Study Design.
Retrospective epidemiological study.
Objective.
To describe differences based on biological sex in the epidemiology and treatment of the economic burden of traumatic spinal cord injury (TSCI) in China (2013–2018).
Summary of Background Data.
Although there have been many regional single-center studies on TSCI in China, there are few reports involving multicenter data, especially those that report on discrepancies related to biological sex.
Materials and Methods.
This study is a nationally representative hospital-based retrospective study. The treatment data of TSCI patients in 30 hospitals in 11 provinces/cities from January 2013 to December 2018 were analyzed. Sociodemographic characteristics, accident and related injury characteristics, treatment methods, and hospital costs were obtained. Regression models were used to evaluate differences in the outcomes of interest based on biological sex and other factors.
Results.
There were 13,465 individuals with TSCI, with a mean age of 50.0 years, and females (52.2) older than males (49.3). Overall, the average ratio of males to females was 3.1:1, ranging from 3.0:1 in 2013 to 2.8:1 in 2018. The overall proportion of patients with TSCI increased from 2013 to 2018 [annual percentage change (APC)=6.8%, 95% CI, 3.3–10.4] (P < 0.05). The percent increase in females (APC=8.2%, 95% CI, 5.6–10.8) was greater than that of males (APC=6.3%, 95% CI, 2.1–10.6). Overall, high-level falls mainly affected males (30.8%), and low-level falls mainly occurred in females (36.6%). Females demonstrated a higher frequency of thoracolumbar trauma and less severe neurological impairment.
Conclusions.
This study suggests that although the main population of TSCI is male, the average ratio of males to females is decreasing. The frequency of TSCI may be increasing faster in females than in males. Therefore, it is necessary to develop sex-specific public prevention measures. In addition, more medical resources should be devoted to improving the ability of hospitals to perform early surgery.
Key words: traumatic spinal cord injury, epidemiology, retrospective study, sex difference, methylprednisolone sodium succinate/methylprednisolone, clinical features, treatment, surgery, costs
Traumatic spinal cord injury (TSCI) is a catastrophic event that frequently results in permanent disability.1,2 Globally, TSCI affects 250,000 to 500,000 people every year.3 The annual incidence of TSCI in the United States is ~54 cases per million people.4,5 The incidence of TSCI in Beijing and Tianjin in China was 60.6 and 23.7 per million, respectively.6–9 Traffic accidents are the most common cause of TSCI in developed countries. In the developing world, falls remain the most common etiology.3–5,9 Some studies have shown that fall-related spinal cord injuries are increasing among older adults around the world due to the global aging population.1,2,10–13 Approximately 80% of patients with TSCI are male, and the incidence of TSCI in young males is 20 times higher than that of young females.14 The ratio of males to females globally with TSCI ranges from 1.6:1 to 8.1:1, with a ratio of 3-4:1 in China.7,15
At present, there are many studies on the treatment of spinal cord injury (SCI), but they mainly focus on early(<24 h) surgery and medical treatment (e.g. administration of methylprednisolone).16–19 Although these treatments have produced beneficial clinical effects, the approach to treatment is still controversial in many respects.18,20,21 Because of the health care expenditures and impact on the capacity to work, SCI has a substantial economic burden on families and society.21,22 Some studies have found that the total national cost of hospitalization for TSCI in the United States approximates $1.69 billion.5,23 Direct hospitalization costs in Canada ($170 million) account for 6.5% of the total national SCI-related costs.24
There are a large number of TSCI patients in China. Although single-center experiences managing TSCI have been reported in the past,6,7,25 there is limited multicenter, or nationally representative, data in this area and restricted evidence around the influence of biological sex on these measures.7 Therefore, this study sought to investigate epidemiological characteristics, treatment status, and hospitalization costs of TSCI patients from multiple centers in China, with an emphasis on contrasting the experience of males and females.
MATERIALS AND METHODS
Study Population
We have established the China Multicenter TSCI Registration Program (CMTSCIRP, ChiCTR1800019691), which is a nationally representative hospital-based retrospective cohort. All patients with TSCI in China who were treated at select large general hospitals or orthopedic specialist centers between January 2013 and December 2018 were included. These locations include 30 hospitals from seven geographical regions of China (Central China, Northern China, Eastern China, Southern China, Northwest China, Southwest China, and Northeast China) and four municipalities (Beijing, Shanghai, Tianjin, and Chongqing). For each region or municipality, we selected three or four large general hospitals or orthopedic centers (Figure S1, Supplemental Digital Content 1, http://links.lww.com/BRS/C86). This study was approved by the Medical Research Ethics Committee of Tianjin Medical University General Hospital [IRB2018-15401].
TSCI was defined as any damage to the function of the spinal cord or cauda equina caused by the application of any external force.3,6 Acute TSCI is defined as admission within 14 days after spinal cord injury. Nonacute TSCI patients were not included in the economic burden of this study, as acute and nonacute TSCI patients received different treatments during hospitalization, which would bias the estimate. We identified TSCI mainly using Chinese medical terms because it is difficult to unify case codes due to the different codes used across hospitals. The Tenth Revision of the International Classification of Diseases code for TSCI, organized by the International Community Survey of Spinal Cord Injury, has also been used to supplement and refine medical terms (Table S1, Supplemental Digital Content 1, http://links.lww.com/BRS/C86).26 With the help of a librarian, we developed our search strategy for retrieving TSCI information. Details of the Chinese medical words used in this study and the Tenth Revision of the International Classification of Diseases code of the SCI are listed in the Supplemental Material (Table S1, Supplemental Digital Content 1, http://links.lww.com/BRS/C86). All cases were verified by trained personnel to ensure that they met the criteria for TSCI. The cases of nontraumatic spinal cord injury (e.g. tumor, pathological fracture, or degenerative compression) were excluded.
During the study, variables were chosen from the international SCI core data set as recommended by Biering-Sorensen et al.27 Sociodemographic variables included biological sex, age, and occupation. The following clinical variables were obtained from the medical records of physical and imaging examinations: etiology, level of injury, and severity of injury. Neurological function was assessed using the American Spinal Injury Association Impairment Scale. In addition, treatment and hospitalization costs during hospitalization were recorded28 (Table S2, Supplemental Digital Content 1, http://links.lww.com/BRS/C86).
Treatment included surgical treatment (decompression) and conservative treatment. According to medical records, surgical approaches were classified as anterior, posterior, anterior-posterior, and minimally invasive approaches.28 According to the definition of early operation (<24 h) in previous studies and the quartile distribution of the data in this study,29 the timing of operation was categorized as: (1) “<24 hours”; (2) “1 to 4.0 days,” “4.0 to 11.9 days,” and “>11.9 days.” Treatment with methylprednisolone sodium succinate/methylprednisolone (MPSS/MP) is still controversial in TSCI,18,30 so we define 500 mg MPSS/MP as the threshold for this study according to the user’s guide. The total cost and daily cost are the expenses associated with patient care during hospitalization due to acute TSCI and are determined from the patient’s medical records during hospitalization. According to recommendations of the China Pharmacoeconomics Evaluation Guide (2020), the total cost and daily cost are converted to 2013 Chinese Yuan (CNY), with an annual discount rate of 5%. In addition, the exchange rate of RMB against USD in 2013 was CNY 619.32 (USD=100), and the costs were expressed in CNY and USD.
Statistical Analysis
All data were collected by professionally trained researchers in a Microsoft Excel spreadsheet (Redmond, WA) and then cross-checked twice to ensure accuracy. Continuous variables were expressed as averages (SD), and classification variables were expressed as numbers (percentages). The demographic characteristics, injury mechanism, treatment method, and cost trends for inpatient treatment were evaluated by annual percentage change (APC), using the following regression model: log (Rt) = a+bt, where “log” represents natural logarithm and “t” is the calendar year. The Joinpoint Regression Program, Version 4.8.0.1-April 2020 (Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute), was used in the calculation of APC. Statistical significance was defined as two-tailed P<0.05. The statistical description of demographic and clinical features, treatment status, and economic burden of TSCI patients was performed using IBM SPSS Statistics Grad Pack 27.0 (IBM SPSS, Chicago, IL). Simple linear regression followed by figure drawing was performed using GraphPad Prism version 9.0.2 for Windows (GraphPad Software, San Diego, California, www. graphpad.com). P < 0.05 was deemed statistically significant.
RESULTS
Characteristics of the Study Population
A total of 13,465 individuals with TSCI were included in the analysis. The proportion of males was 75.7% (10,196 cases), and the male-to-female ratio was 3.1:1. The average age was 50.0 years (range: 15–97), with females (52.2) older than males (49.3) (P <0.001) (Table 1). The peak age for injuries was between 45 and 54 years (27.7%), and among patients aged 65 or above, the proportion of females (22.3%) was higher than that of males (14.3%). Among occupations, farming (38.8%) was the most common regardless of sex, but the proportion of retirees (10.4%) among females was higher than that of males (5.5%) (Table 1).
TABLE 1.
Demographic and Clinical Features Among Patients With TSCI, 2013 to 2018, by Sex
| Category | No. patients (%) | P | ||
|---|---|---|---|---|
| Total, n (%) | Male, n (%) | Female, n (%) | ||
| No. | 13,465 (100.0) | 10,196 (75.7) | 3269 (24.3) | — |
| Age, yr, means (SD) | 50.0 (14.6) | 49.3 (14.3) | 52.2 (15.1) | <0.05 |
| Age groups | — | — | — | <0.05 |
| 15–24 | 705 (5.2) | 549 (5.4) | 156 (4.8) | — |
| 25 –34 | 1458 (10.8) | 1169 (11.5) | 289 (8.8) | — |
| 35–44 | 2342 (17.4) | 1848 (18.1) | 494 (15.1) | — |
| 45–54 | 3733 (27.7) | 2872 (28.2) | 861 (26.3) | — |
| 55–64 | 3040 (22.6) | 2301 (22.6) | 739 (22.6) | — |
| ≥ 65 | 2187 (16.2) | 1457 (14.3) | 730 (22.3) | — |
| Occupation | — | — | — | <0.05 |
| Worker | 1514 (11.2) | 1291 (12.7) | 223 (6.8) | — |
| Farmer | 5218 (38.8) | 3973 (39.0) | 1245 (38.1) | — |
| Retiree | 901 (6.7) | 562 (5.5) | 339 (10.4) | — |
| Office clerk | 613 (4.6) | 451 (4.4) | 162 (5.0) | — |
| Student | 308 (2.3) | 204 (2.0) | 104 (3.2) | — |
| Self-employed | 262 (1.9) | 197 (1.9) | 65 (2.0) | — |
| Civil servant | 195 (1.4) | 131 (1.3) | 64 (2.0) | — |
| Driver | 146 (1.1) | 118 (1.2) | 28 (0.9) | — |
| Others* | 3498 (26.0) | 2653 (26.0) | 845 (25.8) | — |
| Missing | 810 (6.0) | 616 (6.0) | 194 (5.9) | — |
| Etiology | — | — | — | <0.05 |
| High falls (>1 m) | 3953 (29.4) | 3141 (30.8) | 812 (24.8) | — |
| Low falls (≤1 m) | 4049 (30.1) | 2853 (28.0) | 1196 (36.6) | — |
| Traffic accidents | 3242 (24.1) | 2459 (24.1) | 783 (24.0) | — |
| Struck by falling objects | 800 (5.9) | 697 (6.8) | 103 (3.2) | — |
| Sport-related injury | 148 (1.1) | 93 (0.9) | 55 (1.7) | — |
| Others† | 832 (6.2) | 610 (6.0) | 222 (6.8) | — |
| Missing | 441 (3.3) | 343 (3.4) | 98 (3.0) | — |
| Level of injury | — | — | — | <0.05 |
| Cervical | 8254 (61.3) | 6580 (64.5) | 1674 (51.2) | — |
| Thoracic | 2160 (16.0) | 1554 (15.2) | 606 (18.5) | — |
| Lumbosacral | 2601 (19.3) | 1751 (17.2) | 850 (26.0) | — |
| Multisite | 175 (1.3) | 119 (1.2) | 56 (1.7) | — |
| Cauda equina | 29 (0.2) | 21 (0.2) | 8 (0.2) | — |
| Missing | 246 (1.8) | 171 (1.7) | 75 (2.3) | — |
| Severity | — | — | — | <0.05 |
| Complete quadriplegia | 1689 (12.5) | 1412 (13.8) | 277 (8.5) | — |
| Complete paraplegia | 2670 (19.8) | 2061 (20.2) | 609 (18.6) | — |
| Incomplete quadriplegia | 5956 (44.2) | 4653 (45.6) | 1303 (39.9) | — |
| Incomplete paraplegia | 2932 (21.8) | 1905 (18.7) | 1027 (31.4) | — |
| Missing | 218 (1.6) | 165 (1.6) | 53 (1.6) | — |
| ASIA score | — | — | — | <0.05 |
| A | 3428 (25.5) | 2744 (26.9) | 684 (20.9) | — |
| B | 954 (7.1) | 758 (7.4) | 196 (6.0) | — |
| C | 2292 (17.0) | 1819 (17.8) | 473 (14.5) | — |
| D | 6457 (48.0) | 4637 (45.5) | 1820 (55.7) | — |
| E | 197 (1.5) | 134 (1.3) | 63 (1.9) | — |
| Missing | 137 (1.0) | 104 (1.0) | 33 (1.0) | — |
“Others” included “Teachers,” “Unemployed,” and “Freelancers”.
“Others” included “Injuries caused by others,” “Work-related injuries,” “Sharp injuries,” “Massage-related injuries,” “Electric shock injuries”, “Gunshot wounds”, “Crush injuries”, and “Iatrogenic injuries”.
AIS indicates American Spinal Injury Association (ASIA) Impairment Scale; No., number; SD, standard deviation; TSCI, traumatic spinal cord injury.
The top three etiological causes of TSCI were low-level falls (30.1%), high-level falls (29.4%), and traffic accidents (24.1%). Among them, high-level falls (30.8%) were more likely to occur in males, whereas low-level falls (36.6%) were more likely to involve females (Table 1, Figure 1). There are also significant differences in their proportions in different age groups (Figure 1, Table S3, Supplemental Digital Content 1, http://links.lww.com/BRS/C86). Cervical injury (61.3%), incomplete quadriplegia (44.2%), and AIS class D injury (48.0%) were the most common clinical features in the respective groups. Compared with males, females had the highest proportion of lumbar injuries (26.0%), incomplete paraplegia (31.4%), and AIS class D injuries (55.7%) in the corresponding group (Table 1, Table S3, Supplemental Digital Content 1, http://links.lww.com/BRS/C86).
Figure 1.
Etiology of patients with traumatic spinal cord injury (TSCI) in different age groups from 2013 to 2018, by sex. A, The etiology in different age groups of male patients with TSCI. B, The etiology in different age groups of female patients with TSCI.
The overall proportion of patients with TSCI increased from 2013 to 2018 (APC=6.8%, 95% CI, 3.3–10.4) (P < 0.05). The percentage increase in females (APC=8.2%, 95% CI, 5.6–10.8) was greater than in male patients (APC=6.3%, 95% CI, 2.1–10.6). Meanwhile, the ratio of males to females fell from 3.0:1 in 2013 to 2.8:1 in 2018 (Table 2, Figure 2).
TABLE 2.
Percentage Trends of Patients With TSCI in Age Groups From 2013 to 2018, by Sex
| Category | Total | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | APC (95% CI) | P * |
|---|---|---|---|---|---|---|---|---|---|
| Total (%)† | 13,465 (100.0) | 1787 (13.3) | 2155 (16.0) | 2125 (15.8) | 2405 (17.9) | 2422 (18.0) | 2571 (19.1) | 6.8 (3.3, 10.4) | 0.005 |
| Male-to-female ratio | 3.1 | 3.0 | 3.4 | 3.3 | 3.2 | 3.1 | 2.8 | — | — |
| Male | |||||||||
| Age groups, n (%) | |||||||||
| 15–24 | 549 (5.4) | 96 (7.1) | 101 (6.1) | 117 (7.2) | 92 (5.0) | 69 (3.8) | 74 (3.9) | −12.8 (−20.6, −4.1) | < 0.05 |
| 25–34 | 1169 (11.5) | 146 (10.8) | 216 (13.0) | 179 (11.0) | 231 (12.6) | 200 (10.9) | 197 (10.4) | −1.6 (−7.7, 4.8) | 0.51 |
| 35–44 | 1848 (18.1) | 302 (22.4) | 351 (21.1) | 286 (17.6) | 322 (17.6) | 283 (15.5) | 304 (16.0) | −7.2 (−10.6, −3.7) | <0.05 |
| 45–54 | 2872 (28.2) | 350 (26.0) | 428 (25.8) | 466 (28.6) | 511 (27.9) | 572 (31.3) | 545 (28.7) | 3.0 (−0.3, 6.5) | 0.06 |
| 55–64 | 2301 (22.6) | 325 (24.1) | 372 (22.4) | 364 (22.4) | 391 (21.4) | 410 (22.4) | 439 (23.1) | −0.7 (−3.4, 2.0) | 0.49 |
| ≥65 | 1457 (14.3) | 127 (9.4) | 194 (11.7) | 215 (13.2) | 283 (15.5) | 295 (16.1) | 343 (18.0) | 13.3 (9.3, 17.4) | < 0.05 |
| Total ‡ | 10,196 (75.7) | 1346 (10.0) | 1662 (12.3) | 1627 (12.1) | 1830 (13.6) | 1829 (13.6) | 1902 (14.1) | 6.3 (2.1, 10.6) | 0.013 |
| Female | |||||||||
| Age groups, n (%) | |||||||||
| 15–24 | 156 (4.8) | 24 (5.4) | 27 (5.4) | 32 (6.4) | 19 (3.3) | 23 (3.9) | 31 (4.6) | −6.7 (−19.9, 8.5) | 0.27 |
| 25–34 | 289 (8.8) | 51 (11.6) | 42 (8.5) | 51 (10.2) | 54 (9.4) | 38 (6.4) | 53 (7.9) | −7.8 (−17.0, 2.4) | 0.09 |
| 35–44 | 494 (15.1) | 77 (17.5) | 95 (19.3) | 72 (14.5) | 94 (16.3) | 74 (12.5) | 82 (12.3) | −8.1 (−14.2, −1.5) | <0.05 |
| 45–54 | 861 (26.3) | 100 (22.7) | 134 (27.2) | 132 (26.5) | 170 (29.6) | 175 (29.5) | 150 (22.4) | 0.8 (−7.9, 10.4) | 0.81 |
| 55–64 | 739 (22.6) | 102 (23.1) | 120 (24.3) | 108 (21.7) | 107 (18.6) | 139 (23.4) | 163 (24.4) | 0.0 (−7.3, 7.9) | 0.99 |
| ≥65 | 730 (22.3) | 87 (19.7) | 75 (15.2) | 103 (20.7) | 131 (22.8) | 144 (24.3) | 190 (28.4) | 10.0 (1.0, 19.8) | <0.05 |
| Total ‡ | 3269 (24.3) | 441 (3.3) | 493 (3.7) | 498 (3.7) | 575 (4.3) | 593 (4.4) | 669 (5.0) | 8.2 (5.6, 10.8) | 0.001 |
P-value indicates significant difference in APC.
The total trend refers to the change over time in the percentage of patients with TSCI per year to all patients in this study.
The trend of sexes refers to the change over time in the percentage of males or females patients with TSCI per year to all patients in this study.
APC indicates Annual percentage change; No., number.
Figure 2.
Trends in the percentage among patients with traumatic spinal cord injury (TSCI) from 2013 to 2018. A, The total trend refers to the change over time in the percentage of patients with TSCI per year to all patients in this study. The trend of sexes refers to the change over time in the percentage of males or females patients with TSCI per year for all patients in this study. B, Comparison of the ratio between male and female patients from 2013 to 2018.
A total of 74.7% (10,053 cases) of patients received surgery after TSCI, and the ratio of males to females was 3.2:1 (Table 3, Figure 3A). The majority (61.2%; 6078 cases) of patients underwent surgery using the posterior approach, with no significant sex differences. Compared with SCI caused by other traumas, high-level fall-related TSCI had the highest surgical rate (male: 81.0%, female: 82.4%). Similarly, high-level falls were the predominant cause in those receiving surgery through a posterior approach (male: 70.3%, female: 75.9%), whereas low-level falls (male: 40.9%, female: 32.2%) and traffic accidents (male: 42.5%, female: 35.9%) were the predominant cause associated with an anterior approach (Table 3). Only 2.8% (284 cases) of the 10,020 patients with defined operative time underwent surgery within 24 hours, with more females (5.3%) receiving surgery within 24 hours compared with males (3.3%). The timing of surgery was between 4.0 and 11.9 days postinjury in half of the patients (50.2%, 5030 cases).
TABLE 3.
Surgical Treatment in Different Etiology in Patients With TSCI, by Sex
| Males (%) | Females (%) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Category | No. patients | Total | High falls | Low falls | Traffic accidents | Struck by falling objects | Sport-related injury | Total | High falls | Low falls | Traffic accidents | Struck by balling objects | Sport-related injury | P * |
| Treatment method | — | — | — | — | — | — | — | — | — | — | — | — | — | <0.05 |
| Conservative | 3412 (25.3) | 2534 (24.9) | 596 (19.0) | 753 (26.4) | 655 (26.6) | 162 (23.2) | 32 (34.4) | 878 (26.8) | 143 (17.6) | 331 (27.7) | 259 (33.1) | 17 (16.5) | 16 (29.1) | — |
| Surgery | 10053 (74.7) | 7662 (75.1) | 2545 (81.0) | 2100 (73.6) | 1804 (73.4) | 535 (76.8) | 61 (65.6) | 2391 (73.2) | 669 (82.4) | 865 (72.3) | 524 (66.9) | 86 (83.5) | 39 (70.9) | — |
| Total | 13465 (100.0) | 10196 (100.0) | 3141 (100.0) | 2853 (100.0) | 2459 (100.0) | 697 (100.0) | 93 (100.0) | 3269 (100.0) | 812 (100.0) | 1196 (100.0) | 783 (100.0) | 103 (100.0) | 55 (100.0) | — |
| Surgical approach | — | — | — | — | — | — | — | — | — | — | — | — | — | <0.01 |
| Anterior | 3306 (33.3) | 2619 (34.5) | 625 (24.9) | 853 (40.9) | 760 (42.5) | 131 (24.6) | 23 (38.3) | 687 (29.2) | 135 (20.5) | 275 (32.2) | 184 (35.9) | 18 (20.9) | 5 (12.8) | — |
| Posterior | 6078 (61.2) | 4598 (60.6) | 1763 (70.3) | 1124 (53.9) | 952 (53.3) | 375 (70.5) | 32 (53.3) | 1480 (62.9) | 501 (75.9) | 489 (57.3) | 292 (56.9) | 64 (74.4) | 28 (71.8) | — |
| Combination of anterior and posterior | 329 (3.3) | 261 (3.4) | 89 (3.6) | 62 (3.0) | 63 (3.5) | 22 (4.1) | 3 (5.0) | 68 (2.9) | 22 (3.3) | 17 (2.0) | 22 (4.3) | 4 (4.7) | 0 (0.0) | — |
| Minimally invasive | 219 (2.2) | 100 (1.3) | 29 (1.2) | 45 (2.2) | 11 (0.6) | 3 (0.6) | 2 (3.3) | 119 (5.1) | 2 (0.3) | 73 (8.5) | 15 (2.9) | 0 (0.0) | 6 (15.4) | — |
| Total | 9936 (100.0) | 7582 (100.0) | 2507 (100.0) | 2085 (100.0) | 1787 (100.0) | 532 (100.0) | 60 (100.0) | 2354 (100.0) | 660 (100.0) | 854 (100.0) | 513 (100.0) | 86 (100.0) | 39 (100.0) | — |
| Missing | 117 | — | — | — | — | — | — | — | — | — | — | — | — | — |
| Surgery timing † | — | — | — | — | — | — | — | — | — | — | — | — | — | 0.43 |
| Sec. 1 | ||||||||||||||
| < 24 h | 284 (2.8) | 211 (2.8) | 85 (3.3) | 42 (2.0) | 42 (2.3) | 29 (5.4) | 1 (1.6) | 73 (3.1) | 35 (5.3) | 14 (1.6) | 15 (2.9) | 7 (8.1) | 0 (0.0) | — |
| Sec. 2 | ||||||||||||||
| ≥24 | ||||||||||||||
| <4.0 days | 2471 (24.7) | 1865 (24.4) | 771 (30.3) | 409 (19.6) | 389 (21.6) | 149 (28.0) | 14 (23.0) | 606 (25.5) | 202 (30.4) | 178 (20.7) | 143 (27.3) | 29 (33.7) | 6 (15.4) | — |
| 4.0–11.9 d | 5030 (50.2) | 3911 (51.2) | 1260 (49.5) | 1137 (54.3) | 921 (51.2) | 247 (46.3) | 27 (44.3) | 1119 (47.1) | 335 (50.4) | 404 (47.0) | 237 (45.3) | 42 (48.8) | 13 (33.3) | <0.01 |
| >11.9 d | 2519 (25.1) | 1866 (24.4) | 513 (20.2) | 546 (26.1) | 488 (27.1) | 137 (25.7) | 20 (32.8) | 653 (27.5) | 128 (19.2) | 277 (32.2) | 143 (27.3) | 15 (17.4) | 20 (51.3) | — |
| Total | 10020 (100.0) | 7642 (100.0) | 2544 (100.0) | 2092 (100.0) | 1798 (100.0) | 533 (100.0) | 61 (100.0) | 2378 (100.0) | 665 (100.0) | 859 (100.0) | 523 (100.0) | 86 (100.0) | 39 (100.0) | — |
| Missing | 33 | — | — | — | — | — | — | — | — | — | — | — | — | — |
P-values refer to the overall significant difference between males and females.
“Surgery timing” represented the time from injury to surgery (“h” indicates hours, “d” indicates days).
No. indicates number; Sec, section; TSCI, traumatic spinal cord injury.
Figure 3.
Surgical and medical treatment of patients with traumatic spinal cord injury (TSCI by sex from 2013 to 2018. A, Surgical treatment of patients with TSCI according to the etiology of injury by sex. B, Use of methylprednisolone sodium succinate/methylprednisolone at overinstruction dose (≥500 mg) by sex.
There were 2005 patients (14.9%) who received high-dose (≥500 mg) MPSS/MP to treat TSCI, with a male-to-female ratio of 3.4:1. One third of the patients received it within eight hours (male: 30.9%, female: 29.8%; Table S4, Supplemental Digital Content 1, http://links.lww.com/BRS/C86, Fig. 3B). A total of 4665 patients (34.6%) received it continuously with normal doses (<500 mg) of MPSS/MP, with a male-to-female ratio of 3.3:1. Half used it within 1.6 to 9.0 days after injury, and there was no significant sex difference in time duration of treatment.
The mean total cost (¥74,000, $12,000) and the mean daily cost (¥4400, $700) of males were higher than those of females (¥63,100, $10,200 and ¥4300, $700) (PT <0.01, PD=0.09). Both costs decreased with age in both sexes, and they increased with AIS grades (from E to A). In other subgroups, sex-based discrepancies were identified within certain costs (Table 4). Males had a longer length of hospital stay (20.5 d, SD, 27.4) than females (18.4 days, SD, 23.5; Table S6, Supplemental Digital Content 1, http://links.lww.com/BRS/C86).
TABLE 4.
Direct Hospital Costs During Hospitalization Among Patients With TSCI, by Sex
| Male | Female | |||||||
|---|---|---|---|---|---|---|---|---|
| Category | No. patients | Total costs (CNY/USD, thousand), means (SD) | Daily costs (CNY/USD, thousand), means (SD) | No. patients | Total costs (CNY/USD, thousand), means (SD) | Daily costs (CNY/USD, thousand), means (SD) | P T value* | P D value† |
| No. patients | 7919 | ¥74.0 (73.0), $12.0 (12.0) | ¥4.4 (3.4), $0.7 (0.5) | 2490 | ¥63.1 (65.7), $10.2 (10.6) | ¥4.3 (3.5), $0.7 (0.6) | <0.05 | 0.09 |
| Age groups | ||||||||
| 15–24 | 448 | ¥82.4 (72.3), $13.3 (11.7) | ¥4.4 (2.8), $0.7 (0.5) | 124 | ¥87.5 (173.0), $14.1 (27.9) | ¥5.2 (5.1), $0.8 (0.8) | 0.62 | 0.01 |
| 25–34 | 935 | ¥80.0 (72.2), $12.9 (11.7) | ¥4.6 (3.7), $0.7 (0.6) | 229 | ¥74.3 (65.0), $12.0 (10.5) | ¥4.2 (2.8), $0.7 (0.5) | 0.31 | 0.17 |
| 35–44 | 1451 | ¥77.8 (86.2), $12.6 (14.0) | ¥4.5 (3.3), $0.7 (0.5) | 373 | ¥69.2 (55.6), $11.2 (9.0) | ¥4.5 (3.1), $0.7 (0.5) | 0.06 | 0.96 |
| 45–54 | 2248 | ¥76.0 (67.7), $12.2 (10.9) | ¥4.4 (3.5), $0.7 (0.6) | 661 | ¥65.7 (58.0), $10.6 (9.3) | ¥4.3 (3.4), $0.7 (0.6) | <0.01 | 0.35 |
| 55–64 | 1755 | ¥70.0 (62.1), $11.3 (10.0) | ¥4.3 (3.5), $0.7 (0.7) | 567 | ¥56.4 (47.0), $9.1 (7.6) | ¥4.1 (3.6), $0.7 (0.6) | <0.01 | 0.14 |
| ≥65 | 1082 | ¥63.1 (80.0), $10.2 (12.9) | ¥4.2 (2.9), $0.7 (0.5) | 536 | ¥52.2 (49.5), $8.4 (8.0) | ¥4.1 (4.0), $0.6 (0.6) | <0.01 | 0.62 |
| Occupation | ||||||||
| Worker | 1076 | ¥82.9 (80.3), $13.4 (13.0) | ¥4.4 (4.0), $0/7 (0.7) | 184 | ¥68.1 (60.1), $11.0 (9.7) | ¥4.3 (3.8), $0.7 (0.7) | <0.05 | 0.85 |
| Farmer | 3179 | ¥65.2 (55.0), $11.0 (8.9) | ¥4.3 (3.3), $0.7 (0.5) | 957 | ¥62.1 (53.0), $10.0 (8.5) | ¥4.2 (3.3), $0.7 (0.5) | 0.13 | 0.87 |
| Driver | 105 | ¥79.4 (107.9), $12.8 (17.4) | ¥3.8 (2.7), $0.6 (0.4) | 24 | ¥55.9 (33.0), $9.0 (5.3) | ¥3.1 (1.7), $0.5 (0.3) | 0.29 | 0.11 |
| Office clerk | 354 | ¥76.5 (79.7), $12.3 (12.9) | ¥4.5 (4.4), $0.7 (0.7) | 129 | ¥52.3 (49.7), $8.5 (8.0) | ¥3.9 (3.5), $0.6 (0.6) | <0.01 | 0.17 |
| Civil servant | 107 | ¥63.8 (59.9), $10.3 (9.7) | ¥4.0 (3.5), $0.7 (0.6) | 56 | ¥65.8 (65.6), $10.6 (10.6) | ¥3.7 (4.8), $0.6 (0.8) | 0.85 | 0.63 |
| Retiree | 431 | ¥62.4 (57.0), $10.1 (9.2) | ¥4.0 (2.8), $0.7 (0.5) | 268 | ¥47.2 (44.2), $7.6 (7.1) | ¥4.0 (3.6), $0.6 (0.6) | <0.01 | 0.90 |
| Student | 184 | ¥75.1 (63.2), $12.1 (10.2) | ¥3.8 (2.5), $0.6 (0.4) | 91 | ¥90.7 (199.7), $14.6 (32.2) | ¥4.9 (5.6), $0.8 (0.9) | 0.33 | 0.08 |
| Self-employed | 166 | ¥64.0 (56.5), $10.3 (9.1) | ¥4.0 (3.1), $0.7 (0.5) | 53 | ¥51.7 (36.8), $8.3 (5.9) | ¥3.0 (2.2), $0.5 (0.4) | 0.14 | <0.05 |
| Missing | 336 | ¥83.7 (60.8), $13.5 (9.8) | ¥5.6 (3.3), $0.9 (0.5) | 110 | ¥85.4 (61.4), $13.8 (9.9) | ¥5.7 (3.6), $0.9 (0.6) | 0.79 | 0.82 |
| Others‡ | 1981 | ¥84.4 (93.3), $13.6 (15.1) | ¥4.6 (3.1), $0.7 (0.5) | 618 | ¥65.2 (57.1), $10.5 (9.2) | ¥4.3 (3.3), $0.7 (0.5) | <0.01 | <0.05 |
| Etiological groups | ||||||||
| High falls | 2609 | ¥82.7 (70.7), $13.4 (11.4) | ¥4.8 (3.5), $0.8 (0.6) | 675 | ¥77.7 (87.7), $12.5 (14.2) | ¥5.0 (3.7), $0.8 (0.6) | 0.12 | 0.26 |
| Low falls | 2196 | ¥58.0 (52.4), $9.4 (8.5) | ¥3.9 (3.3), $0.6 (0.5) | 906 | ¥47.8 (40.0), $7.7 (6.5) | ¥3.9 (3.3), $0.6 (0.5) | <0.01 | 0.57 |
| Traffic accidents | 1948 | ¥75.7 (77.4), $12.2 (12.5) | ¥4.4 (3.2), $0.7 (0.5) | 619 | ¥67.4 (66.6), $10.9 (10.8) | ¥3.9 (3.2), $0.6 (0.5) | <0.05 | <0.05 |
| Struck by falling objects | 547 | ¥98.6 (119.0), $15.9 (19.2) | ¥4.8 (4.1), $0.8 (0.7) | 77 | ¥87.7 (54.1), $14.2 (8.7) | ¥4.8 (3.3), $0.8 (0.5) | 0.43 | 0.94 |
| Sport related injury | 71 | ¥51.3 (47.0), $8.3 (7.6) | ¥3.7 (2.9), $0.6 (0.5) | 34 | ¥31.6 (29.4), $5.1 (4.7) | ¥5.6 (6.3), $0.9 (1.0) | <0.05 | 0.09 |
| Missing | 134 | ¥74.4 (50.1), $12.0 (8.1) | ¥5.2 (3.1), $0.8 (0.5) | 39 | ¥75.4 (55.4), $12.2 (8.9) | ¥5.9 (3.8), $1.0 (0.6) | 0.92 | 0.25 |
| Others§ | 414 | ¥65.4 (70.6), $10.6 (11.4) | ¥3.5 (2.5), $0.6 (0.4) | 140 | ¥63.1 (63.3), $10.2 (10.2) | ¥3.7 (3.3), $0.6 (0.5) | 0.74 | 0.45 |
| Level of injury | ||||||||
| Cervical | 5075 | ¥68.6 (72.9), $11.1 (11.8) | ¥4.2 (3.2), $0.7 (0.5) | 1260 | ¥57.3 (49.0), $9.2 (7.9) | ¥3.9 (3.2), $0.6 (0.5) | <0.01 | <0.01 |
| Thoracic | 1224 | ¥96.9 (84.4), $15.6 (13.6) | ¥5.0 (3.6), $0.8 (0.6) | 472 | ¥84.4 (107.0), $13.6 (17.3) | ¥4.9 (4.1), $0.8 (0.7) | <0.05 | 0.78 |
| Lumbosacral | 1404 | ¥73.8 (61.1), $11.9 (9.9) | ¥4.5 (3.7), $0.7 (0.6) | 667 | ¥58.9 (49.6), $9.5 (8.0) | ¥4.3 (3.7), $0.7 (0.6) | <0.01 | 0.49 |
| Multisite | 91 | ¥77.7 (44.0), $12.5 (7.1) | ¥4.9 (2.3), $0.8 (0.4) | 33 | ¥66.6 (40.0), $10.8 (6.4) | ¥6.0 (2.9), $1.0 (0.5) | 0.21 | 0.06 |
| Cauda equina | 26 | ¥93.4 (43.5), $15.1 (7.0) | ¥5.2 (1.8), $0.8 (0.3) | 11 | ¥95.8 (30.3), $15.5 (4.9) | ¥4.9 (1.5), $0.8 (0.2) | 0.87 | 0.75 |
| Missing | 99 | ¥56.5 (43.7), $9.1 (7.1) | ¥3.9 (2.7), $0.6 (0.4) | 47 | ¥53.0 (85.8), $8.6 (13.8) | ¥3.4 (2.3), $0.6 (0.4) | 0.74 | 0.36 |
| Severity | ||||||||
| Complete quadriplegia | 1136 | ¥96.0 (108.8), $15.5 (17.6) | ¥4.8 (3.4), $0.8 (0.5) | 220 | ¥78.7 (65.5), $12.7 (10.6) | ¥4.8 (3.3), $0.8 (0.5) | <0.01 | 0.96 |
| Complete paraplegia | 1643 | ¥94.7 (85.3), $15.3 (13.8) | ¥5.0 (4.1), $0.8 (0.7) | 494 | ¥91.7 (107.0), $14.8 (17.3) | ¥5.1 (4.6), $0.8 (0.7) | 0.51 | 0.70 |
| Incomplete quadriplegia | 3530 | ¥59.9 (51.8), $9.7 (8.4) | ¥4.0 (3.1), $0.7 (0.5) | 969 | ¥52.9 (41.7), $8.5 (6.7) | ¥3.8 (3.0), $0.6 (0.5) | <0.01 | <0.05 |
| Incomplete paraplegia | 1524 | ¥68.2 (57.3), $11.0 (9.3) | ¥4. (2.9), $0.7 (0.5) | 784 | ¥53.8 (48.0), $8.7 (7.8) | ¥4.2 (3.3), $0.7 (0.5) | <0.01 | 0.54 |
| Missing | 86 | ¥60.1 (53.3), $9.7 (8.6) | ¥3.8 (2.9), $0.6 (0.5) | 23 | ¥44.7 (43.7), $7.2 (7.1) | ¥2.9 (2.3), $0.5 (0.4) | 0.21 | 0.16 |
| ASIA score | ||||||||
| A | 2259 | ¥97.8 (103.6), $15.8 (16.7) | ¥5.0 (3.9), $0.8 (0.6) | 562 | ¥90.3 (99.5), $14.6 (16.1) | ¥5.2 (4.3), $0.8 (0.7) | 0.11 | 0.37 |
| B | 568 | ¥95.8 (70.7), $15.5 (11.4) | ¥5.2 (3.9), $0.8 (0.6) | 153 | ¥80.6 (75.8), $13.0 (12.2) | ¥4.7 (3.5), $0.8 (0.6) | <0.05 | 0.15 |
| C | 1365 | ¥77.3 (56.4), $12.5 (9.1) | ¥4.4 (2.8), $0.7 (0.5) | 361 | ¥74.1 (56.4), $12.0 (9.1) | ¥4.4 (3.2), $0.7 (0.5) | 0.34 | 0.80 |
| D | 3579 | ¥54.7 (44.6), $8.8 (7.2) | ¥3.9 (3.0), $0.6 (0.5) | 1351 | ¥47.7 (40.7), $7.7 (6.6) | ¥3.8 (3.2), $0.6 (0.5) | <0.01 | 0.44 |
| E | 111 | ¥53.3 (60.3), $8.6 (9.7) | ¥3.3 (3.0), $0.5 (0.5) | 54 | ¥42.7 (39.6), $6.9 (6.4) | ¥3.3 (2.5), $0.5 (0.4) | 0.24 | 0.98 |
| Missing | 37 | ¥74.8 (83.6), $12.1 (13.5) | ¥4.2 (2.3), $0.7 (0.4) | 9 | ¥52.2 (34.2), $8.4 (5.5) | ¥3.5 (1.9), $0.6 (0.3) | 0.43 | 0.42 |
P T value refers to the significant difference in mean total costs between males and females.
P D value refers to the significant difference in mean daily cost between males and females.
“Others” included “Teachers, “Unemployed,” and “Freelancers.”
“Others” included “Injuries caused by others,” “Work-related injuries,” “sharp injuries,” “Massage-related injuries,” “Electric shock injuries,” “Gunshot wounds,” “Crush injuries,” and “Iatrogenic injuries.”
AIS indicates American Spinal Injury Association (ASIA) Impairment Scale; CNY, Chinese Yuan; No., number; TSCI, traumatic spinal cord injury; USD, USA dollar.
The mean total cost decreased for both males and females from 2013 to 2018 (−4.4%, −6.3 to −2.4; and −5.5%, −8.3 to −2.6), with no significant change in the mean daily cost (0.5, −2.0 to 3.1; and 1.7, −1.8 to 5.3) (Table S5, Supplemental Digital Content 1, http://links.lww.com/BRS/C86, Figure 4A, B). In addition, the mean length of hospital stay was reduced across both sexes (−4.5%, −8.0 to −0.9; and −5.5%, −11.7 to 1.1) (Table S6, Supplemental Digital Content 1, http://links.lww.com/BRS/C86, Figure 4A, B).
Figure 4.
Trends over time of hospitalization costs and length of stay for patients with traumatic spinal cord injury (TSCI) by sex from 2013 to 2018. A, Trends over time of hospitalization costs and length of stay in male patients with TSCI. B, Trends over time of hospitalization costs and length of stay in female patients with TSCI. CNY indicates Chinese Yuan.
DISCUSSION
Between 2013 and 2018, the percentage of TSCI increased significantly for both males and females, of which only those aged 65 or above increased statistically. Although males were the main population affected by TSCI, the ratio of males to females decreased from 3.05 to 2.85. For both males and females, the age group primarily burdened by SCI related to high-level falls and traffic accidents gradually became younger, while the age group affected most by SCI related to low-level falls gradually became older.
Most studies have shown that the main population affected by TSCI is males.31,32 The average male-to-female ratio in developed countries is 3~4:1,33,34 while it is even higher (4.8:1) in developing nations.35 Western Norway (4.7:1) and Victoria (3.8:1) possess a higher ratio than encountered in our study,36,37 and Tianjin (2.3:1) and Northwest China (2.6:1) have a lower ratio.6,38 Notably, the ratio of males to females declined during the study period (from 3.05:1 to 2.85:1). This trend was also reported in Manitoba (from 12 to 4.4) and Norway (from 5.3 to 4.2).11,36 In recent years, there may be an increasing number of females suffering from SCI, and the growth rate of TSCI in females may be faster than that in males. Barbiellini Amidei and colleagues declared that this trend is mainly manifested in older females.31 The reasons for these are not only global aging but also the transformation of the roles of males and females in life and work due to the development of the economy and other societal changes 8,39,40. The fact that males of all ages have a consistently high frequency of TSCI warrants further research into whether sex itself might be a risk factor to facilitate targeted public health policies targeting males.
Rahimi-Movaghar and colleagues found that in developing countries, the average age at which TSCI occurs mostly falls between 20 and 40 years old, and it is higher in developed countries.33,35 Since the population under the age of 15 is not included in this study, the average age in this study is higher (50.0 yr), similar to the results of Italy (54 yr),41 Tianjin (50.1 yr)6 and Spain (48 yr).42 Notably, the average age of females and the higher proportion of females ≥65 in the age group compared with males are similar to the findings of Furlan et al and Hagen et al.15,36 Farming is the occupation with the highest representation in this study, which coincides with a study in Chongqing,25 which is undoubtedly due to China being a largely agricultural country. However, the proportion of female retirees was higher in the group than in males. In the United States, 66.3% of patients are working people.43 The discrepancies in age and occupation in this study partly reflect that females with TSCI are older than males. According to the GBD study, the life expectancy of older females is higher than that of males;44 at the same time, postmenopausal females are more likely to suffer from osteoporosis.45 This issue, combined with the increase in older adults who are outdoors, may have contributed to some of the observed sex differences.
Motor vehicle collisions are the largest cause of TSCI in North America and Europe,8,32,46,47 and low-level falls are the leading cause of injury in Western Norway and parts of the United States.13,36 Similarly, falls were the leading cause of injury in this study. Recent studies have shown that in developed countries, because of aging populations, falls may surpass traffic accidents as the leading cause of injury for females over 60 and males over 70.13,22,48–50 This trend seems to be more advanced in this study, as it begins at age 55 for males and 45 for females. The second leading cause in this study was high-level falls, which primarily affect young males. A study in 2016 reported that young people were more likely to fall from heights in buildings while on the job.2,13,51 In addition, because young people tend to be outdoors, they are prone to such injuries. Given the serious consequences caused by TSCI, corresponding preventive measures should be formulated according to different causes of injury to reduce SCI events. Despite the high proportion of TSCI in males, females had a higher proportion of events such as thoracic injury, lumbar injury, incomplete paraplegia, and AIS grade D injury, which seems to be a trend: TSCI in females is not as severe as that in males. This view has also been expressed in the United States and Ireland.13,52
Surgery is one of the early treatment measures for TSCI.53,54 In many studies, 24 hours after injury is regarded as the dividing point between “early” and “late intervention”.21,24,29,54 A prospective study of 313 patients with CSCI showed that surgical intervention in the early stage (<24 h) was 2.8 times more likely than that in the late stage (≥24 h) to improve the AIS grade by at least 2 grades after six months.54 In our study, only 2.8% of surgical patients received the intervention within 24 hours after injury, with more females (5.3%) receiving surgery within 24 hours compared with males (3.3%). However, some studies have reported that >80% of patients received surgical treatment within 24 hours.55,56 In the absence of clinical information on treatment decisions for patients with spinal cord injuries, we cannot determine the exact cause of this phenomenon. Noticeably, research on sex discrepancies in surgical treatment is currently lacking, and more research is needed to further explore this. As some areas in China have not yet established complete emergency channels, most patients are not sent to designated hospitals immediately after injury. Because of limited resources, medical institutions may not be able to complete early operations in time. These factors will affect the current status of TSCI treatment in China going forward.
Studies have shown that glucocorticoids can have a beneficial effect on SCI.18,57 However, their use in SCI remains controversial. In 2002 and 2013, the American Association of Neurosurgeons and Congress of Neurosurgeons raised objections to the use of MPSS/MP in SCI.30,53,58 However, AOSpine recommended a high dose of MPSS/MP within eight hours of ASCI as a treatment option in 2017.57 Some surveys found that, despite the great controversy, most patients preferred MPSS/MP early in injury.59–61 In this study, the utilization rate of high-dose (≥500 mg) MPSS/MP was only 4.6% within eight hours, and there was no significant sex difference at the time of initiation.
In Australia, the average hospitalization cost of TSCI patients ≥65 years old is AUD 31,000, and the total hospitalization cost for females ≥65 years old is as high as AUD 129 million.62 In this study, the average total cost and average daily cost of males were higher than those of females. This may be because TSCI in males is more serious than that in females and requires more medical resources. The average total cost for males was 4.0 times China’s per capita disposable income (¥18.3k) (NBSPRC) in 2013 (National Bureau of Statistics, 2022). During the period of our study, the average total cost of both male and female patients showed a downward trend, while the average daily cost did not change significantly, which may be caused by reductions in the average length of hospital stay.63,64 Our findings are not aligned with National Spinal Cord Injury data.5,65 The reason for the reduction in hospital stay duration may be due to the more complete and mature access to medical treatment in most hospitals in China. Second, the limitations of the economic situation of patients and their families, rather than the reasonable investment of medical resources, may lead to early discharge.
Although this study is the largest multicenter retrospective study of TSCI cases known in China, there are still some limitations. First, this study was not a population-based design, and we could not calculate the sex-specific incidence of TSCI from the entire Chinese population. Second, this study had missing data in some variables (e.g. occupation, etiology, injury degree, severity, and AIS grade of TSCI patients), although the percent of missing data for most variables was <5.0%. Third, we only describe the use of MPSS/MP as a glucocorticoid treatment, without including hydrocortisone and dexamethasone, because it is uncertain whether other glucocorticoids are specifically used in the treatment of TSCI itself. Fourth, this study only collected data from China. However, we think our findings (e.g. increasing incidence of spinal cord injury in females and relatively low percentage of patients who had access to early surgery) could also be useful for other developing nations with comparable sex ratios and levels of economic development.66–69
CONCLUSIONS
This study suggests that although the main population of TSCI is male, the average ratio of males to females is decreasing. The frequency of TSCI may be increasing faster in females than in males. Therefore, it is necessary to develop sex-specific public prevention measures. In addition, more medical resources should be devoted to improving the ability of hospitals to perform early surgery.
Key Points
We collected the clinical data of TSCI patients admitted to multicenter hospitals in mainland China from 2013 to 2018 and retrospectively analyzed the sex discrepancies in epidemiological and clinical characteristics, treatment status, and economic burden of TSCI patients.
We found significant sex discrepancies in epidemiological and clinical characteristics, and the average ratio of males and females is decreasing during the study period.
We did not find significant discrepancies in surgical treatment between male and female patients, and early surgery rates were low for both.
The mean total cost and the mean daily cost of males were higher than those of females.
Supplementary Material
Footnotes
Medical ethics approval was obtained from all 30 hospitals for the study.
S.S., C.W., and W.W. contributed equally to this work and shared the first authorship.
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.spinejournal.com.
Contributor Information
Shenghui Shang, Email: shenghuishang2022@163.com.
Chaoyu Wang, Email: wangcy@tmu.edu.cn.
Wei Wang, Email: wangweify@mail.sdu.edu.cn.
Jinghua Wang, Email: jwang3@tmu.edu.cn.
Yongfu Lou, Email: yflou@tmu.edu.cn.
Chi Zhang, Email: chizhang2020@mail.sdu.edu.cn.
Wenzhao Wang, Email: wayne1898@163.com.
Yi Kang, Email: kykangyi1117@163.com.
Huan Jian, Email: jh0213@tmu.edu.cn.
Yigang Lv, Email: Lvyigang1996@tmu.edu.cn.
Mengfan Hou, Email: houmengfan@tmu.edu.cn.
Hua Zhao, Email: Zhaohuadr@163.com.
Lingxiao Chen, Email: lche4036@uni.sydney.edu.au.
Hengxing Zhou, Email: zhouhengxing@sdu.edu.cn.
Shiqing Feng, Email: shiqingfeng@sdu.edu.cn.
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