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. 2023 Apr 15;15(4):2329–2344.

Bibliometric and visual analysis of trends in tenosynovitis research from 1999 to 2021

Ze Liu 1,2, Qi Liu 1,2, Hongbin Guo 1,2, Min Wang 3, Jieyu Liang 1,2, Yi Zhang 1,2
PMCID: PMC10182489  PMID: 37193139

Abstract

Background: Tenosynovitis is an acute or chronic inflammatory reaction of the tendon/tendon sheath. The purpose of this study is to summarize the current status, hotspots, and development trends in tenosynovitis related research. Methods: Data on tenosynovitis from 1999 to 2021 were identified from the Web of Science core collection (WoSCC) database and analyzed using bibliometric software. CiteSpace was utilized to identify the top 25 references with the strongest citation bursts, the top 25 keywords with the strongest citation bursts, the dual-map overlay of journals, and a timeline of keywords. VOSviewer was utilized to conduct co-citation, academic collaboration, and keyword analysis. Microsoft Excel was used to draw relevant charts. Results: A total of 4,740 publications were collected in this study. The United States ranked first in terms of the H-index, total citations, and total number of publications. The University of California System, University of London, and UDICE-French Research Universities were the major contributing institutions to tenosynovitis research. The Journal of Hand Surgery-American Volume, Skeletal Radiology, and American Journal of Sports Medicine were the main publishing channels for tenosynovitis-related articles. Moreover, Maffulli, N., Van der Helm-van Mil, Annette H.M., Ostergaard, M. were major contributing authors to tenosynovitis research. Finally, research on nonsurgical treatment for tenosynovitis appears to be a future hot spot. Conclusion: Overall, the number of publications on tenosynovitis grew over the 1999-2021 period. Our study summarized the research status and global trends of tenosynovitis from multiple angles (i.e., countries, institutions, authors, publications). These considerations are helpful to better understand the research hotspots and development trends in the field.

Keywords: Tenosynovitis, bibliometrics, research trend, Web of Science, VOSviewer, CiteSpace

Introduction

The tendon sheath is a closed synovial tube that covers and protects the tendon [1]. The tendon sheath wraps around the tendon in two layers with an empty cavity called the synovial cavity. The cavity contains synovial fluid from the tendon sheath. The inner layer is attached to the tendon, whereas the outer layer is lined in the tendon fiber sheath and joined to the bone surface. The function of the tendon sheath is to fix, lubricate, and protect the tendon from compression or friction. However, long-term excessive friction may lead to tendon sheath inflammation and swelling, a condition called tenosynovitis, and permanent mobility problems may develop if the issue is not treated properly. Although tenosynovitis may occur in different age groups, middle-aged and older workers, and women are more likely to develop tenosynovitis [2]. The etiology of tenosynovitis includes the following types: 1) Stenosis tenosynovitis develops occurs under chronic strain and mainly occurs in the fingers, wrists, long head tendon of the biceps brachii, ankles and children’s congenital flexor pollicis longus tendon; 2) Pyogenic tenosynovitis is mostly caused by infection after stabbing of the tendon sheath; 3) Acute fibrous tenosynovitis is caused by congestion and swelling of connective tissue around the tendon sheath (i.e., the swollen tendon sheath compresses and rubs the tendon, causing inflammation); 4) Rheumatic tenosynovitis is a reaction of acute rheumatic fever; and 5) Tuberculous tenosynovitis [3]. The symptoms of tenosynovitis are local pain, tenderness, and limited movement of affected joints. The therapy methods include general, drug, local blocking and surgical treatment [4].

Bibliometrics is an interdisciplinary method that combines statistics and bibliography to quantitatively analyze academic publishing through statistical methods to discover research hotspots and development trends [5]. Most clinical research on the diagnosis and treatment of tenosynovitis has been published only in the past few decades [6,7]. However, very few studies have investigated the hotspots and characteristics of tenosynovitis worldwide. A bibliometric and visual analysis may help understand the development and future trend of research in tenosynovitis. Therefore, our study has explored the progress of research in tenosynovitis from the perspective of bibliometrics to reveal constructive information in the field.

Methods

Data sources

The WoSCC database, which includes the Science Citation Index-Expanded (SCI-Expanded), Arts & Humanities Citation Index (AHCI), Social Science Citation Index (SSCI), Conference Proceedings Citation Index Social Science & Humanities (CPCI-SSH), Conference Proceedings Citation Index-Science (CPCI-S), Current Chemical Reactions-Expanded (CCR-Expanded), Index of Copurnicus (IC) and Emerging Sources Citations Index (ESCI), is frequently utilized in bibliometric analysis.

Search strategy

All text files were retrieved from the WoSCC in September, 2022. The search formula was: (TS = tenosynovitis OR peritendinitis OR tendovaginitis OR tendinitis OR thecitis). Articles published in English between January 1999 and December 2021 were included in this study. In the search, only “article” and “review article” were selected in article types.

Data collection

Full records and cited references (e.g., authors, titles, source, years of publications, nationalities, cited references, institutions of authors, abstract, keywords, total citations, etc.) were exported from the WoSCC database for bibliometric and visual analysis. The records were imported into VOSviewer (v.1.6.18), CiteSpace (v.6.1.R2) and Microsoft Excel 2021 for analysis. All the data in the following tables were acquired from the citation report in the WoSCC database.

Results

Trends in publications and citations over time

Through the aforementioned search strategy, a total of 5,342 tenosynovitis-related records were identified in our study. After filtering article types and removing duplicate articles, 4,740 studies remained (Figure 1). The 4,740 publications included in this study came from 18,560 authors and 4,996 institutions in 88 countries and were published in 1,001 journals. These publications cited 76,793 references from 11,788 journals. These articles are mainly distributed in orthopedics, surgery, rheumatology, sports science, and radiology nuclear medical imaging (Figure 2). The number of citations about tenosynovitis grew steadily over the 1999-2021 period, peaking at 325 in 2021 (Figure 3).

Figure 1.

Figure 1

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Process of study selection in this study.

Figure 2.

Figure 2

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Research area analysis of global publications in tenosynovitis from 1999 to 2021.

Figure 3.

Figure 3

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Trends in publications and citations of tenosynovitis research.

Quality analysis of global publications

Country

According to the amount of literature on tenosynovitis in each country (Table 1), the United States was firmly in first place with 1,452 publications, followed by England (438 articles, 9.24%), Italy (352 articles, 7.43%), Germany (277, 5.84%), and the Netherlands (228, 4.81%). As Figure 4 shows, in addition to the United States, which has a relatively high growth momentum, the other four countries showed little change between the beginning and the end. In addition, the United States ranked first in terms of publications, total citations, and H-index, whereas Canada, England and the Netherlands are the top three countries in terms of average citations.

Table 1.

The top 10 countries by publications

Rank Country Publications % of 4,740 Total citations Average citations H-index
1 United States 1,452 30.63 36,950 25.45 87
2 England 438 9.24 18,255 41.68 72
3 Italy 352 7.43 11,067 31.44 52
4 Germany 277 5.84 10,371 37.44 53
5 Netherlands 228 4.81 8,686 38.1 51
6 Japan 226 4.77 2,593 11.47 24
7 France 210 4.43 7,339 34.95 44
8 Turkey 187 3.96 1,924 10.29 22
9 Canada 183 3.86 7,751 42.36 47
10 China 183 3.86 2,643 14.44 27
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Figure 4.

Figure 4

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Tenosynovitis-related publications of the top 5 countries over time.

Institution

Speaking of the top ten research institutions (Table 2), the United States has three, England has two, France has two, Switzerland has two, and Denmark has one. The institution with the most publications on tenosynovitis research was the University of California System. However, the University of London had the highest H-index. UDICE-French Research Universities have the highest total citations. However, the institution with the highest average number of citations was the University of Copenhagen.

Table 2.

Top 10 institutions distributed by publications

Rank Institution Publications Total citations Average citations H-index Original country
1 University of California System 92 2,025 22.01 28 United States
2 University of London 85 3,696 43.48 36 England
3 UDICE-French Research Universities 83 4,307 51.89 32 French
4 University of Copenhagen 73 4,233 57.99 29 Denmark
5 Assistance Publique Hopitaux Paris (APHP) 71 3,477 48.97 32 French
6 Leiden University 69 1,479 21.43 21 Netherlands
7 Harvard University 68 2,073 30.49 25 United States
8 Mayo Clinic 68 1,093 16.07 18 United States
9 Leiden University Medical Center (LUMC) 67 1,437 21.45 21 Netherlands
10 University of Leeds 64 3,119 48.73 28 England
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Author

As shown in Table 3, among the top ten contributors to tenosynovitis, three are from England, two are from the Netherlands, two are from Denmark, two are from Italy, and one is from Spain. Maffulli, N had the highest H-index, the most publications, and the highest total citations and average citations.

Table 3.

Top 10 authors distributed by publications

Rank Author Publications Total Citations Average Citations Country Institution H-index
1 Maffulli, N. 56 5,913 105.59 England Keele University 40
2 van der Helm-van Mil, Annette H.M. 43 696 16.19 Netherlands Leiden University 14
3 Ostergaard, M. 37 2,625 70.95 Denmark University of Copenhagen 22
4 Iagnocco, A. 35 2,264 64.69 Italy Sapienza University of Rome 22
5 Reijnierse, M. 32 713 22.28 Netherlands Leiden University 15
6 Emery, P. 30 1,876 62.53 England Leeds General Infirmary 23
7 Naredo, E. 28 1,320 47.14 Spain Severo Ochoa University Hospital 17
8 Filippucci, E. 26 2,125 81.73 Italy Marche Polytechnic University 19
9 Conaghan, P.G. 25 2,145 85.8 England University of Leeds 18
10 Terslev, L. 25 911 36.44 Denmark University of Copenhagen 12
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Journal

Table 4 shows the top ten journals that publish the most literature on tenosynovitis. The impact factor (IF) and journal quartile were excerpted from Journal Citation Reports 2021. The top three most-published journals were the Journal of Hand Surgery-American Volume, Skeletal Radiology, and American Journal of Sports Medicine. The American Journal of Sports Medicine had the highest total citations and H-index. Annals of the Rheumatic Diseases (IF = 27.973) had the highest average citations. Figure 5 shows the dual-map overlay of journals on tenosynovitis. The cited journals are on the right, the citing journals are on the left, and the colored path indicates the citation relationship. It can be seen from the figure that there are seven paths between the citing journals and the cited journals.

Table 4.

Top 10 journals distributed by publications

Rank Journal Publications Total Citation Average Citations H-index Impact factors JIF quartile
1 Journal of Hand Surgery-American Volume 109 2,267 20.8 27 2.342 Q3
2 Skeletal Radiology 97 1,661 17.12 23 2.128 Q3
3 American Journal of Sports Medicine 92 6,264 68.09 49 7.01 Q1
4 Foot & Ankle International 75 2,330 31.07 28 3.569 Q2
5 Rheumatology 71 2,485 35 28 7.046 Q1
6 Clinical Rheumatology 64 946 14.78 18 3.65 Q3
7 Journal of Rheumatology 64 3,221 50.33 28 5.346 Q2
8 Annals of the Rheumatic Diseases 58 4,320 74.48 39 27.973 Q1
9 Journal of Shoulder and Elbow Surgery 53 2,392 45.13 30 3.507 Q2
10 Equine Veterinary Journal 51 1,695 33.24 23 3.752 Q2
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Figure 5.

Figure 5

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Dual-map overlay of journals on tenosynovitis-related research.

Academic collaboration

Academic cooperation and exchanges between various countries/regions, institutions and authors are crucial to fostering in-depth academic research. In Figure 6A, each node stands for a different country. Node colors represent different clusters (i.e., research topics). The node connection line represents the collaborative relationship. The thicker the connection line, the more closely the two entities cooperate. The size of the nodes represents the number of articles published after their collaboration. This figure displays the cooperation between the 56 most-connected countries. Clearly, the United States, the country with the most publications, occupies the leading status in the tenosynovitis field. In Figure 6B, institutions with a frequency of five or more are selected. The University of Leeds, Leiden University, and Mayo Clinic stand out. Through VOSviewer software, 235 authors whose number of publications is equal to or more than five are included. Some of these authors are not connected with others. The largest set of connected authors consists of 105 items (Figure 6C). Authors with more academic collaborations are highly consistent with the results of the top ten authors.

Figure 6.

Figure 6

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A. Academic collaboration among different countries/regions; B. Collaboration among different institutions; C. Collaboration among different authors.

Co-citation analysis

Co-cited authors

When two articles from different authors are simultaneously cited by a third author, the authors have co-citation relationship. If they have more co-citations, then this indicates that they are more closely related to each other academically. Co-citation analysis lists a total of 50,093 authors in the tenosynovitis field. Maffulli, N (685 citations) had the most citations, followed by Rompe, JD (678 citations) and Khan, KM (502 citations). Through VOSviewer software, 1,101 authors have at least 20 citations. After clustering these scientists, eight clusters were formed (Figure 7A).

Figure 7.

Figure 7

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A. VOSviewer visualization map of co-cited authors devoted to tenosynovitis research; B. VOSviewer visualization map of co-cited journals devoted to tenosynovitis research; C. VOSviewer visualization map of co-cited references devoted to tenosynovitis research.

Co-cited journals

Figure 7B shows the relationship among the 814 identified journals (one of which has a minimum number of citations of 20 or more). The top three journals by citations were the Annals of the Rheumatic Diseases (5,056 citations), American Journal of Sports Medicine (4,784 citations), and The Journal of Bone and Joint Surgery-American volume (4,149 citations).

Co-cited references

Clustering of cited literature reflects the development trends in the field of the study to a certain extent. A total of 681 references with a minimum number of 20 citations are shown in Figure 7C. The top three co-cited references were R.J. Wakefield et al. [8] (155 citations), K.M. Khan et al. [9] (125 citations), and L. Gerdesmeyer et al. [10] (123 citations). These articles focus on the histopathology, detection, and treatment of tendonitis, indicating the centrality of these aspects to tendonitis research. Figure 8 shows the top 25 references about tenosynovitis with the strongest citation bursts, which means that these articles are frequently cited over a period of time. “Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis” by E. Naredo et al. has the strongest burstiness [11]. In addition to the references, there are still six references in burstiness: 1) “Ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy: What is the evidence? A systematic review with proposals for future reporting” by E. Lanza et al. [12]; 2) “Magnetic Resonance Imaging-Detected Features of Inflammation and Erosions in Symptom-Free Persons From the General Population” by L. Mangnus et al. [13]; 3) “Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 1: definition and development of a standardised, consensus-based scoring system” by M.A. D’Agostino et al. [14]; 4) “The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology” by I. Möller et al. [15]; 5) “Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system” by L. Terslev et al. [16]; and 6) “The OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging (MRI) Scoring System: Updated Recommendations by the OMERACT MRI in Arthritis Working Group” by M. Østergaard et al. [17].

Figure 8.

Figure 8

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Top 25 references with the strongest citation bursts involved in tenosynovitis.

Analysis of highly cited articles

The top ten most-cited articles are shown in Table 5. “Musculoskeletal ultrasound including definitions for ultrasonographic pathology” by R.J. Wakefield et al. [8] reports that a group of international ultrasound experts met together to describe standardized scanning methods of ultrasound and standardized definitions of pathology, which spoke of tenosynovitis, either hypoechoic or anechoic thickened tissue with or without fluid in the tendon sheath. “Tendon injury and tendinopathy: healing and repair” by P. Sharma et al. [18] described the structure, function and the pathophysiology of tendons, the various stages of tendon injury and healing, and possible strategies to optimize tendon healing and repair. “Histopathology of common tendinopathies. Update and implications for clinical management” by K.M. Khan et al. [9] concluded that an effective treatment for athletes with tendinopathy must target its noninflammatory state.

Table 5.

Top 10 most-cited articles

Rank Author Title Total citations Journal
1 Wakefield, RJ Musculoskeletal ultrasound including definitions for ultrasonographic pathology 1,017 Journal of Rheumatology
2 Sharma, P Current concepts review tendon injury and tendinopathy: Healing and repair 751 Journal of Bone and Joint Surgery-American Volume
3 Khan, KM Histopathology of common tendinopathies - update and implications for clinical management 612 Sports Medicine
4 Coleman, BD Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies 572 Scandinavian Journal of Medicine & Science in Sport
5 Robinson, JM The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy 453 British Journal of Sports Medicine
6 Wang, CJ Shock wave therapy induces neovascularization at the tendon-bone junction - a study in rabbits 429 Journal of Orthopaedic Research
7 Arora, Rohit Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate 404 Journal of Orthopaedic Trauma
8 Balint, PV Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy 389 Annals of the Rheumatic Diseases
9 Shiri, R Prevalence and determinants of lateral and medial epicondylitis: A population study 369 American Journal of Epidemiology
10 Gerr, F A prospective study of computer users: I. Study design and incidence of musculoskeletal symptoms and disorders 366 American Journal of Industrial Medicine
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Analysis of keywords

Keywords represent the core concepts of the literature, which reflects the research hotspots in a certain field. The top ten keywords ranked in this study and their frequencies were tendinitis (1,048), tenosynovitis (928), ultrasound (485), tendon (466), tendinopathy (433), shoulder (400), ultrasonography (355), management (355), diagnosis (337), and hand (302). By clustering these keywords with frequencies greater than or equal to five, a total of 1,420 identified keywords were included. Figure 9 shows the overlay visualization of co-occurring keywords. In this figure, bone marrow edema, reliability, inflammation and short-term are colored yellow as emerging fields. In addition, burst keywords are words that frequently appear during a specific period. This shows the evolution of research hotspots over time and predicts future research trends (Figure 10). The burst keyword with the highest strength is tennis elbow. However, American colleges, classification criteria, extracorporeal shock wave therapy, recommendations, reliability and, scores have received more attention in recent years. The timeline of keywords on tenosynovitis (Figure 11) shows the top three high-frequency keywords in each cluster over time. There are ten clusters: 1) rotator cuff, 2) jumper’s knee, 3) tendinitis, 4) mesenchymal stem cells, 5) rheumatoid arthritis, 6) trigger finger, 7) tendon sheath, 8) hand, 9) quervain disease, and 10) systemic lupus erythematosus.

Figure 9.

Figure 9

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VOSviewer visualization map of co-occurring keywords over time.

Figure 10.

Figure 10

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Top 25 keywords with the strongest citation bursts of tenosynovitis articles from 1999 to 2021.

Figure 11.

Figure 11

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Timeline of keywords on tenosynovitis from 1999 to 2021.

Discussion

In this study, various bibliometric methods were utilized to summarize the published tenosynovitis-related articles in the WoSCC database. The earliest reference to tenosynovitis dates back to 1910 “Tertiary Syphilis (Gummatous Teno-synovitis)” by J.H. Sequeira et al. [19]. Since then, the number of publications and citations of tenosynovitis-related research is has gradually risen, indicating the growing popularity of tenosynovitis related research among scientists. According to the study of E.L. Rowbotham et al., interosseous tenosynovitis of the hand occurred in 47.7% of RA patients [20]. In addition, with the popularity of mobile phones and computers, tenosynovitis has increasingly become common. Therefore, it is predictable that tenosynovitis related research will continue to increase worldwide.

The H-index, an indicator proposed by Hirsch in 2005 [21], represents the academic influence of a country, institution, journal, or author in a certain field. The United States has the highest H-index, followed closely by European countries (eg, England, Italy, and Germany). The top ten institutions and authors are all from developed countries in Europe and the United States, which indicates that the research on tenosynovitis in developing countries lags behind that in developed countries by a wide margin. Among the top ten journals, the Journal of Hand Surgery-American Volume, Skeletal Radiology, and American Journal of Sports Medicine ranked as the top three. These journals are mainly related to sports, surgery, medical, and other fields, which is also shown in the dual-map overlay of journals on tenosynovitis. The American Journal of Sports Medicine (IF = 7.01), the authoritative journal in orthopedics, had the highest average citations and H-index.

Academic cooperation, which is mutually beneficial for all parties, is widespread among different countries, institutions, and outstanding authors. The countries, institutions and authors that collaborate more have a higher publication output and rank. This proves that cooperation is an effective way to promote the development of tenosynovitis academic research. According to an analysis of the highly cited literature, studies on tenosynovitis are mainly distributed in incidence and treatment [22,23]. The yearly distribution of keywords and burst keywords clearly reveals the progress of research in tenosynovitis. The keyword with the longest outbreak duration was rotator cuff tendinitis (2002-2010) (Figure 10). Rotator cuff tendinitis is a common cause of shoulder pain. Calcified shoulder tendinitis can progress to rotator cuff tears and shoulder osteoarthritis [24]. Extracorporeal shock wave therapy (ESWT) and ultrasound-guided acupuncture are thought to be beneficial for rotator cuff tendinitis [25]. The timeline of keywords on tenosynovitis shows that the eight clusters, except for mesenchymal stem cells and tendon sheath, all lasted from 1999 to 2021. Ultrasound-guided intralesional injection of mesenchymal stem cells is considered as the benchmark for cell delivery in tendonitis. However, the safety and reliability still need to be verified in vivo [26]. Immune diseases, such as systemic partner lupus, may develop into bacterial infections due to immunosuppressive therapy, leading to tenosynovitis [27]. Moreover’, De Quervan tenosynovitis is a relatively common wrist disease with a reported prevalence of 0.5% in male and 1.3% in female patients [28]. The treatments for De Quervan tenosynovitis include surgical interventions, as well as conservative nonsurgical approaches (eg, physical therapy, corticosteroid injections, and oral nonsteroidal anti-inflammatory drugs). Among these, surgical treatment seems to be the most effective method with a reported cure rate of 91% [29].

Although the etiology, diagnosis, and treatment of tenosynovitis are relatively mature, nonsurgical treatment with great efficacy is a future hot spot. In addition, the incidence of tenosynovitis is increasing every year. Interestingly, some novel forms of tenosynovitis have been clarified recently, such as: sclerosing tenosynovitis in a patient with pan-sclerotic morphea and rice bodies in tenosynovitis due to psoriatic arthritis [30,31]. These novel forms of tenosynovitis may receive more attention in the future.

Strengths and limitations

To the best of our knowledge, few studies have extensively investigated the current situation and trends of research in tenosynovitis. Therefore, software such as VOSviewer and CiteSpace were used to visualize the information about countries, institutions, authors, and journals in the field. Our study provides useful information for scientists to better understand the development of tenosynovitis research. Moreover, we also provide potential new research ideas and perspectives for frontier exploration.

However, the limitations of this study should also be acknowledged. We restricted our search to articles published in the English language, which may affect our results. Nevertheless, English articles in WoSCC are the most commonly used data source in bibliometrics analysis. Only articles from 1999 to 2021 were included in this study due to the limitations of the database. In addition, only articles from the WoSCC database were considered in this study due to the limited capabilities of the analysis software.

Conclusion

This study identifies tenosynovitis-related publications from 1999 to 2021, and comprehensively presents their global status and trends. Overall, publications about tenosynovitis have generally increased over the past 22 years. The United States ranks first in terms of the H-index, total citations, and total number of publications. The University of California System, University of London, and UDICE-French Research Universities were the major contributing institutions to tenosynovitis research. The Journal of Hand Surgery-American Volume, Skeletal Radiology, and American Journal of Sports Medicine were the main publishing channels for tenosynovitis-related articles. Moreover, Maffulli, N., van der Helm-van Mil, Annette H.M., Ostergaard, M. were the major contributing authors to tenosynovitis. Finally, research on nonsurgical treatment for tenosynovitis seems to be a hot spot in the future.

Acknowledgements

This study was supported by National Natural Science Foundation of China (82102581, 82270930), National Postdoctoral Science Foundation of China (2021M693562), Provincial Natural Science Foundation of Hunan (2019JJ40517, 2022JJ40843), Provincial Outstanding Postdoctoral Innovative Talents Program of Hunan (2021RC2020), Young Investigator Grant of Xiangya Hospital, Central South University (2020Q14), Fuqing Postdoc Program of Xiangya Hospital, Central South University (176) and Fund of Reform and Practice of Ideological and Political in Xiangya Hospital, Central South University (36, 40).

Disclosure of conflict of interest

None.

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