Abstract
Background:
Chronic subdural hematoma (CSDH) is a common neurosurgical condition, particularly among the elderly, that often requires surgical drainage. Due to economic and logistical constraints, traditional closed-system drains are often impractical in low- and middle-income countries (LMICs). Foley catheter drainage has also been proposed as a cost-effective alternative, yet few studies have evaluated its safety and efficacy. This study investigates the clinical outcomes of patients with CSDH who underwent Foley catheter drainage, focusing on its effectiveness and safety.
Materials and methods:
This retrospective analysis examined the case records of 134 patients who underwent burr-hole craniotomy with Foley catheter drainage for chronic subdural hematoma (CSDH) at our hospital from January 2022 to December 2024. Patient demographics, presenting symptoms, postoperative recovery, recurrence rates, and complications were assessed. Statistical analysis, including Chi-square tests and Pearson correlation, was conducted using SPSS 28, with a significance threshold set at P < 0.05.
Results:
One hundred thirty-four patients were studied, with a mean age of 61.8 years and male predominance (80.6%). The most frequent presenting symptoms were headache (77.6%) and motor deficits (55.97%). Postoperative recovery was satisfactory, with 85% of patients making a complete recovery. The rate of recurrence was 3.7%, and the most common complications were pneumocephalus (7.5%) and infections (5.2%). There was a positive correlation (r = 0.48, P < 0.0001) between preoperative Glasgow Coma Scale (GCS) scores and functional recovery. However, it was not strong enough to serve as a stand-alone predictor, and clinical correlation, which considers other variables, needs to be taken into consideration while interpreting. The mortality rate was 3%.
Conclusion:
Foley catheter drainage of cerebrospinal fluid (CSF) hygroma (CSDH) can be considered a reliable and safe alternative in low- and middle-income countries (LMICs), with recovery rates of 85% and a low risk of recurrence. However, further prospective studies are required to prove these findings, as this is a single-arm retrospective study. Though complications were tolerable, attention to surgical technique and vigilant postoperative observation continues to be vital. Further studies and refinement of management are warranted to confirm these results.
Keywords: burr-hole craniostomy, chronic subdural hematoma, complications, Foley catheter drainage, neurosurgical outcomes, resource-limited settings
Introduction
Chronic subdural hematoma (CSDH) is a common neurosurgical condition, particularly affecting older adults in high-income countries (HICs), where the elderly represent up to 90.9% of cases, with the average age being 83.8 years. In contrast, in low- and middle-income countries (LMICs), the age distribution of CSDH patients is generally younger, with the elderly comprising a smaller proportion of cases. In many LMICs, such as those in sub-Saharan Africa, the peak age of patients tends to be around 60 years, and the average age is often closer to 46–50 years, reflecting different injury patterns and risk factors[1].
It is characterized by the gradual accumulation of blood within the subdural space, often leading to progressive neurological deterioration, including headaches, cognitive decline, motor deficits, and, in severe cases, altered levels of consciousness[2]. CSDH has an incidence ranging from 8 to 58 cases per 100 000 people annually, with its prevalence significantly increasing among populations over the age of 65[3]. This condition imposes a significant burden on healthcare systems, particularly in resource-limited settings such as low- and middle-income countries (LMICs) in terms of delayed diagnosis and multiple hospital admissions[4]. In these regions, delays in surgical treatment are common due to various factors, including limited access to neurosurgical care. Additionally, the clinical presentation of CSDH often mimics other prevalent conditions in the same age group, such as stroke, dementia, and Parkinson’s disease. Additionally, neurosurgeons represent a small minority of physicians in LMICs, and advanced diagnostic imaging modalities such as CT and diagnostic centers are only available in urban areas[1].
The standard treatment for CSDH is surgical evacuation, most commonly through burr hole craniostomy, followed by the placement of a closed-system drainage catheter to reduce postoperative recurrence[5]. The role of postoperative drainage is particularly critical, as evidence has demonstrated a relative 12% lower recurrence rate with drain use, as demonstrated by Brennan et al. In patients without recurrence, 86% had a drain inserted, compared to 74% in the recurrence group. The odds ratio (OR) of 0.414 and P-value of 0.011 indicate a statistically significant reduction in the risk of symptomatic recollection requiring repeat surgery within 60 days[6]. However, in LMICs, where access to specialized neurosurgical equipment may be limited, the use of commercially available or specialized drains is often not feasible due to cost constraints and resource limitations[7]. The prices of prefabricated subdural drains, based on a Google search, indicate that the Medtronic Subdural Evacuating Port System (SEPS) ranges from 28 000 Rs to 30 000 Rs (approximately 100–150 USD), the Blake drain is priced between 9800 and 11 000 Rs (35–USD), and the Jackson-Pratt drain costs between 8000 Rs and 9800 Rs (25–35 USD). These commercially available drains, although effective, may not always be easily accessible in all healthcare settings due to cost constraints and supply limitations[8]. This necessitates the adaptation of locally available and cost-effective solutions.
Traditionally used for urinary drainage, Foley catheters have recently gained attention as a cost-effective alternative for postoperative drainage in managing chronic subdural hematomas (CSDH) in low- and middle-income countries (LMICs)[8]. These catheters are widely available, affordable, and can be repurposed as subdural drains with relative ease[9]. The Foley catheter price is around 380 to 400 Rs (1–1.5 USD)[8].
Additionally, the healthcare challenges specific to LMICs—such as delayed diagnosis, limited access to advanced imaging, inadequate follow-up systems, and a high patient-to-neurosurgeon ratio—further complicate the management of chronic subdural hematoma (CSDH)[10]. In this context, repurposing Foley catheters presents a practical solution to bridge the gap between limited resources and optimal patient care. Nevertheless, there is a lack of robust clinical evidence supporting their routine use. The current literature remains fragmented, with a limited number of studies assessing the safety, efficacy, and long-term outcomes of Foley catheter drainage for chronic subdural hematoma (CSDH) in resource-limited settings[11]. Moreover, factors such as healthcare infrastructure, patient demographics, and disease severity may influence this approach’s success and complication rates, highlighting the need for context-specific research.
This study addresses these gaps by retrospectively analyzing clinical outcomes associated with Foley catheter drainage for CSDH in LMICs. Using hospital records, this research will provide a descriptive evaluation of the outcomes, safety, and recurrence rates associated with this technique. Additionally, it will examine factors that influence patient outcomes, including demographics, comorbidities, and treatment protocols. The findings will contribute to the growing body of knowledge on cost-effective neurosurgical innovations and provide insights that may inform the management of CSDH in resource-limited settings.
HIGHLIGHTS
Chronic subdural hematoma (CSDH) is a common neurosurgical condition, especially among elderly populations, commonly needing surgical drainage.
Because of economic and logistical limitations, traditional closed-system drains are not always applicable in LMICs. Foley catheter drainage has also been proposed as a cost-effective substitute, but few data have assessed its safety and efficacy.
This research compares the clinical outcomes of patients with CSDH undergoing Foley catheter drainage in an LMIC.
Materials and methods
This retrospective study was conducted after obtaining ethical approval from the Institutional Review Board (IRB No. 523/LRH/MTI), Lady Reading Hospital, Peshawar, a tertiary care hospital. The study did not involve direct patient contact, and informed consent was waived due to the retrospective design. Data were collected from the Hospital Management Information System (HMIS) for all patients who underwent Foley catheter drainage for chronic subdural hematoma (CSDH) between 1 January 2022, and 31 December 2024. A total of 153 consecutive cases were identified using surgical logs and HMIS records to reduce selection bias. Nineteen patients were excluded due to incomplete medical records, resulting in a final sample size of 134 patients.
Eligible patients were those with a confirmed clinical and radiological diagnosis of CSDH who had undergone Foley catheter drainage and had complete medical records available for review. Patients with acute or mixed-density subdural hematomas, those managed conservatively, or those with incomplete outcome data were excluded.
Procedure
All procedures were performed under strict aseptic precautions, either under general anesthesia or local anesthesia where indicated. A single burr hole was created at the site of maximum hematoma thickness as determined by preoperative imaging. A 10 French Foley catheter was inserted into the subdural space following coagulation and cruciate dural incision, without prior lavage. The balloon was inflated with 3 mL of saline and retracted until locked against the inner skull table, then connected to a non-suction drainage bag. Postoperative observation was conducted in a post-anesthesia care unit for 6 to 24 hours before transfer to the general ward. A postoperative CT scan was performed within 24 hours to evaluate hematoma size, maximum thickness, midline shift, and any secondary findings. The catheter was maintained for a minimum of 48 hours, depending on the patient’s clinical condition and imaging. Patients were typically discharged between the fourth and seventh postoperative day, or referred to rehabilitation if neurological deficits persisted.
Outcomes and data analysis
The primary outcomes included functional recovery (categorized as complete, partial, or none), symptom resolution, recurrence requiring re-intervention, and postoperative complications. Functional outcomes were inferred retrospectively using clinical records and aligned with the modified Rankin Scale (mRS), where complete recovery corresponded to mRS ≤ 2, partial to mRS 3–4, and no recovery to mRS 5–6. Secondary analyses examined the associations between functional recovery and variables such as preoperative Glasgow Coma Scale (GCS) scores, comorbidities (hypertension, diabetes mellitus, and ischemic heart disease), and Markwalder Grading Scale scores. The Markwalder Grade ranges from 0 (asymptomatic) to 4 (coma with decerebrate posturing), and its correlation with outcomes was analyzed using Chi-square tests, with Bonferroni correction applied for multiple comparisons.
All statistical analyses were performed using SPSS version 28. Pearson correlation was used for continuous variables (e.g., GCS versus outcome), and Chi-square tests were used for categorical data, along with Cramér’s V to assess the strength of association. Subgroup analyses were conducted with Bonferroni-adjusted significance thresholds set at P < 0.0167. Missing data cases were excluded from analysis, and there was no loss to follow-up during hospitalization. A post hoc power analysis using G*Power version 3.1 revealed that the study had 91% power to detect associations between Markwalder Grade and functional recovery at α = 0.05, and 88% power for subgroup analysis of GCS (13–15 vs. 9–12) at a Bonferroni-adjusted α = 0.0167.
The work has been reported in accordance with the STROCSS criteria[12].
Results
Patient demographics and clinical characteristics
A total of 134 patients diagnosed with chronic subdural hematoma (CSDH) were included in this study. The mean age was 61.8 years, with a male predominance observed in 108 patients (80.6%). Comorbidities were prevalent among patients, with hypertension being the most common (27 patients, 20%), followed by diabetes mellitus (20 patients, 15%) and ischemic heart disease (13 patients, 10%). A detailed demographic summary is provided in Table 1.
Table 1.
Patient demographics and clinical characteristics
| Characteristic | Value | Percentage (%) |
|---|---|---|
| Total patients | 134 | 100% |
| Mean age | 61.8 years | – |
| Male | 108 | 80.6% |
| Female | 26 | 19.4% |
| Hypertension | 27 | 20% |
| Diabetes mellitus | 20 | 15% |
| Ischemic heart disease | 13 | 10% |
Clinical presentation and functional outcomes
Clinical presentation
Neurological symptoms at presentation varied. Headache was the most frequently reported symptom (104 patients, 77.6%), followed by motor deficits or hemiplegia (75 patients, 56%), cognitive decline (59 patients, 44%), altered consciousness (34 patients, 25.3%), and vomiting (13 patients, 9.7%). Less common symptoms included urinary incontinence (2 cases), and isolated cases of seizures with vomiting, irritability, or vertigo. The mean Glasgow Coma Scale (GCS) score at presentation was 12 (range 6–15), and most patients were categorized as Markwalder grade 2 (drowsy/disoriented with mild focal deficits) (Table 2).
Table 2.
Clinical presentation of the patients with chronic subdural hematoma
| Category | Number of Patients | Percentage (%) | 95% CI |
|---|---|---|---|
| Clinical presentation | |||
| Headache | 104 | 77.6% | 72.5%–82.3% |
| Motor deficits/hemiplegia | 75 | 56% | 49.1%–62.9% |
| Cognitive decline | 59 | 44% | 37.1%–51.2% |
| Altered consciousness | 34 | 25.3% | 19.7%–31.5% |
| Vomiting | 13 | 9.7% | 5.5%–15.4% |
| Urinary incontinence | 2 | 1.5% | 0.2%–5.4% |
| Vomiting & fits | 1 | 0.75% | 0.0%–3.9% |
| Irritability | 1 | 0.75% | 0.0%–3.9% |
| Vertigo | 1 | 0.75% | 0.0%–3.9% |
Functional outcomes
Postoperative recovery was assessed based on symptom resolution and inferred modified Rankin Scale (mRS) scores. Complete recovery (mRS ≤2) was achieved in 114 patients (85%), partial recovery (mRS 3–4) in 13 patients (10%), and no recovery (mRS ≥5) in 7 patients (5%). A statistically significant correlation was observed between GCS at presentation and likelihood of complete recovery (r = 0.48, P < 0.0001), indicating better outcomes with higher initial GCS scores.
Post hoc subgroup analyses were performed to assess the relationship between GCS at presentation and functional recovery, as well as the impact of comorbidities (diabetes mellitus, hypertension) on postoperative outcomes. To control for multiple comparisons, Bonferroni correction was applied (three comparisons, α = 0.05/3 = 0.0167).
Patients with mild GCS (13–15) were significantly more likely to experience complete recovery compared to those with moderate (9–12) and severe (3–8) GCS scores (P = 0.009 and P = 0.001, respectively; both significant after Bonferroni correction).
Diabetic patients had a significantly lower rate of complete recovery compared to non-diabetics (P = 0.012), a difference that remained statistically significant after correction.
No significant difference in outcome was observed between hypertensive and non-hypertensive patients (P = 0.21, not significant after correction). However, it may indicate insufficient power (55%) rather than an actual null effect.
Association between Markwalder grade and functional recovery
A significant association was observed between Markwalder grade and functional recovery (χ2 = 21.37, P < 0.001). As the Markwalder grade increased, the likelihood of achieving full functional recovery declined. A Low pre-operative Markwalder grade has a better outcome as compared to a higher grade.
Post hoc pairwise comparisons revealed that patients with lower grades (0, 1, and 2) had significantly higher rates of complete recovery compared to Grade 4:
Grade 0 vs. 4: 100% vs. 28.6%, P < 0.001
Grade 1 vs. 4: 95.2% vs. 28.6%, P = 0.002
Grade 2 vs. 4: 86.2% vs. 28.6%, P = 0.008
The difference between Grade 3 (66.7% full recovery) and Grade 4 was not statistically significant (P = 0.12); this comparison was underpowered (45%) due to small subgroup sizes (n =15 vs n = 7).
Notably, patients in Grade 4 had 12 times higher odds of partial or no recovery compared to those in Grade 0 (OR = 12.0, 95% CI: 2.8–51.4).
Post hoc power analysis
A post hoc power analysis was conducted for the subgroup comparison of Markwalder grade and functional recovery. Based on an effect size of w = 0.40, α = 0.05, and total sample size of 134, the analysis yielded a power of 91%, indicating the study was adequately powered for this primary outcome. For the GCS-based comparison (GCS 13–15 vs 9–12), the observed effect size (OR = 6.42) provided 88% power at α = 0.0167 (Bonferroni-corrected). However, comparisons involving comorbidities may have been underpowered due to smaller subgroup sizes.
Postoperative complications, recurrence, mortality, and symptom resolution
Correlation between comorbidities and recurrence
The relationship between comorbidities and recurrence was evaluated using Cramér’s V. A moderate association was observed (Cramér’s V = 0.42); however, it was not statistically significant (P = 0.6161). This suggests that recurrence was not strongly influenced by comorbidity status in this cohort (Table 3).
Table 3.
Postoperative complications, recurrence, mortality, and symptom resolution
| Category | No. of Patients | Percentage (%) | 95% CI |
|---|---|---|---|
| Postoperative complications | |||
| Pneumocephalus | 10 | 7.5% | 4.1%–13.2% |
| Surgical site infections | 7 | 5.2% | 2.4%–9.9% |
| Suboptimal drainage | 4 | 3% | 1.2%–6.9% |
| Seizures/neurological deterioration | 3 | 2.3% | 0.6%–5.9% |
| Other complications (e.g., incontinence, hydrocephalus) | – | 2% | 0.6%–5.4% |
| Recurrence | 5 | 3.7% | 1.6%–8.4% |
| Mortality (intra-hospital) | 4 | 3% | 1.2%–7.4% |
| Symptom resolution | |||
| Complete resolution | 120 | 90% | 83.2%–93.7% |
| Partial improvement | 9 | 7% | 3.6%–12.5% |
| No improvement | 5 | 3% | 0.8%–6.6% |
No significant association was found between diabetes, hypertension, or ischemic heart disease and recurrence in the subgroup analysis (P > 0.05 for each). These findings did not withstand Bonferroni correction and, therefore, should be interpreted with caution.
Recurrence and mortality
Recurrence requiring reoperation occurred in 5 patients (3.7%, 95% CI: 1.6%–8.4%). Intra-hospital mortality was observed in 4 patients (3%, 95% CI: 1.2%–7.4%).
Symptom resolution
Postoperative recovery was favorable in most cases, with complete symptom resolution in 120 patients (90%, 95% CI: 83.2%–93.7%). Partial improvement was observed in 9 patients (7%), while five patients (3%) showed no clinical improvement.
Cost effectiveness
The following table shows the cost-effectiveness of the Foley catheter with a conventional closed drainage and irrigation system (Table 4).
Table 4.
Cost Effectiveness Comparison: Foley Catheter vs Closed System Drainage
| Parameter | Foley Catheter Drainage | Closed System Drainage with Irrigation |
|---|---|---|
| Drainage Equipment Cost | 1-1.5 USD | Lowest costing drain 35-50 USD |
| Availability | Widely available | Not readily available |
| Operating Time | Shorter | Slightly longer due to setup |
| Recurrence Needing Reoperation (%) | Will add less to cost | Will further increase cost |
| Overall Cost per Patient (USD) | Lower(10-15 USD) | Higher(average 100-130 USD) |
| Cost-Effectiveness Summary | More cost-effective | Less cost-effective |
Discussion
Chronic subdural hematoma (CSDH) is a common neurosurgical condition, particularly in older people, and remains a significant but reversible cause of disability. The primary mode of treatment is surgical evacuation. The most common surgical therapies, including twist drill craniostomy, burr hole drainage, and craniotomy, result in differing degrees of reoperation rates, ranging from 5% to 27.8%, with burr-hole craniostomy being the most widely practiced approach. However, variations in surgical techniques, including the number of burr holes, use of irrigation, and type of drainage system, have led to ongoing debate over the most effective and safest method. Despite extensive research, no definitive consensus has been reached[2,13,14]. For example, Mondorf et al report that the number of patients undergoing craniotomy exceeds that of burr hole treatments by more than three times[13]. Sambasivan analyses 2300 cases of CSDH, with more than 2200 managed through craniotomy and only 51 treated using a burr hole drainage[15]. Lee et al compare 38 patients who underwent burr hole drainage to 13 patients treated with a different method craniotomy[16].
In our study, we observed a predominantly male patient population, with the most common presenting symptoms being headaches (77.6%), motor deficits (56%), and cognitive decline (44%). These findings align with previously published data, where motor deficits, cognitive impairment, and altered sensorium were frequently reported as leading neurological presentations in patients with chronic subdural hematoma. For instance, earlier studies have noted unilateral weakness in up to 61.9% of cases and acute confusion in 10.8%, which is comparable to the motor deficits and cognitive changes seen in our cohort.17,18 Most of our patients demonstrated a favorable postoperative outcome, with 85% achieving full functional recovery, as assessed using the modified Rankin Scale (mRS). Only 5% of patients showed no improvement. A statistically significant moderate positive correlation was found between initial Glasgow Coma Scale (GCS) scores and functional recovery (r = 0.48, P < 0.0001), supporting findings from prior literature that a higher preoperative GCS score is associated with better postoperative outcomes[11].
Postoperative complications remain a relevant concern in chronic subdural hematoma (CSDH) management. In our cohort, the recurrence rate was 3.7%. While Fig. 1 is numerically lower than recurrence rates reported in several previous studies (10–20%)[13,17] direct comparisons should be interpreted with caution. Our study is a single-arm retrospective analysis without a control group. Recurrence of CSDH has been associated with factors such as poor brain re-expansion, pneumocephalus, and tearing of fragile cortical vessels[18].
Figure 1.
Age distribution.
The incidence of pneumocephalus in our study was 7.5%, which is lower than the 11% reported in some earlier studies[19,20]. This may reflect intraoperative techniques or drain placement protocols, although variations in imaging timing and diagnostic thresholds across studies must be acknowledged as potential confounding variables.
Surgical site infections were identified in 5.2% of cases, consistent with rates reported in prior studies[21,22]. However, comparisons remain limited by variability in infection definitions and detection methods across studies. In our cohort, infections included superficial wound infections and one case of subdural empyema, diagnosed based on clinical findings and microbiological culture results. Infections in CSDH surgery may result from prolonged drain placement or colonization of the hematoma membrane, underscoring the importance of strict adherence to aseptic protocols[23].
Postoperative seizures occurred in 2.3% of our patients, a lower incidence than the 5–13% range noted in previous literature[11,13,19]. We hypothesize that early mobilization, meticulous surgical technique, and cautious drain placement may have contributed to this reduced rate. However, we recognize that other factors, such as anticonvulsant use, patient comorbidities, and hematoma characteristics, may also play a role and warrant further investigation.
The overall mortality rate in our study was 3%, aligning with reported ranges of 1.1% to 5%[17,21,24]. In our cohort, mortality was primarily attributed to medical complications and pre-existing comorbidities rather than direct neurosurgical causes. Literature suggests that mortality in CSDH is often associated with acute neurological deterioration or systemic complications.[25–28] This underscores the importance of optimizing patients’ preoperative conditions and ensuring prompt surgical management.
In conclusion, our findings support the safety and efficacy of burr-hole craniostomy with foleys catheter drainage for the management of CSDH, with relatively low recurrence and complication rates. However, the retrospective nature of our study, the absence of a control group, potential selection bias, and unmeasured confounders such as differences in postoperative care protocols limit the generalizability of our results. Future large-scale prospective studies with standardized protocols are essential to validate our findings and refine the optimal approach to CSDH management.
Limitations
This study has several limitations. First, the retrospective design restricts the ability to establish causal relationships and may introduce selection bias. Second, the data were obtained from a single tertiary care center, which may limit the generalizability of the findings to other healthcare settings or populations. Third, although the sample size was adequate for the primary analyses, it may have been underpowered to detect differences in smaller subgroups or post hoc comparisons. Fourth, while Bonferroni correction was applied to minimize the risk of type I error in multiple comparisons, it may have increased the risk of type II error, potentially masking meaningful associations.
Conclusion
Chronic subdural hematoma is a common neurosurgical entity whose potential severity belies its high curability. Burr-hole craniostomy with Foley catheter drainage is a viable alternative to conventional drainage in low- and middle-income countries, yielding favorable functional outcomes in the majority of patients. Our study reports its efficacy, wherein most patients showed clinical improvement, and a low recurrence rate was achieved. However, the retrospective nature of the study result cannot be generalized, and it indicates that meticulous surgical planning and technique are of paramount importance in yielding good results.
Although there were complications such as infection, seizures, and pneumocephalus, their frequency was consistent with previous literature. However, further prospective studies are needed to validate these findings.
While our findings support the safety and effectiveness of burr-hole craniostomy with Foley catheter drainage, further prospective multicenter comparative studies and randomized controlled trials comparing different drainage techniques are required to optimize surgical procedures and further determine how to decrease recurrence and complications. A tailored treatment approach that considers each patient’s clinical profile can enhance outcomes and reduce morbidity in the management of chronic subdural hematoma.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Contributor Information
Muhammad Sohaib Khan, Email: Muhammadsohaibkhan107@gmail.com.
Nafees Uddin, Email: Nafeesuddin0335@gmail.com.
Abdur Rahim, Email: Drabdurraheem8@gmail.com.
Adnan Khan, Email: Adnankhan-067@yahoo.com.
Ijaz Ul Haque, Email: Drijazulhaque221160@gmail.com.
Bipin Chaurasia, Email: trozexa@gmail.com.
Ethical approval
Ethical approval for this study (Lady Reading Hospital Medical Teaching Institutions) Peshawar, Ref. No. 523/LRH/MTI, Pakistan on 5 December 2024.
Consent
Written informed consent was obtained from all study participants for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Source of funding
No external funding was received to prepare this manuscript.
Author contributions
Writing the paper: M.S.K.; study concept or design, data collection, data analysis or interpretation: S.S.S., N.U., A.R., A.K., I.U.H., B.C.
Conflicts of interest disclosure
The authors declare that they have no competing interests.
Guarantor
Bipin Chaurasia.
Research registration unique identifying number (UIN)
Lady Reading Hospital Medical Teaching Institutions, Peshawar, Pakistan (Ref. No. 523/LRH/MTI).
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.