Abstract
Objective
The outcome of female patients after adult cardiac surgery has been reported to be less favourable compared with the outcome of male patients. This study compares men with women with respect to patient and procedural characteristics and early mortality in a contemporary national cohort of patients who underwent aortic valve (AV) and combined aortic valve/coronary (CABG/AV) surgery.
Methods
All patients who underwent AV (n=8717, 56% male) or a combined CABG/AV surgery (n=5867, 67% male) in the Netherlands between January 2007 and December 2011 were included.
Results
In both groups, women were generally older than men (p<0.001) and presented with higher logistic EuroSCORES. In isolated AV surgery, men and women had comparable in-hospital mortality (OR 1.20, 95% CI 0.90 to 1.61; p=0.220). In concomitant CABG/AV surgery, in-hospital mortality was higher in women compared with men (OR 2.00, 95% CI 1.44 to 2.79; p<0.001). The area under the curve for logistic EuroSCORE 1 was systematically higher for men versus women in isolated AV surgery 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) and in concomitant CABG/AV surgery 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74). Finally, (the weight of) risk factors associated with in-hospital mortality differed between men and women.
Conclusions
There are substantial male-female differences in patient presentation and procedural aspects in isolated AV and concomitant CABG/AV surgery in the Netherlands. Further studies are necessary to explore the mechanisms underlying the observed differences. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.Brief title:
Keywords: carotid disease, valvular heart disease, quality and outcomes of care, valve disease surgery, cardiac risk factors and prevention.
Key questions.
What is already known about this subject?
The outcome of female patients after adult cardiac su-rgery has been reported to be less favourable compared with the outcome of male patients. Most studies addressing male-female differences have focused on coronary artery bypass graft (CABG) surgery, and little is known on outcomes in patients undergoing aortic valve (AV) surgery or concomitant CABG/AV surgery in particular.
What does this study add?
The observed male-female differences in presentation, procedural characteristics and treatment outcomes in isolated AV or concomitant CABG/AV surgery illustrate that male-female differences in cardiac surgery extend beyond isolated CABG and are also apparent in AV surgery. This study also accentuates the complexity of addressing male-female differences in cardiac surgery, as differences are apparent in presentation and treatment, and in outcome and risk stratification approaches.
How might this impact on clinical practice?
Further studies are necessary to explore the mechanisms underlying the observed differences in men and women. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.
Introduction
The overall number of female patients undergoing cardiac surgery in Europe and USA is increasing each year.1 2 The outcome of female patients after adult cardiac surgery, however, has been reported to be less favourable compared with the outcome of male patients. Especially, in-hospital mortality risk has been reported to be higher in female patients.3–11 In addition, there is an increasing awareness of the male-female differences in the timing of diagnosis in the disease process, as well as the disease presentation.12 Most studies addressing male-female differences have focused on coronary artery bypass graft (CABG) surgery, and little is known on outcomes in patients undergoing aortic valve (AV) surgery or concomitant CABG/AV surgery.3–11 13
Exploration of male-female differences in patient and procedural characteristics in adult AV and concomitant CABG/AV surgery will allow better insight in potential differences in disease presentation, surgical treatment and early survival between male and female patients, and will provide valuable information towards a more effective approach of modifiable risk factors.
The objective of the present study was, therefore, to compare adult men with women with respect to preoperative and procedural characteristics, risk factors and short-term outcome in a contemporary national Dutch cohort of patients who underwent AV or concomitant CABG/AV surgery.
Methods
Source of study data
The national database of The Netherlands Association for Cardio-Thoracic Surgery was used for this study. The prospective database contains data on all cardiac surgery procedures performed in the Netherlands since 1 January 2007. Procedures were included in the database if open heart surgery was performed in a patient of >18 years. Open heart surgery is defined by a surgical intervention to the heart with opening of the pericardium. The data set included the date and type of intervention, anonymised patient information, risk factors and outcomes. The risk factors for cardiac mortality were defined according to the EuroSCORE 1 model.14 A detailed description of the database has been published previously.15
Study population
A total of 134.039 cardiac surgery procedures were performed in the Netherlands between 1 January 2007 and 31 December 2011. Procedures were considered for inclusion if they involved patients >18 years who underwent isolated AV surgery (n=8717) or concomitant CABG/AV surgery (n=5867). Baseline characteristics of these patient groups can be found in tables 1 and 2.
Table 1.
Baseline variable patients with isolated AV surgery
| Characteristics | Total AV cohort (n=8717) n (%) |
Male (n=4888, 56%) n (%) |
Female (n=3829, 44%) n (%) |
P values |
| Age | 68.5±11.8 (18–94) | 66.2±12.0 (18–93) | 71.4±10.9 (19–94) | < 0.001 |
| Chronic lung disease | 1209 (13.9) | 707 (14.5) | 502 (13.1) | 0.074 |
| Extracardiac arteriopathy | 699 (8.0) | 443 (9.7) | 256 (6.7) | < 0.001 |
| Neurological dysfunction | 244 (2.8) | 142 (2.9) | 102 (2.7) | 0.498 |
| Prior cardiac surgery | 867 (9.9) | 603 (12.3) | 264 (6.9) | < 0.001 |
| Serum creatinine (>200 μm/L) | 149 (1.7) | 111 (2.3) | 38 (1.0) | < 0.001 |
| Active endocarditis | 354 (4.1) | 290 (5.9) | 64 (1.7) | < 0.001 |
| Critical preoperative state | 181 (2.1) | 122 (2.5) | 59 (1.5) | 0.002 |
| Unstable angina | 18 (0.2) | 15 (0.3) | 3 (0.1) | 0.020 |
| LV function | ||||
| Good | 7284 (83.6) | 3918 (80.2) | 3366 (87.9) | |
| Moderate | 1160 (13.3) | 760 (15.5) | 400 (10.4) | |
| Poor | 268 (3.1) | 207 (4.2) | 61 (1.6) | |
| Recent myocardial infarction | 108 (1.2) | 67 (1.4) | 41 (1.1) | 0.209 |
| Pulmonary hypertension | 256 (2.9) | 142 (2.9) | 114 (3.0) | 0.843 |
| Emergent surgery | 214 (2.5) | 156 (3.2) | 58 (1.5) | < 0.001 |
| Surgery on thoracic aorta | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Postinfarct septal rupture | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Prior PCI | 363 (4.2) | 231 (4.7) | 132 (3.4) | 0.002 |
| Prior CABG | 377 (4.3) | 283 (5.8) | 94 (2.5) | < 0.001 |
| Prior valve surgery | 372 (4.3) | 237 (4.8) | 135 (3.5) | 0.002 |
| Prior aorta surgery | 41 (0.5) | 237 (4.8) | 135 (3.5) | 0.197 |
| Prior other cardiac surgery | 232 (2.7) | 121 (2.5) | 111 (2.9) | 0.247 |
Significant values are depicted in bold.
AV, aortic valve; CABG, coronary artery bypass graft; LV, left ventricular; PCI, percutaneous coronary intervention.
Table 2.
Baseline variable patients with concomitant CABG/AV surgery
| Characteristics | Total CABG/AV cohort (n=5867) n (%) |
Male (n=3937, 67%) n (%) |
Female (n=1928, 33%) n (%) |
P values |
| Age | 72.8±8.2 (31–94) | 71.7±8.2 (31–93) | 75.0±7.5 (33–94) | < 0.001 |
| Chronic lung disease | 894 (15.2) | 660 (16.8) | 234 (12.1) | < 0.001 |
| Extracardiac arteriopathy | 992 (16.9) | 743 (18.9) | 249 (12.9) | < 0.001 |
| Neurological dysfunction | 181 (3.1) | 136 (3.5) | 45 (2.3) | < 0.001 |
| Prior cardiac surgery | 250 (4.3) | 186 (4.7) | 64 (3.3) | < 0.001 |
| Serum creatinine (>200 μm/L) | 132 (2.2) | 105 (2.7) | 27 (1.4) | < 0.001 |
| Active endocarditis | 48 (0.8) | 41 (1.0) | 7 (0.4) | < 0.001 |
| Critical preoperative state | 108 (1.8) | 73 (1.9) | 35 (1.8) | 0.918 |
| Unstable angina | 148 (2.5) | 95 (2.4) | 53 (2.7) | 0.440 |
| LV function | ||||
| Good | 4463 (76.1) | 2878 (73.1) | 1583 (82.1) | |
| Moderate | 1128 (19.2) | 833 (21.2) | 295 (15.3) | < 0.001 |
| Poor | 274 (4.7) | 225 (5.7) | 49 (2.5) | < 0.001 |
| Recent myocardial infarction | 368 (6.3) | 256 (6.5) | 112 (5.8) | 0.305 |
| Pulmonary hypertension | 176 (3.0) | 110 (2.8) | 65 (3.4) | 0.222 |
| Emergent surgery | 121 (2.1) | 77 (2.0) | 44 (2.3) | 0.408 |
| Surgery on thoracic aorta | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Postinfarct septal rupture | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Prior PCI | 532 (9.1) | 388 (9.9) | 144 (7.5) | 0.002 |
| Prior CABG | 172 (2.9) | 131 (3.3) | 41 (2.1) | 0.010 |
| Prior valve surgery | 60 (1.0) | 131 (3.3) | 41 (2.1) | 0.447 |
| Prior aorta surgery | 13 (0.2) | 11 (0.3) | 2 (0.1) | 0.178 |
| Prior other cardiac surgery | 137 (2.3) | 106 (2.7) | 31 (1.6) | 0.009 |
Significant values are depicted in bold.
AV, aortic valve; CABG, coronary artery bypass graft; LV, left ventricular; PCI, percutaneous coronary intervention.
Study design
This is a retrospective cohort study of prospectively collected data from all consecutive adult cardiac surgery procedures in the Netherlands. Male-female differences in adult cardiac surgery may be due to sex (the anatomy of an individual’s reproductive system, and secondary sex characteristics) or due to gender, which can refer to either social roles based on the sex of a person (gender role) or personal identification of one’s own gender based on an internal awareness (gender identity), or a combination of both. In this study we therefore employ the term male-female differences and avoid the term gender, as the database only provided us with data on sex.
EuroSCORE
The EuroSCORE 1 was calculated based on a set of predefined preoperative risk factors.14 16 The additive and logistic EuroSCORE 1 models were applied to all patients undergoing cardiac surgery.
Study outcome
The outcome of interest in the present study was differences in preoperative and procedural characteristics and in-hospital mortality between male and female patients after isolated AV surgery or concomitant CABG/AV surgery. In addition, risk factors for in-hospital mortality were explored for male and female patients separately.
Statistical analyses
Continuous data are presented as means (SD; range), and comparison was done using the unpaired t-test unless the data were not normally distributed (Kolmogorov-Smirnov test); in these instances, we used the Mann-Whitney U test for comparison. Categorical data are presented as proportions, and comparison was done using the Χ2 test or the Fisher exact test where appropriate. Binary logistic regression analysis was used in both univariable and multivariable modelling to identify independent variables associated with in-hospital mortality. The following model-building strategy was used. Univariable analysis using logistic regression was used to identify variables that were significantly associated with the outcome of interest in-hospital mortality. All independent variables with a significance level of 0.05 or less were entered in the multivariable analysis using the backward stepwise method. ORs are reported with associated 95% CIs. Correlation between variables was assessed with Pearson or Spearman correlation coefficient, whenever appropriate. In case of significant correlation, the clinically most important variable was chosen to be included in the model.
Model discrimination (statistical accuracy) of the EuroSCORE 1 was tested with the receiver operating characteristic curve.17 Model calibration (statistical precision) of the EuroSCORE 1 was determined with Hosmer-Lemeshow goodness-of-fit statistic.18 The interpretation of Hosmer-Lemeshow goodness-of-fit statistic is that well-fitted models show non-significance, indicating that model prediction is not significantly different from observed values.
All statistical tests were two sided, and a p value of 0.05 was used to establish statistical significance. All statistical analyses were performed using SPSS (V.20, IBM).
Missing values
Data completeness for the perioperative data in The Netherlands Association for Cardio-Thoracic Surgery database is exceptionally high. For approximately 99% of the cases included in the database the data were complete. However, there were some variables with regard to patients’ history which had more missing data. Therefore, multiple imputation method was used to account for missing values in the present study. Five multiple imputation data sets were created for each subgroup using SPSS software. The imputation model included all baseline variables available. The multiple imputation data sets were used for binary logistic regression analysis in order to identify independent variables associated with in-hospital mortality.
Results
Preoperative and procedural characteristics
AV surgery
Of the total 8717 AV surgeries (98.8% replacement, 1.2% reconstruction), 56% were male and 44% were female. Female patients were generally older (mean age, 71 vs 66 years, p<0.001). Perioperative patient characteristics are shown in.().(table 1 and 3)
Table 3.
Procedural variable patients with isolated AV surgery
| Characteristics | Total AV cohort (n=8717) n (%) |
Male (n=4888, 56%) n (%) |
Female (n=3829, 44%) n (%) |
P values |
| Type of procedure | <0.001 | |||
| Repair | 105 (1.2) | 77 (1.6) | 28 (0.7) | |
| Replacement | 8612 (98.8) | 4811 (98.4) | 3801 (99.3) | |
| Type of implant | ||||
| Bioprosthesis unstented | 399 (4.6) | 166 (3.4) | 233 (6.1) | < 0.001 |
| Bioprosthesis stented | 5485 (62.9) | 2855 (58.4) | 2630 (68.7) | < 0.001 |
| Mechanical | 2718 (31.2) | 1785 (36.5) | 933 (24.4) | < 0.001 |
| Homograft | 10 (0.1) | 5 (0.1) | 5 (0.1) | < 0.001 |
| EuroSCORE | ||||
| Additive EuroSCORE | 6.2±2.7 (0–23) | 5.7±2.9 (0–23) | 6.9±2.4 (1–22) | < 0.001 |
| Logistic EuroSCORE | 7.8±8.8 (1–95) | 7.1±9.2 (1–95) | 8.7±8.3 (1–92) | < 0.001 |
| Outcome | ||||
| Hospital mortality | 184 (2.1) | 95 (1.9) | 89 (2.3) | 0.220 |
Significant values are depicted in bold.
AV, aortic valve.
online supplementary tables 1 and 2 display univariable and multivariable analyses of factors associated with increased hospital mortality.
openhrt-2018-000868supp001.docx (24.7KB, docx)
CABG/AV surgery
Of the 5867 patients who underwent AV surgery with concomitant CABG (99.1% concerned replacements and 0.9% reconstructions), 67% were male and 33% were female. Female patients were generally older (mean age, 75 vs 72 years, p<0.001). Perioperative patient characteristics are shown in.()(table 2 and 4).
Table 4.
Procedural variable patients with concomitant CABG/AV surgery
| Characteristics | Total CABG/AV cohort (n=5867) n (%) |
Male (n=3937) n (%) |
Female (n=1928) n (%) |
P values |
| Type of procedure | 0.168 | |||
| Repair | 50 (0.9) | 29 (0.7) | 21 (1.1) | |
| Replacement | 5815 (99.1) | 3908 (99.3) | 1907 (98.9) | |
| Type of implant | < 0.001 | |||
| Bioprosthesis unstented | 259 (4.4) | 157 (4.0) | 100 (5.2) | |
| Bioprosthesis stented | 4465 (76.1) | 2896 (73.6) | 1568 (81.3) | |
| Bioprosthesis unknown | 1093 (18.6) | 0 (0.0) | 1 (0.1) | |
| Mechanical | 238 (4.1) | 853 (21.7) | 238 (12.3) | |
| Homograft | 2 (0.03) | 2 (0.1) | 0 (0.0) | |
| Autograft | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Type of graft | ||||
| Total arterial graft | 1456 (24.8) | 902 (22.9) | 554 (28.7) | < 0.001 |
| Total venous graft | 1613 (27.5) | 1035 (26.3) | 578 (30.0) | < 0.001 |
| Utilisation of both arterial and venous graft | 2794 (47.6) | 1999 (50.8) | 795 (41.2) | < 0.001 |
| EuroSCORE | ||||
| Additive EuroSCORE | 6.9±2.6 (0–20) | 6.5±2.6 (0–20) | 7.8±2.3 (3–20) | < 0.001 |
| Logistic EuroSCORE | 9.0±8.9 (1–87) | 8.2±8.9 (1–85) | 10.5±8.6 (2–87) | < 0.001 |
| Outcome | ||||
| Hospital mortality | 134 (3.4) | 105 (5.4) | 239 (4.1) | < 0.001 |
Significant values are depicted in bold.
AV, aortic valve; CABG, coronary artery bypass graft.
Online supplementary tables 3 and 4 display univariable and multivariable analyses of factors associated with increased hospital mortality.
In-hospital mortality, EuroSCORE performance and separate male-female risk factor analyses
AV surgery
In-hospital mortality was 2.1% (n=184). Female patients had comparable in-hospital mortality with male patients (OR 1.20, 95% CI 0.90 to 1.61; p=0.220) as displayed in table 3.
In men, the area under the curve (AUC) for the logistic EuroSCORE 1 was 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) in women. The calibration of the logistic EuroSCORE 1 model resulted in p values of 0.002 and 0.0033 for men and women, respectively.
Univariate logistic regression analyses revealed several patient and procedure-related characteristics which were correlated with higher in-hospital mortality (online supplementary table 1). Multivariable logistic regression analysis showed that female patients were not associated with substantially higher risk of in-hospital mortality as compared with male patients. Online supplementary table 2 provides an overview of factors found to be associated with the outcome of male and female patients.
CABG/AV surgery
In-hospital mortality was 4.1% (n=239) and higher in female compared with male patients (OR 2.00, 95% CI 1.44 to 2.79; p<0.001) as displayed in table 4.
In men, the AUC for the logistic EuroSCORE 1 was 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74) in women. The calibration of the logistic EuroSCORE 1 model resulted in p values of <0.001 and 0.09 for men and women, respectively.
Univariate logistic regression analyses revealed several patient and procedure-related characteristics which were correlated with higher in-hospital mortality (online supplementary table 3). Multivariable logistic regression analysis showed that female patients were still associated with substantially higher risk of in-hospital mortality as compared with male patients (2.00, 95% CI 1.44 to 179; p<0.001).
Online supplementary table 4 summarises the risk factors that were found to be associated with the outcome of male and female patients.
Discussion
The observed male-female differences in presentation, procedural characteristics and treatment outcomes in isolated AV or concomitant CABG/AV surgery illustrate that male-female differences in cardiac surgery extend beyond isolated CABG and are also apparent in AV surgery. This study also accentuates the complexity of addressing male-female differences in cardiac surgery, as differences are apparent in presentation and treatment, and in outcome and risk stratification approaches.
In this discussion, we will address key findings for the two surgical treatments separately, the limitations of standard risk models and potential further studies that may help optimise cardiac surgery treatment for both men and women.
AV surgery
Our analysis showed that in-hospital mortality for AV surgery was comparable between male and female patients. The AUC for the logistic EuroSCORE 1 was larger in men than in women, indicating that this model is a better predictor of outcome for men. Our findings confirm the results of earlier studies where no male-female differences in mortality outcome and non-cardiac morbidity were found.19–23 In contrast, Andrei et al 24 found that women with bicuspid AVs undergoing AV surgery were at a higher risk of in-hospital mortality. Short-term (30 days) and long-term mortality, however, appeared to be similar.
CABG/AV surgery
For concomitant CABG/AV surgery, in-hospital morality was significantly higher in women than in men in the present study. Again, the AUC for the logistic EuroSCORE 1 was larger in men than in women, indicating that this model is a better predictor of outcome for men. Doenst et al 25 reported a higher perioperative risk profile in women undergoing concomitant valve and CABG surgery and found the following risk factors to be associated with higher perioperative mortality in women: hypertension, diabetes mellitus, congestive heart failure, atrium fibrillation and stroke. None of these factors appeared to show a significant association with higher female in-hospital mortality in our study. Similar to our findings, Flameng et al 26 reported female sex, in addition to patient age, to be an independent preoperative risk factor of early mortality in concomitant valve and CABG surgery. This observation was not found by Saxena et al.27 The authors report a mean age of 76 in women in their cohort and argue that their results may reflect the impact of advanced age in reducing male-female bias.
Interestingly, in line with the current literature,24 25 27–29 we also found female patients to be older in both surgical groups, which might explain why in both groups, women received significantly less often a mechanical valve and more often stented and stentless bioprosthesis as compared with men. This age difference in male versus female patients could also fuel speculations concerning later presentation of female patients in the disease process or even higher levels of frailty at time of presentation, potentially explaining the worse outcomes in female patients after CABG/AV surgery.
Based on our results, we could additionally speculate whether the observed differences in male-female outcomes after CABG/AV surgery are due to other possible risk factors not included in the current study, including genetic or hormonal risk factors specific for women. These potential risk factors form a separate challenge altogether given the complexity of the potential underlying mechanisms. Therefore, future studies in these domains are warranted to unravel other potential female-specific risk factors after cardiac surgery.
EuroSCORE
Although EuroSCORE 1 is one of the most widely used cardiac surgical risk models, several studies have shown during the last decade that it overpredicts patient mortality and is no longer appropriately calibrated. In our study for both groups, the performance of the EuroSCORE 1 in men and women, both in terms of accuracy and calibration, is suboptimal. In addition, the accuracy of the model was inferior in female patients in both subgroups. This observation might be explained by the fact that 72% of the original EuroSCORE population was male. Although EuroSCORE 1 includes woman versus man as a separate risk factor, it has been shown that a female-specific weighing of the other 16 risk factors that are included in EuroSCORE 1 is needed for adequate prediction of outcome in female patients.30
Gender-specific risk prediction models
In our patient population there were only a few risk factors, which are included in EuroSCORE 1, predictive of short-term mortality in both male and female patients. In this regard, male and female-specific risk prediction models are needed for patients undergoing cardiac surgery. More recently, the new EuroSCORE 2 has been developed.14 Although improvements have been made with this updated model, the risk score was again built using a mixed population of male and female patients who underwent predominantly CABG surgery. Future studies need to clarify whether the performance of this updated model is also adequate in female patients.
The observed differences in (the weight of) risk factors between men and women in the predictive in-hospital mortality models that we constructed for men and women separately underline the need for further refinement of current prediction models in cardiac surgery. Probably, the best approach will be to develop, next to generic models such as EuroSCORE 2 that are mainly useful for benchmarking purposes, separate risk models for men and women in order to improve predictive ability for both sexes, but also to further stimulate research into the causes of the observed differences between men and women, be it sex, gender or a combination of the two.
Future recommendations
Further studies need to focus on exploration of the underlying mechanisms of the observed male-female differences in presentation, procedure and early mortality in order to optimise treatment for both male and female AV and combined CABG/AV surgery.
Given the significantly worse outcome in women compared with men for combined CABG/AV surgery, underlying factors contributing to worse disease outcome should be further investigated. Especially interesting are the effect of possible referral bias, atypical female presentation and/or differences in procedural characteristics for women on female outcomes as compared with men.
Finally, given the literature, there seems to be an age effect in the observed male-female differences, further studies zooming in on the intersection of age and male-female differences, especially the treatment of younger female patients, are warranted.
Strengths and limitations
The main strength of this study is that we were able to use a large contemporary national database with high-quality information (99% completeness) about all cardiac surgical interventions from all hospitals in the Netherlands. The major limitation of the current study, inherent to the type of database used, is the absence of detailed information regarding the disease aetiology, the absence of information on survival beyond hospital stay.
Footnotes
Contributors: MMM and JJMT were involved in the conception of the work. MMM was involved in data collection. MMM, SST and JJMT were involved in data analysis and interpretation. MMM and SST were involved in drafting the article. All authors were involved in critical revision of the article as well as in final approval of the version to be published.
Funding: This work was supported by a NWO Veni grant of the Netherlands Organisation for Scientific Research [NWO grant number 916.160.87] to [MM].
Competing interests: This research was conducted on behalf of the data registry committee of the Netherlands
Association for Cardio-Thoracic Surgery.
Patient consent: Not required.
Provenance and peer review: Not commissioned; externally peer reviewed.
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