 0.004). Catheter-directed thrombolysis had greater efficacy than anticoagulant therapy. The area under the curve for SWE in staging patients was 0.917, with a sensitivity of 92.36% and specificity of 93.81%. Significant differences in Young’s modulus were found between the thrombus head and thrombus body and tail but not between the thrombus body and thrombus tail.

CONCLUSION:

Measurement of Young’s modulus using SWE can serve as an auxiliary means of evaluating staging, predicting pulmonary embolism and selecting treatment in patients with DVT.

Keywords

Real-time shear wave elastography lower-limb deep vein thrombosis diagnosis treatment plan

1. Introduction

Deep vein thrombosis (DVT) of the lower limbs is a venous reflux disorder caused by abnormal coagulation of blood components, primarily characterised by swelling and pain in the lower limbs [1]. Key risk factors include prolonged immobility due to bed rest, pregnancy, postpartum or postoperative states, traumas, malignant tumours and long-term contraceptive use [2]. The pathogenic factors of DVT involve vein wall injury, venous stasis and a hypercoagulable state. Thrombi may remain localised to their site of origin, self-ablate over time or spread to the venous trunk. As thrombosis progresses, activation of the endogenous fibrinolytic system and iatrogenic thrombolytic interventions may cause thrombi to detach. These detached thrombi, upon reaching the pulmonary arteries, can cause pulmonary embolism (PE), manifested by pulmonary circulatory and respiratory dysfunctions. Pulmonary embolism represents the most severe complication of DVT, with high mortality and disability rates. Research indicates [3] that the 7-day mortality for PE ranges from 1.9% to 2.9% and 30-day mortality from 4.9% to 6.6%. Post-thrombotic syndrome (PTS) is the most common chronic complication of DVT, severely impacting the quality of life and work productivity of patients. Approximately 20%–50% of patients with DVT develop PTS within 2 years [4]. An epidemiological study indicates that the average annual incidence of DVT is approximately 100 per 100,000 individuals, with incidence rates increasing with age, particularly in individuals over 60 years [5]. Statistics reveal that approximately 80% of lower-limb DVT cases exhibit no clinical symptoms, over 70% of PE cases are detected post-mortem and approximately two-thirds of patients with PE die within 2 hours. Therefore, early, accurate and timely diagnosis and treatment of lower-limb DVT are crucial to preventing PE and substantially reducing mortality risks.

The pathology and tissue composition of DVT evolves through its acute, subacute and chronic phases, which influence the treatment plan and prognosis. The accurate staging of thrombosis is, therefore, of great clinical significance [6]. The commonly used methods for DVT treatment include anticoagulant therapy, systemic thrombolysis and catheter-directed thrombolysis. Anticoagulant therapy, which aims to inhibit the formation of fresh thrombi and prevent their development, serves as the foundation of DVT treatment. However, Broderick et al. [7] noted that anticoagulant therapy alone is unable to dissolve existing thrombi, leading to a higher incidence of both immediate- and long-term PTS and venous ulcers.

Systemic thrombolysis, a prevalent thrombolytic method in China for the early treatment of DVT [8], involves the systemic administration of thrombolytic drugs through peripheral venous access. Schweizer et al. [9] demonstrated that systemic thrombolysis, compared with anticoagulant therapy alone, achieves a higher venous recanalization rate and a lower incidence of PTS, although with a higher risk of bleeding. Despite this risk, systemic thrombolysis can improve limb discomfort and restore venous access, leading to lower hospitalisation costs and higher patient acceptance [10].

Catheter-directed thrombolysis involves the insertion of a thrombolytic catheter with side holes into the thrombus, allowing direct contact between the thrombolytic drugs and the thrombus. Wang et al. [11] report that nearly 80% of thrombus clearance in DVT is achieved through this method. A 32-month follow-up study found a 21% incidence of PTS. The clinical efficacy and complication rate of catheter-directed thrombolysis are superior to those of systemic thrombolysis; however, the bleeding risk remains substantial. Additionally, this method has disadvantages such as a lengthy thrombolytic cycle, long-term catheterisation and increased catheter-related risks [12].

As medical technology advances, thrombolytic methods for treating DVT are proliferating. However, few methods exist for evaluating the therapeutic efficacy of venous thrombosis in clinical practice. Commonly used methods include monitoring changes in D-dimer levels, observing clinical symptoms, conducting routine colour Doppler examinations and performing lower-limb deep vein angiography. Each of these methods has drawbacks, such as a lack of specificity, low accuracy or invasiveness.

Shear wave elastography (SWE) is a technique that generates ultra-high-resolution elastic images by creating shear waves in tissue using focused acoustic radiation force impulses. It calculates Young’s modulus using the built-in quantitative analysis system (Q-BOX) of the SWE instrument, thereby reflecting the elasticity and hardness of the target tissue [13]. Shear wave elastography has proven to be more objective in measuring soft tissue elasticity and has been used in the clinical diagnosis of various diseases, such as breast cancer [14] and cervical cancer [15]. However, its application in DVT staging has rarely been investigated.

In this study, SWE was employed for the real-time quantitative analysis of the elasticity of venous thrombi. By observing changes in Young’s modulus, the study explored the potential of this technology in determining the course of thrombosis, predicting PE and selecting appropriate treatment plans. The findings aim to provide a more robust basis for identifying clinical methods for DVT treatment. This research is expected to improve the success rate of thrombolysis, enhance the quality of life for patients and reduce the health and economic burdens on patients and society.

2. Participants and methods

2.1 Participants

This retrospective study included patients definitively diagnosed with venous thrombosis through colour Doppler ultrasound at the First People’s Hospital of Tianshui between November 2021 and July 2022. A total of 91 eligible patients were selected based on specific inclusion and exclusion criteria. According to the clinical staging criteria for lower-limb DVT [16], the patients were divided into three groups: the acute phase (Group A, $n=$ 29, a disease course $<$ 14 days), subacute phase (Group B, $n=$ 30, a disease course of 15 days to 6 months) and chronic phase (Group C, $n=$ 32, a disease course $>$ 6 months). These patients were further divided into subgroups based on their treatment protocols: anticoagulant therapy, catheter-directed thrombolysis and systemic thrombolysis. Specifically, Group A comprised an anticoagulant therapy subgroup ( $n=$ 9), a catheter-directed thrombolysis subgroup ( $n=$ 10) and a systemic thrombolysis subgroup ( $n=$ 10); Group B comprised an anticoagulant therapy subgroup ( $n=$ 10), a catheter-directed thrombolysis subgroup ( $n=$ 10) and a systemic thrombolysis subgroup ( $n=$ 10); Group C comprised an anticoagulant therapy subgroup ( $n=$ 10), a catheter-directed thrombolysis subgroup ( $n=$ 11) and a systemic thrombolysis subgroup ( $n=$ 11). Figure 1 provides the study flowchart

Figure 1.

Flow-chart of the study design.

The inclusion criteria were as follows: (1) initial onset of DVT with no previous history; (2) definitive diagnosis of DVT through colour Doppler ultrasound; (3) unilateral lower limb involvement with central or mixed thrombosis; (4) good compliance and a minimum follow-up period of 1 year; and (5) no contraindications to anticoagulant or thrombolytic therapies. The exclusion criteria were as follows: (1) a previous history of DVT; (2) bilateral lower-limb thrombosis or peripheral thrombosis; (3) allergic reactions to contrast agents; (4) severe cardiovascular, cerebrovascular or pulmonary diseases, hepatic or renal dysfunction, or hemodynamic instability; (5) contraindications to anticoagulant or thrombolytic therapies; (6) refusal to participate or poor compliance.

2.2 Instruments and operating methods

2.2.1 Shear wave elastography

Real-time SWE was performed using an AixPlorer diagnostic ultrasound system (ShearwaveTM, Supersonic Imagine, France) with a 4–15 MHz L15-4 linear array probe set to a lower-limb vein preset mode. The patients were instructed to lie in a supine position, with abduction and external rotation of the affected limbs. Ultrasound-guided exploration commenced with the probe positioned on the skin to display the cross section of the selected vessels. Pressure scanning was conducted at intervals of 2–3 cm to determine the location of vascular thrombi and to assess patency. Subsequently, the mode was switched to SWE for a dual-view display of two-dimensional grayscale and elastic images (elasticity range, 0–180 kPa). Depending on the diseased vascular structure, the position of the region of interest was adjusted to encompass the affected vascular structure and appropriate surrounding tissues. The images were frozen after stabilisation of the elastic image. Thereafter, the area function of Young’s modulus measurement (Q-BOX) was activated, and the Q-BOX was positioned within the thrombi for automatic calculation of the average Young’s modulus (unit: kPa). The Young’s modulus of the head, body and tail of the same thrombus were measured separately. The measurements were repeated three times, and the averages were recorded.

2.3 Treatment methods

2.3.1 Anticoagulant therapy

All patients received subcutaneous injections of enoxaparin sodium (Guoyao Zhunzi H20153099, Changzhou Qianhong Bio-pharma Co. Ltd.), administered every 12 hours at a dose of 70–80 anti-XaIU/kg body weight. Four days after initiating the enoxaparin sodium regimen, warfarin sodium tablets (Guoyao Zhunzi H37021314, Qilu Pharmaceutical Co. Ltd.) were administered orally every 12 hours at a dose of 0.25 mg for 7 consecutive days.

2.3.2 Catheter-directed thrombolysis

In the catheter-directed thrombolysis groups, an inferior vena cava filter was placed prior to catheterisation to prevent thrombus detachment and PE. Under ultrasound guidance, a popliteal vein puncture was performed on the affected side, followed by the insertion of a catheter sheath. A super-slippy guide wire facilitated the insertion of an angiography catheter, through which a contrast agent was injected to delineate the thrombosis extent. Depending on the length of the thrombus, catheters with side holes of varying lengths were chosen, with the tips positioned at the proximal end of the thrombi. During treatment, the catheter’s position was periodically adjusted according to the progress of thrombolysis until its withdrawal. Intraoperatively, 300,000–400,000 U of urokinase was administered through the thrombolytic catheter, and postoperatively, 600,000–800,000 U/day of urokinase was infused via the thrombolytic catheter using a micropump over 7 consecutive days. Patients diagnosed with Cockett’s syndrome after angiography underwent additional balloon dilation of the iliac vein or stent implantation.

2.3.3 Systemic thrombolysis

Urokinase (700,000–900,000 U/d) was administered slowly through the dorsalis pedis vein of the affected limb. During administration, the ligation site, adjusted according to the thrombus location, was secured with a tourniquet. For thigh DVT, ligation was positioned 5–10 cm below and above the patella. The force applied ensured that the tourniquet was snug against the skin without leaving impressions. Patients needed to experience a sensation of constriction. The treatment duration was approximately 7 days. During this period, routine blood and coagulation markers were closely monitored to adjust the dosage or discontinue the medication as necessary.

2.4 Statistical analysis

Data processing was conducted using SPSS 26.00. The Kolmogorov–Smirnov method was used to assess normality. Quantitative data that followed a normal distribution were presented as mean $\pm$ standard deviation. Comparisons among multiple groups were performed using a one-way analysis of variance, with pairwise comparisons conducted through the Bonferroni test. Enumeration data were expressed as frequency ( $n$ ) or rate (%), and intergroup comparisons were conducted using the $\chi^{2}$ test. The diagnostic effectiveness of Young’s modulus post-treatment in patients with different stages of DVT was evaluated by plotting ROC curves. A significance level was set at $\alpha=$ 0.05.

3. Results

3.1 General data

In Group A, there were 17 men and 12 women, with an average age of 64.37 $\pm$ 14.33 years. This group comprised 18 patients with mixed DVT, 11 with central DVT, 16 with left lower-limb DVT and 13 with right lower-limb DVT, with 14 patients having identified causes and 15 without. In Group B, there were 15 men and 15 women, with an average age of 66.81 $\pm$ 12.28 years. It included 20 patients with mixed DVT, 10 with central DVT, 21 with left lower-limb DVT and 9 with right lower-limb DVT, with 13 patients having identified causes and 17 without. In Group C, there were 15 men and 17 women, with an average age of 61.92 $\pm$ 15.51 years. This group comprised 21 patients with mixed DVT, 11 with central DVT, 19 with left lower-limb DVT and 13 with right lower-limb DVT, with 14 patients having identified causes and 18 without. Comparison of general data among the three groups revealed no statistically significant differences in gender, age, type of thrombosis or cause of the affected limb (all $P>$ 0.05), as detailed in Table 1.

Table 1
Comparison of general data among difference stage groups

Item	Group A ( $n=$ 29)	Group B ( $n=$ 30)	Group C ( $n=$ 32)	$\chi^{2}/t$	$P$
Gender (male/female)	17/12	15/15	15/17	0.889	0.641
Age (year, $x\pm s$ )	64.37 $\pm$ 14.33	66.81 $\pm$ 12.28	61.92 $\pm$ 15.51	2.04	0.187
Type (mixed type/central type)	18/11	20/10	21/11	0.150	0.928
Affected limb (left/right)	16/13	21/9	19/13	1.467	0.480
Cause (yes/no)	14/15	13/17	14/18	0.179	0.914

Notes: A. acute phase; B. subacute phase; C. chronic phase.

3.2 Comparison of Young’s modulus among patients with deep vein thrombosis at different stages before and after different treatments

Before treatment, Young’s modulus displayed statistically significant differences among patients with DVT at different stages, with the values for Group A being lower than those for Group B and those for Group B lower than those for Group C ( $P<$ 0.001). After treatments involving anticoagulant therapy, catheter-directed thrombolysis and systemic thrombolysis, statistically significant differences in Young’s modulus were observed among the patients at the same stage receiving different treatments in Groups A, B and C (acute phase, subacute phase and chronic phase: all $P<$ 0.001). Young’s modulus was lowest in the catheter-directed thrombolysis groups, followed by the systemic thrombolysis groups, and it was highest in the anticoagulant therapy groups (Table 2). Further multiple comparisons between the groups revealed that Young’s modulus in the catheter-directed thrombolysis groups was significantly lower than that in the anticoagulant therapy groups across all stages (acute phase: $P=$ 0.003; subacute phase: $P=$ 0.014; chronic phase: $P=$ 0.004). However, no statistically significant differences were found between the other groups ( $P>$ 0.05) (Table 3).

Table 2
Comparison of Young’s modulus among DVT patients before and after different treatments

Stage	Before treatment	Anticoagulant therapy	Catheter-directed thrombolysis	Systemic thrombolysis	$F$	$P$
A ( $n=$ 29)	9.54 $\pm$ 2.51	6.49 $\pm$ 2.03	3.03 $\pm$ 2.32	5.17 $\pm$ 1.96	65.427	$<$ 0.001
B ( $n=$ 30)	15.66 $\pm$ 3.34	8.63 $\pm$ 3.85	4.21 $\pm$ 3.41	6.11 $\pm$ 3.38	69.076	$<$ 0.001
C ( $n=$ 32)	27.18 $\pm$ 7.01	9.35 $\pm$ 2.97	5.13 $\pm$ 2.84	7.24 $\pm$ 2.57	75.318	$<$ 0.001
$F$	362.715
$P$	$<$ 0.001

Notes: A. acute phase; B. subacute phase; C. chronic phase.

Figure 2.

ROC curve of SWE in staging lower-limb DVT.

3.3 ROC curve of shear wave elastography in staging patients with lower-limb deep vein thrombosis

Analysis of the ROC curve, using Young’s modulus and clinical staging results, revealed that the area under the curve (AUC) for SWE in staging patients with lower-limb DVT was 0.917. This indicates a high predictive value with a sensitivity of 92.36% and specificity of 93.81% (95% CI: 0.883–0.946, $P<$ 0.001), as illustrated in Fig. 2.

Table 3
Results of multiple comparisons

Stage	Group	$t$	$P$
A	D	3.441	0.003
	E	1.441	0.168
	F	2.228	0.039
B	D	2.718	0.014
	E	1.555	0.137
	F	1.251	0.227
C	D	3.328	0.004
	E	1.745	0.097
	$F$	1.827	0.083

Notes: A. acute phase; B. subacute phase; C. chronic phase; D. comparison between anticoagulant therapy and catheter-directed thrombolysis; E: comparison between anticoagulant therapy and systemic thrombolysis; F: comparison between catheter-directed thrombolysis and systemic thrombolysis; significant level after correction, $\alpha=$ 0.017.

3.4 Comparison of Young’s modulus at different thrombus parts

Statistically significant differences were observed in Young’s modulus at different parts of the thrombus, with the modulus being lowest at the thrombus head, higher at the tail and highest at the body ( $P<$ 0.001). Pairwise comparisons revealed that Young’s modulus at the thrombus head was significantly lower than that at the body ( $t=$ 6.868, $P<$ 0.001) and also lower than that at the tail ( $t=$ 5.288, $P<$ 0.001). Significant differences were noted between Young’s modulus of the thrombus head and those of the body and tail. However, there were no significant differences in Young’s modulus between the thrombus body and thrombus tail ( $t=$ 1.533, $P=$ 0.127), as detailed in Table 4.

Table 4
Comparison of Young’s modulus at different thrombus parts

Part	Young’s modulus	$t$ of pairwise comparison	$P$
Thrombus head ( $n=$ 91)	16.82 $\pm$ 5.27	6.868^a	$<$ 0.001
Thrombus body ( $n=$ 91)	22.85 $\pm$ 6.51	1.533^b	0.127
Thrombus tail ( $n=$ 91)	21.39 $\pm$ 6.34	5.288^c	$<$ 0.001
$F$	294.104
$P$	$<$ 0.001

Notes: a: comparison between thrombus head and thrombus body; b: comparison between thrombus body and thrombus tail; c: comparison between thrombus head and thrombus tail; significant level after correction, $\alpha=$ 0.017.

4. Discussion

Deep vein thrombosis is a commonly encountered vascular disease, primarily treated with anticoagulation and thrombolysis. Anticoagulation is the basic treatment, whereas thrombolysis addresses the root cause [17, 18]. Accurately determining the timing of thrombosis is crucial for developing effective clinical treatment plans. Currently, the staging of DVT relies primarily on a combination of patient self-reporting, clinical symptoms and imaging assessments. However, the inability of some patients to precisely estimate the onset time compromises the accuracy of the diagnosis. Conventional grayscale ultrasound and Doppler ultrasound are extensively used in clinical radiology to assess various traumas and pathological conditions of muscle and skeletal tissues. Notably, in the early stages of diseases, pathological and healthy tissues can display similar echogenicity under conventional ultrasound. In recent years, SWE has emerged as a rapidly developing technique that provides additional insights into tissue properties by evaluating tissue elasticity, potentially enhancing the accuracy of diagnoses and the evaluation of treatment efficacy in various diseases [19, 20, 21].

Thrombus composition varies at different stages of lower-limb DVT and is related to thrombus hardness. As a result, thrombus elasticity may vary at different stages. The present study used SWE to evaluate staging and treatment efficacy in patients with DVT. Findings revealed that before treatment, Young’s modulus identified statistically significant differences between patients at various stages of DVT (Group A $<$ Group B $<$ Group C; all $P<$ 0.001). Similarly, patients at the same stage undergoing different treatments exhibited significant differences in Young’s modulus post-treatment (catheter-directed thrombolysis groups $<$ systemic thrombolysis groups $<$ anticoagulant therapy groups; acute phase: $P<$ 0.001; subacute phase: $P<$ 0.001; chronic phase: $P<$ 0.001). These findings underscore the value of SWE in assessing the staging and treatment efficacy of thrombosis. The underlying mechanism involves SWE emitting acoustic radiation force impulses through a probe, which generates shear waves within the tissue. The propagation speed of these shear waves indicates the tissue’s hardness; the faster they travel, the higher the absolute Young’s modulus and elastic coefficient, indicating greater tissue hardness [21, 22, 23, 24, 25]. As thrombus formation evolves in patients with DVT, the components change; fibrin and collagen, which have higher Young’s moduli, increase, whereas neutrophils and erythrocytes, with lower Young’s moduli, decrease. Thus, SWE can gauge thrombus ‘hardness’ by measuring Young’s modulus, aiding in the staging of DVT and evaluating the effectiveness of thrombolytic therapy.

The primary methods for treating acute lower-limb DVT typically involve anticoagulation and thrombolysis, where anticoagulation serves as the foundational treatment and thrombolysis acts as the principal intervention. Thrombolysis primarily functions by activating plasminogen within thrombi through plasminogen activators, converting it into plasmin and subsequently dissolving the thrombi [6, 26]. The efficacy of thrombolysis is contingent not only upon the timing of thrombosis but also on the concentration of thrombolytic drugs reaching the thrombotic site. Moreover, the route of administration influences the drug concentration at the thrombotic site. Clinical practice commonly employs two routes, catheter-directed thrombolysis and systemic thrombolysis. Catheter-directed thrombolysis involves the direct injection of drugs into the thrombotic site, thereby reducing the time for drug dilution and attenuation, ultimately achieving optimal thrombolytic concentration. The findings of the present study indicated that in Groups A, B and C, catheter-directed thrombolysis exhibited superior efficacy compared with anticoagulant therapy, with statistically significant differences (acute phase: $P=$ 0.003; subacute phase: $P=$ 0.014; chronic phase: $P=$ 0.004). However, no significant differences were observed between anticoagulant therapy and systemic thrombolysis or between catheter-directed thrombolysis and systemic thrombolysis in patients with DVT at different stages. According to the ROC curve analysis conducted in this study, the AUC of SWE in staging patients with lower-limb DVT was 0.917, with a sensitivity of 92.36% and specificity of 93.81%, indicating high diagnostic efficiency. These results suggest that SWE can serve as a valuable reference for staging patients with lower-limb DVT.

Furthermore, statistically significant differences were observed in Young’s modulus measured at different parts of the thrombus in the same patient, with Young’s modulus of the thrombus head (16.82 $\pm$ 5.27) being lower than that of the thrombus tail (21.39 $\pm$ 6.34) and thrombus body (22.85 $\pm$ 6.51) ( $P<$ 0.001). Pairwise comparisons revealed that the Young’s modulus of the head was lower than that of the body ( $t=$ 6.868, $P<$ 0.001) and tail ( $t=$ 5.288, $P<$ 0.001) within the same thrombus. Statistically significant differences were found in Young’s modulus between the thrombus head and thrombus body and tail but not between the thrombus body and thrombus tail ( $t=$ 1.533, $P=$ 0.127). Therefore, the hypothesis suggests that the lower hardness of the thrombus head makes this region more prone to detachment, potentially increasing the risk of PE in patients. Consequently, accurately diagnosing lower-limb DVT and identifying the location of the thrombus head can aid in treatment planning and prevent PE occurrence in patients. However, this study has some limitations. First, it is a single-centre study with a small sample size, potentially introducing selection bias and limiting the generalisability of the results. Additionally, the sample size is relatively small for comparing Young’s modulus among patients with DVT at different stages before and after different treatments. Therefore, conducting larger multi-centre studies is recommended to provide more robust evidence for evaluating the actual differences among different treatment methods in patients with DVT at different stages using SWE.

5. Conclusion

The measurement of Young’s modulus based on SWE has the potential to serve as an auxiliary method for evaluating the staging, predicting PE and assessing the efficacy of treatment in patients with DVT. Its application in clinical practice warrants promotion and consideration.

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of First People’s Hospital of Tian Shui.

Consent for publication

Not applicable.

Author contributions

Conception and design of the work: Wu J.

Data collection: Yang XY, Liu Y, Xi F, Lei P.

Supervision: Wu J.

Analysis and interpretation of the data: Yang XY, Liu Y, Xi F, Lei P.

Statistical analysis: Wu J, Lei P.

Drafting the manuscript: Wu J.

Critical revision of the manuscript: all authors.

Approval of the final manuscript: all authors.

Funding

Supported by Gansu Provincial Science and Technology Plan, Project No. 21JR7RE904.

Availability of data and materials

All data generated or analyzed during this study are included in the article.

Footnotes

Acknowledgments

Not applicable.

Conflict of interest

None of the authors have any personal, financial, commercial, or academic conflicts of interest.

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