Mapping the scientific landscape of intestinal failure: forty-five years of evidence, imbalance, and emerging priorities

Abstract

Background:

Intestinal failure is a severe condition that requires complex, multidisciplinary management and long-term nutritional support. Despite its clinical relevance, no previous bibliometric analyses have mapped the global research landscape on intestinal failure, nor have they explored geographic or socioeconomic disparities in evidence production. This study aimed to characterize the evolution, distribution, and thematic focus of global research on intestinal failure.

Methods:

A scientometrics study was conducted using Scopus, Web of Science, and PubMed. Publications were included if they addressed intestinal failure as defined by the MeSH term “Intestinal Failure” (Unique ID: D00090124). Quantitative indicators were calculated using R and Python. Countries were classified by income level and geographic region according to the World Bank. Collaboration networks, keyword trends, and thematic evolution were analyzed through network and visual mapping.

Results:

A total of 3513 articles were included. Research output was dominated by high-income countries (90.2%), particularly the United States (32.4%), the United Kingdom (12.6%), and Western Europe. Latin America, Africa, and South Asia were markedly underrepresented. Thematic concentration centered on parenteral nutrition, short bowel syndrome, and intestinal transplantation, while emerging topics included catheter infections, sarcopenia, and microbiota. Temporal analyses revealed increased output and impact since 2010, peaking in 2022.

Conclusions:

Global research on intestinal failure is growing, but remains geographically and economically inequitable. This analysis reveals structural gaps in evidence generation and underscores the need to foster inclusive, context-relevant research agendas to advance scientific equity in the field of intestinal failure.

Introduction

Intestinal failure is a complex and severe condition characterized by the inability of the gastrointestinal tract to maintain adequate nutrient, fluid, and electrolyte balance, thereby requiring the use of intravenous supplementation to sustain life or growth^[1^]. This condition may result from a wide range of etiologies, including short bowel syndrome, extensive resections, mucosal disease, and severe dysmotility disorders^[2^]. While advances in parenteral nutrition and surgical interventions have improved outcomes, the clinical management of intestinal failure remains highly specialized and resource-intensive^[3^], often demanding prolonged multidisciplinary care and access to advanced healthcare infrastructure^[3^].

HIGHLIGHTS

• Global inequities in intestinal failure research.

• High-income countries dominate the evidence base.

• Lower-income regions show minimal research output.

• Parenteral nutrition remains the core research focus.

• Emerging themes: microbiota, quality of life, complications.

Despite significant technological and therapeutic progress, intestinal failure continues to be associated with considerable morbidity, healthcare costs, and mortality, especially in settings with limited access to home parenteral nutrition programs or intestinal rehabilitation units^[4^]. These challenges underscore the need for a deep understanding of the existing body of evidence, as well as a critical appraisal of the thematic directions and priorities that have shaped global research efforts in this domain^[5,6^].

Identifying which aspects of intestinal failure have been most thoroughly investigated, and conversely, which remain underexplored, is essential not only for guiding future studies but also for aligning research agendas with clinical and epidemiological needs^[7^].

To date, no comprehensive scientometrics study has systematically examined the global evolution of research on intestinal failure. More importantly, the distribution of scientific production has not been analyzed through the lens of economic development or geographic disparities. The absence of such analyses impedes the recognition of structural inequities in knowledge generation and the formulation of policies to address them^[8^].

In response to this gap, the present study conducted a scientometrics analysis aimed at characterizing the volume, evolution, and thematic focus of the scientific literature on intestinal failure, with a specific emphasis on differences across countries, world regions, and income groups. By doing so, this work offers a quantitative foundation for identifying knowledge gaps and research asymmetries in one of the most clinically challenging areas of gastrointestinal and nutritional medicine^[9–11^].

Methods

Study design

This study was designed as a scientometrics analysis conducted using a systematic search framework. Unlike traditional systematic reviews aimed at clinical evidence synthesis, this investigation focused on mapping publication patterns, collaboration structures, citation dynamics, and thematic evolution within the field of intestinal failure research^[12,13^].

Source database

A structured search was conducted across three major scientific databases: Scopus, Web of Science All Collections, and PubMed. These platforms are widely recognized as the most comprehensive and authoritative repositories of peer-reviewed scientific output, providing access to high-impact journals and the most relevant publications across diverse fields of research^[14^].

Search design

The search was conducted to retrieve all relevant publications addressing the topic of interest, using the MeSH term “Intestinal Failure” (MeSH Unique ID: D00090124). According to the MeSH database, this term is classified as a distinct descriptor without associated synonyms. To preserve construct specificity, no loosely related gastrointestinal or malabsorptive conditions were incorporated as surrogate search terms, as this would have expanded the corpus beyond the defined scientific domain of intestinal failure and introduced substantial semantic heterogeneity.

Searches were conducted across PubMed, Scopus, and Web of Science databases, using title, abstract, and keyword fields as applicable to each platform.

The analysis included documents that fulfilled the following criteria: (A) Scientific articles published in peer-reviewed journals with regular editorial processes; and (B) publications with a clear and general objective related to the analysis, discussion, investigation, or synthesis of aspects concerning the pathophysiology, etiology, epidemiology, diagnosis, management, or outcomes related to intestinal failure.

Documents were excluded if they met any of the following conditions: (1) They were conference proceedings, book chapters, book series, full books, errata, data papers, conference reviews, or retracted publications; or (2) they lacked essential bibliographic metadata such as author names, journal title, or affiliation/contact details.

Furthermore, articles written in English, Spanish, or Portuguese were considered eligible for inclusion. Publications in other languages were also included, provided they contained an abstract in at least one of these three languages and met all inclusion criteria without falling into any of the exclusion categories. No time restrictions were applied, as this was designed as a historical and longitudinal bibliometric analysis.

Data collection

The search was conducted up to 12 May 2025, applying the “journals” filter to ensure the inclusion of serial publications. Two authors (K.F.M.Q. and J.G.-B.) independently performed a manual screening of the retrieved records, eliminating duplicates and excluding those deemed irrelevant based on their titles, abstracts, or keywords. This initial selection process was carried out using Rayyan.

Subsequently, a second review was undertaken by two authors (K.F.M.Q. and J.G.-B.), who were responsible for data cleaning and the standardization of bibliographic information across the final dataset. Publications classified as “articles” were considered original research papers, while the “review” category encompassed narrative reviews, scoping reviews, systematic reviews, and meta-analyses.

Although one of the predefined inclusion criteria required that all documents undergo peer review, it is worth noting that the majority of journals indexed in the selected databases follow standardized peer-review procedures as a prerequisite for indexing. However, documents identified as “Editorials” or “Letters” do not necessarily conform to these standards, as they may have only been subject to editorial evaluation and not full peer review.

Data analysis and visualization

To explore historical trends and patterns in research output, we applied a combination of bibliometric techniques and scientific network analysis^[12,13^]. Quantitative bibliometric indicators were computed using the bibliometrix package in R (version 4.3.1)^[15^]. In parallel, descriptive variables related to study characteristics and author contributions, such as frequency distributions and percentages, were processed and visualized using R (version 4.3.1) or Matplotlib in Python (version 3.9)^[16^].

To assess scientometrics indicators, data were gathered on the journal quartile ranking and h-index corresponding to each publication, adjusted according to the year of reference. These metrics were obtained from the historical repositories of Scimago Journal & Country Rank (available from 1999) and Journal Citation Reports (available from 1997), selecting the most favorable metric available for the journal in which each article was published.

The corresponding author’s country was used as the reference for assigning each publication to its respective geographic region and income group classification. For the geographical analysis, countries were classified based on their income level, low, lower-middle, upper-middle, and high income, according to the latest World Bank categorization^[17^]. In addition, each country was assigned to one of the official World Bank regions: East Asia and the Pacific, Europe and Central Asia, Latin America and the Caribbean, the Middle East and North Africa, North America, South Asia, and Sub-Saharan Africa^[17^].

Country attribution was based on the corresponding author’s institutional affiliation, as this role generally reflects intellectual stewardship, coordination responsibility, and primary institutional accountability. This approach was selected to examine patterns of geographic leadership and agenda-setting within the field rather than collaborative participation alone.

Collaboration networks were constructed based on co-occurrence patterns among countries and institutional affiliations, allowing the visualization of international and inter-institutional research dynamics. Additionally, word clouds were generated from the most frequently used author keywords to identify thematic focus areas within the field. Temporal trend analyses were also performed to highlight the evolution of keyword usage over time. Finally, three-level Sankey diagrams were designed to illustrate the specific research trends associated with the most prolific countries, geographic regions, and income groups, providing a multidimensional view of how scientific priorities vary across different global contexts.

All parameter settings remained consistent throughout analyses. Source scripts can be made available by the corresponding author upon reasonable request.

Results

General bibliometric characteristics

A total of 3513 articles were included after applying the eligibility criteria (Fig. 1). Given that the first publication on the topic appeared in 1980^[18^], the analysis covered a 45-year period (1980–2025). The majority of the publications consisted of original research articles (68.72%; n = 2414), followed by review papers (24.45%; n = 859). On average, each publication involved six co-authors, and international collaboration was observed in 13.89% of the studies (Table 1). According to Lotka’s Law, 79% of authors contributed only a single publication, while 12% authored two publications.

Figure 1.

Flowchart of included publications.

Table 1.

Bibliometric characteristics of global research on intestinal failure (N = 3513).

	n	%
Article type
Original article	2414	68.72
Review	859	24.45
Editorial	92	2.62
Others	148	4.21
Collaboration
Articles with single authorship	334	–
Average number of co-authors per article	6	–
International co-authorship	–	13.89
Average article age (years)	9	–
Average citations per document	19.09	–
Journal quartile
Q1	1773/3273	54.2
Q2	866/3273	26.4
Q3	364/3273	11.1
Q4	270/3273	8.3
Funding
Yes	911	25.9
No	2602	74.1
Top five most prolific countries
United States	939	32.4
United Kingdom	366	12.6
Italy	175	6
France	173	6
Canada	148	5.1
Others	1094	37.9
Geographic region
East Asia and the Pacific	297	10.2
Europe and Central Asia	1344	46.4
Latin America and the Caribbean	92	3.2
Middle East and North Africa	48	1.6
North America	1087	37.5
South Asia	17	0.6
Sub-Saharan Africa	10	0.5
Income level
High-income economies	2613	90.2
Upper-middle-income economies	257	8.9
Lower-middle-income economies	25	0.9

Out of 3273 articles published in journals with assigned quartiles, 54.2% appeared in Q1 journals, followed by 26.4% in Q2, reflecting a strong presence of the field in high-impact journals (Table 1). Regarding funding, only 25.9% (n = 911) of the publications reported financial support (Table 1).

From the total corpus, 2895 documents provided complete metadata on the corresponding author’s country. The United States led the global production with 939 articles (32.4%), followed by the United Kingdom (12.6%), Italy (6%), France (6%), and Canada (5.1%). Collectively, these five countries accounted for 62.1% of the publications (Table 1).

Europe and Central Asia was the most prolific region, contributing 46.4% (n = 1344) of the articles. North America followed with 37.5% (n = 1087), and East Asia and the Pacific with 10.2% (n = 297). Other regions had substantially lower representation (Table 1).

High-income countries dominated the field, accounting for 90.2% (n = 2613) of the publications. Upper-middle-income countries contributed 8.9% (n = 257), while lower-middle-income countries were nearly absent, with only 25 articles (0.9%) (Table 1). There was no publication from any low-income country.

Evolution of scientific activity over time

In terms of scientific evolution, publication activity remained modest during the initial years following the first report in 1980. However, a gradual increase was observed over time, reaching its peak in 2022 (Fig. 2A). Compared to the first three decades, the period starting in 2010 marked a significant rise in both interest and impact, as reflected by the higher volume of citations, particularly those linked to articles published in 2018 (Fig. 2A).

Figure 2.

Annual scientific growth of global research on intestinal failure. (A) Global growth of publications and citations on intestinal failure. (B) Annual distribution of publications on intestinal failure by geographical region. (C) Annual distribution of publications on intestinal failure by country income group. (D) Annual publication trends in the top 10 most prolific countries.

It was revealed a sustained predominance of Europe and Central Asia and North America, which together accounted for nearly 84% of the publications with identifiable corresponding authorship (Europe and Central Asia: 46.4%; North America: 37.5%, n = 1087) (Fig. 2B). A clear upward trend in both regions began after 2005, with a peak in 2022. East Asia and the Pacific showed gradual growth, especially after 2010, contributing 10.2% (n = 297) of the total (Fig. 2B). In contrast, other regions such as Latin America and the Caribbean (3.2%, n = 92), the Middle East and North Africa (1.6%, n = 48), South Asia (0.6%, n = 17), and Sub-Saharan Africa (0.5%, n = 10) exhibited minimal and inconsistent contributions over the study period (Fig. 2B). The temporal peak in 2022 was followed by a visible drop in 2024–2025, likely due to indexing lags for recent publications.

An overwhelming majority of the scientific output originated from high-income economies, representing 90.2% of all documents with identifiable corresponding authorship (Fig. 2C). These countries showed continuous growth since the early 2000s, with a sharp increase after 2010 and a production peak around 2022. Upper-middle-income economies contributed 8.9% of the publications, with increased activity after 2015 and a moderate peak between 2020 and 2023 (Fig. 2C). Lower-middle-income countries never surpassed a few publications per year (Fig. 2C).

The United States consistently led research on intestinal failure, and showed accelerated growth after 2005, reaching a pronounced peak between 2020 and 2022 (Fig. 2D). The United Kingdom, Italy, France, and Canada followed as the most prolific countries, with stable contributions throughout the last two decades. China and Japan demonstrated increasing activity in recent years, but remained below the top five (Fig. 2D).

International collaboration

Regarding international collaboration networks, the University of Bologna emerged as the most prominent institution in terms of consistent and robust scientific partnerships. Other institutions also stood out for their strong global engagement, including the University of Toronto, the University of Manchester, and Harvard Medical School (Fig. 3A). At the country level, several collaborative clusters were identified; however, the United Kingdom and the United States maintained the most extensive and influential networks, primarily linked to other European nations (Fig. 3B). In contrast, countries from Latin America and the Caribbean, as well as from Africa, did not exhibit notable co-occurrence within these major collaborative hubs.

Figure 3.

Collaboration networks and the strength of international collaboration in global research on intestinal failure. (A) Institutional collaboration (affiliations). (B) Country-level collaboration.

Historical thematic trends and research hotspots

The word cloud highlights the most frequently used author keywords in the literature on intestinal failure (Fig. 4A). The terms “short bowel syndrome” and “parenteral nutrition” dominate the landscape, reflecting the core clinical focus of the field. Other prominent terms include “intestinal transplantation,” “liver disease,” “cholestasis,” and “home parenteral nutrition,” suggesting a strong research emphasis on both surgical and supportive management approaches (Fig. 4A). Concepts such as “quality of life,” “catheter infection,” “sepsis,” and “lipid emulsion” also appear frequently, pointing to a thematic concern with long-term outcomes, complications, and metabolic support in patients requiring chronic parenteral care (Fig. 4A).

Figure 4.

(A) Word cloud generated from the most frequently used keywords. (B) Most commonly studied topics prior to 2022. (C) Most frequently addressed topics between 2003 and 2013. (D) Most frequently explored topics since 2014.

During 1987 to 2022, research themes were heterogeneous and largely exploratory (Fig. 4B). Frequently cited topics included cytomegalovirus antibody, nutrition disorders, prostaglandin E1, and cyclosporine A, reflecting interest in immunosuppression, infectious complications, and nutritional challenges (Fig. 4B). Emerging terms such as acquired immunodeficiency syndrome, economic aspects, and home nursing suggest early attempts to contextualize intestinal failure within broader healthcare and socioeconomic frameworks (Fig. 4B).

Between 2003 and 2013, the field matured considerably (Fig. 4C). High-density terms included “intestinal transplantation,” “liver transplantation,” “treatment indication,” and “graft survival,” signaling the consolidation of transplantation as a central therapeutic and research axis. Concurrently, keywords such as “methodology,” “psychology,” “outcomes research,” and “quality of life” emerged, suggesting a shift toward evaluating long-term results and patient-centered outcomes (Fig. 4C). Notably, pediatric-focused terms such as “child,” “growth hormone,” and “psychosocial” began to gain visibility, indicating expanding interest in younger populations (Fig. 4C).

From 2014 to 2025, research has shifted further toward quality improvement, long-term management, and interdisciplinary outcomes (Fig. 4D). Dominant topics include “short bowel syndrome,” “parenteral nutrition,” “home parenteral nutrition,” and “quality of life,” indicating sustained focus on chronic care models. Also prominent are “catheter infection,” “cholestasis,” “complications,” and “nutritional monitoring,” reflecting attention to clinical safety and metabolic optimization (Fig. 4D). Emerging topics such as “sarcopenia,” “demographics,” and “epidemiology” point to a growing integration of public health and population-based approaches. Terms related to pediatric care and transplant outcomes remain consistently present, reinforcing the centrality of surgical and developmental perspectives in the field (Fig. 4D).

Research topics by countries, geographic region, and income level

At the regional level, Europe and Central Asia and North America account for the majority of research flows, which are primarily directed toward core topics such as parenteral nutrition, short bowel syndrome, and home parenteral nutrition (Fig. 5A). These three topics represent the most intensively studied areas across both regions. Additionally, though less frequent, topics include intestinal transplantation, catheter-related infections, pediatrics, sepsis, gut microbiota, teduglutide, and intestinal adaptation, some of which are more prominently associated with East Asian and Latin American countries, reflecting emerging thematic priorities in those regions (Fig. 5A).

Figure 5.

Topics in intestinal failure are explored according to countries, geographic regions, and income groups. (A) Three-level Sankey diagram: Countries, geographical regions, and research topics in intestinal failure. (B) Three-level Sankey diagram: Country income group, geographical region, and research topics in intestinal failure.

High-income countries concentrated their efforts on parenteral nutrition, short bowel syndrome, home parenteral nutrition, and intestinal transplantation (Fig. 5B). These topics reflect a mature research agenda focused on long-term management, advanced therapeutics, and surgical outcomes. In contrast, upper-middle-income countries showed relatively more interest in themes like pediatrics, catheter-related infections, sepsis, gut microbiota, teduglutide, and intestinal adaptation (Fig. 5B). While less prevalent in volume, these topics point toward localized clinical concerns and emerging research areas in developing contexts.

Discussion

This analysis reveals not only the progressive consolidation of intestinal failure as a specialized research domain but also the pronounced disparities that exist in the generation and dissemination of evidence across regions and income groups.

The dominance of high-income countries, particularly the United States, the United Kingdom, and several Western European nations, confirms the concentration of research capacity and resources in well-established academic and clinical ecosystems^[19^]. These countries have led investigations in core topics such as parenteral nutrition, intestinal transplantation, and long-term complications, which reflect the sophistication and technological infrastructure required to manage intestinal failure comprehensively^[20^]. In contrast, countries in Latin America, Africa, and parts of Asia remain underrepresented, contributing marginally to the body of knowledge, especially in areas that demand sustained financial and institutional investment^[21^].

The limited participation of low- and middle-income country institutions likely reflects structural constraints intrinsic to the clinical complexity of intestinal failure^[19,20^]. Chronic intestinal failure management requires established home parenteral nutrition programs, long-term catheter surveillance systems, multidisciplinary teams, and sustained biochemical monitoring capacity^[2,4^]. In many resource-constrained settings, such infrastructure remains limited or fragmented, which restricts the development of longitudinal cohorts and registry-based research initiatives^[20^].

In addition, intestinal failure research is frequently embedded within high-cost clinical platforms, including transplant centers and advanced nutritional rehabilitation units^[20^]. Large multicenter studies and international registries are typically coordinated by institutions in high-income countries, where funding mechanisms, regulatory support, and industry partnerships are more accessible^[19,20^]. Institutions in low- and middle-income countries may participate as recruiting sites but less commonly assume coordinating or senior authorship roles, reinforcing geographic leadership concentration.

Finally, the historical consolidation of intestinal failure research networks in Western Europe and North America has generated established collaboration ecosystems that may inadvertently perpetuate centralization. Entry into these networks often requires preexisting infrastructure, sustained funding, and accumulated academic capital, factors that are unevenly distributed globally^[19^]. These structural determinants should be considered when interpreting the observed geographic imbalance, as they reflect not only disparities in research productivity but also asymmetries in clinical capacity and resource allocation.

The unequal distribution of scientific production, as quantified in this analysis, exposes a structural knowledge gap: most clinical decisions and management protocols are derived from settings that may not be generalizable to resource-constrained environments^[22^]. This imbalance raises ethical and operational concerns, as it limits the global applicability of evidence-based recommendations and may perpetuate clinical inequities^[22^].

Promoting scientific equity in the field of intestinal failure demands targeted efforts to strengthen research capacity in underrepresented regions^[23^]. Upper-middle-income and lower-middle-income countries, many of which face a rising burden of gastrointestinal diseases and malnutrition, must be prioritized for research development initiatives^[24^]. This includes fostering international collaborations, improving access to funding mechanisms, and enhancing infrastructure for clinical research and data reporting^[25^]. International societies, funding agencies, and leading academic institutions have a responsibility to support these efforts through inclusive research agendas and equitable knowledge-sharing platforms^[26^].

Beyond publication counts, the geographic concentration of intestinal failure research raises questions of external validity and therapeutic equity. Most clinical guidelines and management standards in this field are derived from cohorts managed within established home parenteral nutrition programs, transplant-capable centers, and highly specialized multidisciplinary units^[3,27^]. Such infrastructure is not uniformly available across health systems. When evidence is generated predominantly in high-resource environments, its direct applicability to settings with constrained infrastructure may be limited^[22^].

In the absence of locally generated data, adaptation of care models becomes extrapolative rather than evidence-based^[2,8^]. From a global health perspective, this asymmetry extends beyond academic representation. Scientific concentration shapes research priorities, defines therapeutic benchmarks, and influences what is considered standard care^[28–30^]. Underrepresentation of low- and middle-income settings may therefore contribute to gaps in contextualized evidence, with potential downstream implications for patient outcomes and health system decision-making^[28–30^].

At the same time, the field must evolve beyond traditional themes and explore emerging dimensions of intestinal failure that are both context-sensitive and globally relevant. These include the development of cost-effective alternatives to parenteral nutrition, models of care adaptable to rural or underserved populations, and the integration of quality-of-life metrics into long-term outcomes research^[27^]. Addressing these dimensions is essential to ensure that future advances in intestinal failure are both scientifically rigorous and responsive to diverse health system contexts.

Gaps and opportunities

The complexity of intestinal failure, both in its pathophysiology and management, requires a multidimensional research approach. However, this study demonstrates that the scientific agenda has remained relatively narrow, with a persistent focus on short bowel syndrome, parenteral nutrition, and intestinal transplantation. While these topics are undeniably central, the emerging burden of intestinal failure in low-resource settings, as well as the evolving challenges in long-term survivorship, demand an expansion of the research horizon^[24^].

Several thematic gaps became evident in this analysis. First, the near absence of publications from low- and lower-middle-income countries indicates a lack of contextualized evidence that addresses the realities of care delivery where resources are limited. Second, there is a paucity of studies focusing on public health dimensions of intestinal failure, including epidemiology, health systems integration, and the social determinants of access to care. Third, research on pediatric intestinal failure, despite its growing complexity, remains largely concentrated in high-income nations, leaving unanswered questions about outcomes, growth trajectories, and neurodevelopment in children managed outside specialized centers.

Future investigations must embrace interdisciplinary perspectives, combining clinical, surgical, nutritional, epidemiological, and technological expertise to generate solutions that are both scientifically robust and globally applicable^[28–31^]. Narrowing the knowledge gap in intestinal failure will require not only more research, but more inclusive research, deliberately designed to serve those who have been historically excluded from the evidence base.

This study has some limitations. Our country-level analysis was based on corresponding-author affiliation, which may underestimate collaborative contributions from co-authors in low- and middle-income countries. While this approach captures structural leadership patterns, future studies employing fractional or full-affiliation counting methods may provide complementary insight into global collaboration dynamics and scientific inclusivity within intestinal failure research.

Conclusions

This study provides the first global scientometrics mapping of intestinal failure research, delineating how scientific production has evolved over four decades and identifying the structural contours that shape this field. Research output remains concentrated within high-income settings, where clinical infrastructure and long-standing academic networks support sustained investigation and thematic diversification. Contributions from middle-income regions, although present, remain limited in scale and influence.

Dominant research themes, including parenteral nutrition, short bowel syndrome, and intestinal transplantation, reflect the priorities of advanced clinical environments. At the same time, the growing prominence of complications, quality of life, and microbiota-related research signals an expanding conceptualization of long-term disease management.

By situating publication patterns within their geographic and economic contexts, this analysis clarifies not only where knowledge is produced, but also how global research dynamics shape the evidence base informing intestinal failure care. These findings underscore the importance of broadening participation and strengthening research ecosystems in underrepresented settings to ensure that future advances are informed by diverse clinical realities.

Ethical approval

Ethical approval was not required for this analysis because open-access secondary data were used.

Consent

Informed consent was not required for this review.

Sources of funding

None.

Author contributions

Conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, writing – review and editing: K.F.M.Q.; conceptualization, investigation, methodology, writing – original draft, writing – review and editing: J.G.B.; conceptualization, investigation, methodology, writing – original draft, writing – review and editing: K.P.R.P.; conceptualization, investigation, methodology, writing – original draft, writing – review and editing: S.K.

Conflicts of interest disclosure

All authors declare that there exist no commercial or financial relationships that could, in any way, lead to a potential conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Sulaiman Kalokoh.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Data will be shared upon request to the author of the correspondence.