Climate change and environmental sustainability in emergency medicine: a narrative review

Introduction

Climate change is one of the foremost global challenges of the 21st century, encompassing rising temperatures, changing precipitation and dust patterns, and an escalating frequency of extreme weather events such as heatwaves, storms, and floods (1). These environmental shifts pose direct and indirect threats to human health, ranging from heat-related illnesses, acute respiratory exacerbations, and vector-borne diseases, to the psychological distress and infrastructural damage caused by natural disasters (2). Increased exposure to heat has also been associated with spikes in emergency department (ED) visits, reflecting both the acute and chronic burdens that climate change places on healthcare systems (1,3-5).

Paradoxically, the healthcare sector also contributes substantially to global warming and climate change. High energy consumption for lighting, heating, and cooling systems, together with the use of single-use medical items and pharmaceuticals, yield significant greenhouse gas emissions and extensive waste production (6-8). According to estimates, if healthcare were regarded as its own country, it would rank among the top global emitters of greenhouse gases (9). Hence, sustainability in healthcare has become an urgent priority, underscoring the tension between the sector’s mission to protect health and reducing its environmental footprint (10). This is especially relevant to emergency medicine as EDs typically operate round the clock, use energy-intensive diagnostic modalities such as computed tomography (CT), and rely on disposable equipment for rapid turnover and infection control (11). Though essential for acute patient care, these practices can create considerable ecological strain, leading to calls for integrated sustainability frameworks (12).

Recurrent climate-related disasters, including typhoons, floods, and prolonged heatwaves, can overburden EDs with surge capacity needs and demands for backup power and additional medical supplies (1,13). Incidences of cardiac arrests, strokes and sepsis could also increase due to global warming, as demonstrated in various regions such as China’s mainland, Taiwan and Bangladesh (14-17). Increased ED utilization during heatwaves has been associated with higher healthcare expenditures, straining already limited resources (4,18). Studies of climate-sensitive events have shown that hospital costs attributable to extreme heat and associated conditions can be substantial (19,20). In addition, flooding and other environmental catastrophes often disrupt medical supply chains, heightening the need for robust and resilient ED infrastructure (21,22). These factors reinforce the importance of integrating sustainability in emergency medicine, not solely to mitigate carbon emissions, but also to build healthcare systems that remain operational and effective during climate disasters (11,23). Emerging literature underscores the need for health professionals to act as leaders in both climate adaptation and mitigation. In this vein, the roles of clinicians and administrators extend beyond patient care to encompass environmental stewardship and policy advocacy (12,24).

Considering these converging imperatives, this narrative review aims to synthesize the current state of sustainability in medicine, examining how climate change may affect ED operations, and to suggest strategies to reduce environmental impact. We present this article in accordance with the Narrative Review reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-25-57/rc).

Methods

We performed a literature search of published studies on healthcare environmental sustainability and climate change in PubMed, Embase, Google Scholar and Scopus databases using the following search terms: (“climate change” OR “global warming” OR “heatwave” OR “heat wave” OR “greenhouse effect”) AND (“emergency department” OR “emergency medicine” OR “emergency, hospital services”), (“sustainability in healthcare” OR “environmental footprint” OR “carbon footprint” OR “carbon emission” OR “greenhouse gas” OR “energy us*” OR “waste”) AND (“health care system” OR “health system” OR “health care” OR “healthcare” OR “health sector”). Study team members conducted independent searches of articles and evaluated the eligibility of included studies based on the selection criteria. Any discrepancy between two members was resolved by a third independent co-investigator to ensure a consensus was reached for inclusion and eligibility. Our inclusion criteria were studies that were relevant to environmental sustainability, climate change and emergency medicine (such as procedures or resources relevant to EDs). All English language and peer-reviewed articles that were published from 1 January 2015 to 31 October 2024 were eligible for inclusion.

In addition, references of narrative reviews, scoping reviews, systematic reviews and meta-analyses were searched to include the original articles. Articles that were not published in English, studies that included only animals, conference proceedings, editorials, letters to editors and abstracts were excluded. The search strategy is summarized in Table 1. Due to the substantial variability in designs and non-quantitative nature of current studies on sustainability in healthcare, existing evidence in this review is narratively described.

Discussion

Effects of climate change on disease patterns and ED attendances

Climate change brings about extreme weather events that pose direct and indirect health threats. Extreme weather events, both cold and hot spells, following climate change increases respiratory-related ED presentations (25). Cold spells, thunderstorms, and blizzards can cause high winds and heavy rain, increasing the pollen and spore particles in the air that tend to aggravate inflammatory airway diseases (26). Apart from a rise in ED attendances by as much as 25% (26), patients who developed lower respiratory tract diseases also saw significant increase in morbidity during periods of cold spells (25). On the other extreme, periods of heatwaves can lead to more wildfires and bushfires, triggering asthma presentations to the EDs (27,28). Air quality readings of particulate matter strongly correlates with various respiratory-related ED presentations, including chronic obstructive pulmonary diseases (COPD) and bronchitis (28-31). Asthmatic patients exposed to higher levels of the air pollutants are at higher risk of developing asthma-COPD overlap syndrome as a long-term side effect resulting in higher rates of exacerbations and more frequent ED visits (32). Prolonged wildfire smoke exposure causing poor air quality resulted in higher incidence of pneumonia-related ED presentations (29).

Globally, stroke and ischemic heart disease were found to be the top two non-communicable causes of death (33). Besides metabolic risk factors, environmental risk factors such as surge in ambient particulate matter and household air pollution contributed significantly to stroke-related disability-adjusted life years (DALY) (34). By 2065, climate change projections estimated significant increases in temperature-related stroke risk and corresponding stroke-related ED visits (15). Ischemic stroke incidence rates in particular will rise a projected 7.8% under global warming levels (GWL) of 2 ℃ to 36% under GWL of 4 ℃. Additionally, increases in short-term temperature variability following climate change increases cardiovascular workload via thermoregulation impairment and autonomic cardiac dysfunction, contributing to increased ED visits for congestive cardiac failure, myocardial infarction, dysrhythmia and other associated cardiovascular diseases (35).

Escalation in ambient temperature and periods of heat waves are contributing risk factors to acute kidney injury, primarily from pre-renal azotemia (36). Occupational heat strains with increased core temperature, kidney disease and change in urine specific gravity are 4 times more prevalent among workers in extreme heat conditions (37). Other genitourinary system diseases, such as renal colic, were also found to have increased hospital admissions via the ED in periods of warmer climate in South Korea (38). These findings were also observed in other geographical regions experiencing periods of extreme heat exposure, such as America (39) and South Australia (40).

Extreme changes in weather conditions can potentially impact the transmission of infectious disease via numerous pathways through the pathogens, vectors and transmission routes. In increasingly warmer climates and higher humidity regions, vector-borne diseases like dengue and zika virus can shorten their reproduction cycles, in turn leading to increased disease transmission (41). Periods of heavy rains are associated with malarial outbreaks, while droughts with water pools accumulated with rotten organic materials may increase the concentration of water-borne pathogens such as Vibrio cholerae triggering cholera outbreaks (41). Meanwhile, regions of heavy winds and dust storms tend to propagate airborne viruses like influenza from endemic regions to others, causing outbreaks in surrounding geographical regions (17), taking a toll on healthcare resources.

The World Health Organization has identified 970 million people globally living with mental disorders and their vulnerability and need for accessibility to mental health care. Coupled with the equally pressing issue of climate change, there has been greater attention to the effects of global warming and extreme weather events on mental health. A systematic review found associations between heat exposures and a range of mental-health related outcomes; increases in temperature was associated with significant mood disorders, organic mental disorders, schizophrenia and anxiety disorders (42). Warmer temperatures were associated with higher rates of ED attendances for substance use disorders, anxiety related disorders, mood disorders, schizophrenia related disorders and self-harm (43). There is also increased usage of psychotropic drugs such as antidepressants, antipsychotics and mood stabilizers (5), identified amongst adults presenting to the ED during periods of heatwaves. The effects of climate change on mental health are not only prevalent amongst adults but in the pediatric population as well; Niu et al. identified higher risks of mental health-related ED encounters amongst children, particularly affecting those aged 6 to 11 years old. These children, adolescents and young adults present with reaction disorders, anxiety and bipolar disorders, and psychosis, respectively (44). Periods of heatwaves, drought or compound events involving the two were also associated with increased risks of ED visits for suicide and mood disorders amongst children (45). Associations between air pollution and mental health related ED attendances have been identified as well (46,47).

While climate change influences the disease patterns described above, the most affected groups are the vulnerable populations, particularly the elderly, children and the homeless. Older adults are generally more susceptible to extreme heat waves with the natural impairment of the body’s thermoregulatory mechanism and inability to maintain temperature homeostasis (48); heat wave periods across the United States saw increases in ED visits with those above 65 years of age being at greatest risk (49) for various conditions such as fluid and electrolyte imbalances, renal diseases, asthma exacerbations or intestinal infections (50). Moreover, the elderly have pre-existing comorbidities that increase their risk of ED attendances and heat related illnesses (5). They are also more susceptible to the effects of ambient air pollution (51), development of acute kidney injury (38) and stroke (35) during periods of heatwaves. Extreme weather events put children at higher risk of developing allergic respiratory disease exacerbations and respiratory infections. Air pollution and aeroallergens alter pollen production and prolong pollen seasons, increasing susceptibility to children developing allergic rhinitis and asthma exacerbations requiring ED visits (52). Every 1 ℃ in temperature variation could increase the risk of pediatric pneumonia by 6% (53). ED visits for electrolyte disorders and dehydration were almost doubled; and more bacterial infections such as enteritis and ear infections were also described (54). Apart from extremes of age, socially vulnerable individuals like the homeless are also at higher exposure risk to weather elements and may be more susceptible to injuries like pavement burns (55) with rising ambient temperatures.

The increase in natural disasters such as tropical cyclones, severe storms and floods have resulted in physical injuries and were associated with higher rates of ED utilization up to weeks following the disaster (56). This puts additional strain on ED services and resources, leading to extra costs, capacity constraints and additional stress on manpower. The estimated costs of excess ED visits are expected to increase 185% by the year 2030, and 1,854% by the year 2060 (57). Additionally, the length of stay of patients within the ED would be longer as well (58), further increasing healthcare costs. Natural disasters can also potentially affect ED efficiency by causing damage to infrastructure and jeopardizing ED operations both directly and indirectly; reduced manpower, affected disposition processes and transfer capabilities, and having less resources following damage (59). Additionally, with scarcity of resources and migration from climate change, it is possible that international conflicts may be more frequent (60), thus contributing to physical injuries and infrastructural destruction.

Given its role as the frontliners of health services, EDs play pivotal roles in leading the healthcare system towards adopting more sustainable practices to build a more resilient ED both structurally and operationally to address the rising healthcare costs and meet the demands and needs of the population in the face of climate change. A summary of the effects of climate change on the ED is illustrated in Figure 1.

Figure 1 Summary of the effects of climate change on the ED. ED, emergency department.

Wastage and environmental effect

The healthcare industry is a considerable source of global greenhouse gas (GHG) emissions. Accounting for 4% to 5% of total global emissions (61), the carbon footprint of various healthcare sectors in the Asia Pacific have been estimated, ranging from 35,772 kilotons to 315 megatons of carbon dioxide equivalent (CO₂e) emission (62-64). Given its significant negative impact on the environment, this highlights the need for far reaching global sustainability initiatives.

Single-use disposable items contribute significantly to wastage and healthcare costs. Practice Greenhealth, an organization that promotes sustainable healthcare solutions has reported that hospitals generate more than 29 pounds of waste per bed per day (65). In high-acuity settings like the ED, where preparedness and expeditiousness are valued, the overpreparation of disposable items used during emergencies can result in significant wastage. Surgical supplies like sponges, gloves, disposable towels and surgical sutures are also frequently wasted and can amount to more than 10% of the total surgical supply cost (66).

Medical therapeutic devices are a major contributor to environmental pollution. Pressurized metered dose inhalers (pMDI) are a considerable source of carbon emissions due to the high global warming potential (GWP) of the hydrofluorocarbon propellants (67). Given its impact on the environment, there has been a global push to utilize alternative inhaler devices that are clinically efficacious and reduce GHG emissions. In a study comparing budesonide/formoterol dry powder inhaler (DPI) versus as required salbutamol pMDI with maintenance budesonide DPI, budesonide/formoterol demonstrated a 95.8% and 93.6% reduction in carbon footprint per person relative to the latter (68).

Electricity consumption is a significant contributor to GHG emissions within the ED itself, driven by its round-the-clock operations and usage of energy-intensive diagnostic modalities like CT scans. In studies done in similar settings such as the operating theater and diagnostic imaging department, electricity for heating, ventilation, air-conditioning and lighting accounted for three-quarters of the carbon footprint (69). CT scanners alone generated 9.2 kg CO₂e for each scan, as compared to chest X-rays which emits 0.53 kg CO₂e (70). Additionally, a significant amount of energy is utilized by the machines left on standby compared to when the machines were switched off. In the ED setting where machines are required to remain constantly operational for emergency use, this creates a significant impact on the hospital and department’s carbon footprint.

Perspectives of patients and healthcare providers

Most healthcare professionals recognize that climate change is real (71-73) and largely driven by human-related emissions (73). Many also acknowledge healthcare waste as a critical issue and agree that healthcare professionals have a responsibility to conserve resources within their practice (74-78). However, despite this recognition (79), there is substantial variation across healthcare centers in the number of professionals actively taking steps to make their practices more sustainable (71,80). Some of the key challenges frequently cited by healthcare professionals regarding environmental sustainability include a lack of awareness and knowledge, lack of prioritization, time constraints (77,81), and lack of resources (72).

Healthcare professionals express motivation and interest in engaging with environmental sustainability, but often lack the awareness and knowledge (82-84) on how to implement sustainable practices (77,82). Some may feel disempowered when trying to address sustainability at work (77). Change must occur at multiple levels to successfully integrate environmental sustainability (82). Governments, healthcare providers, and other stakeholders need to collaborate to promote sustainable healthcare practices (78) and increase awareness (85).

Healthcare professionals also view themselves as key figures in raising awareness among patients about environmental sustainability (72,74,76,78). However, André et al. found that barriers that prevent healthcare professionals from engaging patients in climate change discussions include shortage of time, lack of clinical recommendations, and insufficient knowledge (76). Similarly, patients have expressed willingness to opt for climate-friendly treatments, and knowledge of the environmental impact of treatments has been shown to influence behavior (79,86). Although many patients have a solid understanding of climate change, many do not fully understand how it relates to healthcare (86). Cost and climate impact are often considered less important than the effectiveness and side effects of a therapy (79). There is also a tendency to stick to habitual practices. For instance, despite total intravenous anesthesia having a significantly lower carbon footprint than inhalational anesthesia, it remains less commonly used due to anesthesiologists’ familiarity with traditional methods (80,87).

Healthcare professionals face the challenge of competing priorities. Many consider environmental sustainability as “important” but not “urgent” (85), practicing it only when possible (82). Environmental care is perceived as secondary to patient safety, which remains the top priority when making decisions regarding environmental sustainability (80,87). Many healthcare professionals perceive environmental sustainability as financially burdensome (72), making it something only the privileged can afford (82). Therefore, it is crucial to identify ways to promote sustainability while also maximizing cost savings (77). Challenges in hospital include institutional resistance due to financial limitations, concerns about rules, regulations, and infection control (84). Current challenges faced by healthcare workers and patients are summarized in Figure 2.

Figure 2 Challenges faced by patients and healthcare providers.

Interventions and future directions

The significance of environmental sustainability has garnered increasing attention in academic literature in recent years. Notably, a comprehensive systematic review by Braithwaite et al. evaluated 205 studies examining the efforts of healthcare services to limit GHG emissions (88). Extensive review of the literature reveals a lack of specific interventions in EDs aimed at GHG reduction and environmental sustainability. This gap underscores the imperativeness for emergency physicians to recognize and act upon the climate crisis confronting us. We have delineated several key actions that we believe are essential in addressing sustainable healthcare within ED. Our proposed interventions can commence at the individual level, although systematic changes are equally crucial for a robust response to the climate crisis.

To tackle this urgent issue, we introduce the SCRAP framework—an acronym representing (I) Stewardship of resources; (II) Carbon footprint reduction; (III) Research; (IV) Advocacy for change; and (V) Policies and education (Figure 3). We also summarized some practical steps that can be undertaken at the individual and departmental level based on this framework (Table 2).

Figure 3 Future directions—SCRAP. SCRAP, an acronym representing Stewardship of resources, Carbon footprint reduction, Research, Advocacy for change, and Policies and education.

Stewardship of resources

As emergency physicians, we serve as stewards of resources—including investigations, medications, and patient disposition. Our decisions to initiate admissions or specific investigations significantly contribute to healthcare emissions. Low-value or harmful interventions contribute up to 40% of the carbon footprint associated with clinical care (89). Importantly, up to 90% of healthcare emissions are indirect, arising from global supply chains, as well as the manufacturing and distribution of healthcare products and services (63).

Minimizing low-value wasteful practices is a critical step that all physicians can undertake to reduce greenhouse gas emissions. Initiated in 2012, the Choose Wisely campaign aims to curtail low-value investigations and wasteful interventions. Various emergency medical organizations, including the American College of Emergency Physicians and the Royal College of Emergency Medicine, have published recommendations on commonly overused investigations. A pertinent example is the overreliance on CT scans; this increased utilization inevitably leads to incidental findings, which prompt further investigations—contributing not only to financial costs but also to travel emissions associated with additional clinic visits or hospital admissions. The additional tests further contribute to GHG emission.

Carbon footprint reduction

Approximately 70% of healthcare emissions are attributable to the supply chain involving the production, provision, and disposal of pharmaceuticals and medical devices (90). Procuring domestically or regionally produced products can significantly reduce emissions associated with transportation.

In addition to avoiding unnecessary interventions, emergency physicians can actively reduce our carbon footprint by opting for reusable medical instruments (91). Of relevance to ED, practices such as utilization of reusable laryngeal mask airways (LMAs), increasing number of LMAs autoclaved in a single cycle, using reusable drug trays, sharps containers and laryngoscopes can reduce GHG emissions effectively (9,92-95). The usage of reusable isolation gowns can also reduce energy consumption by 28%, GWP by 30% along with a 93–99% reduction of solid waste generation (96).

Reducing carbon emissions through recycling packaging is an easily achievable approach, especially in medical practices where individual packaging is prevalent. Implementing a recycling program for uncontaminated packaging can significantly lower waste and incineration rates. In addition, the utilization of renewable sources of electricity, installation of energy-efficient lighting, heating and air-conditioning will aid in minimizing electricity use and reducing ED’s carbon footprint. The 24-hour utilization of high-energy requiring imaging modalities can be mitigated by reducing the number of operational machines during low-demand periods like weekends, public holidays or late at night.

In the post-COVID-19 era, a shift towards telemedicine has been shown to reduce fossil fuel consumption and traffic-related emissions by up to 6,655 tons of CO₂e from decreasing transportation to clinics (97,98). Similarly, by opting for digital medical reports instead of printed copies, CO₂e emissions can be further diminished (97).

Research

Effectively addressing waste and GHG emissions in the ED necessitates quantifying the problem and evaluating the impact of mitigation efforts. There is a notable deficiency in research and audits focusing on environmental sustainability within the ED. A comprehensive carbon footprint analysis of ED practices is essential, with a potential starting point being the evaluation of the carbon footprint per patient treated in the ED. This could reveal hotspots in processes with the greatest environmental impact. Further research is required to develop sophisticated yet user-friendly methods for quantifying carbon footprint, and to foster innovation for low-carbon solutions that can be validated for safety and efficacy.

Advocacy

The World Health Organization has proposed that assembling a multisectoral team is the first step toward enhancing climate resilience and sustainability in healthcare facilities (99). Establishing a “Green Team” dedicated to advocating environmental sustainability in the ED is crucial for the successful implementation of these interventions. This team should comprise various stakeholders, including staff in senior management positions. Much like patient safety committees, the “Green Team” must establish baselines, outline short-term and long-term goals, and monitor the department’s performance in sustainable practices. These environmental champions should be responsible for educating and training other departmental members to raise awareness and implement carbon-reducing protocols.

To drive sustainable decarbonization, supportive system incentives are crucial. Regulatory mechanisms, such as hospital accreditation, financial incentives, health insurance reimbursements, and taxes, can propel innovative strategies. Simultaneously, community engagement must be prioritized to ensure that interventions reflect local needs and advance sustainability in a socially inclusive manner. Partnering with sustainability offices in local health care departments and academic institutions can also allow corroboration and continuity of practices.

Policies and education

While the aforementioned initiatives hinge on behavioral changes among individual clinicians, decarbonizing the ED requires a multifaceted approach, including robust policies to prioritize environmentally sustainable practices and systemic changes. The Healthcare Professional Boards of Singapore recently published their inaugural sustainability disclosure for the financial year 2023, articulating a commitment to sustainability goals with an aim to optimize energy and water usage, minimize waste and achieving net-zero emissions (100). This reflects a growing recognition that environmental sustainability is essential for resilience in the future, even in a small island city-state like Singapore.

While national-level policies that include the adoption of energy-efficient appliances and promotion of recycling practices can result in reduction in carbon emissions, given that the majority of healthcare carbon footprint arise from supply chain emissions, further national policies are needed to mitigate these environmental impacts. For example, mandating that companies producing or importing medical supplies disclose their carbon footprint, thus enabling EDs to make environmentally conscious procurement decisions. Additionally, incentivizing evidence-based and guideline-based practices while disincentivizing low-value care at the system level can provide a direct means to accelerate GHG reductions in the ED.

To foster awareness of the climate crisis, educational initiatives can begin in medical schools in the form of journal clubs, team-based learning and core rotations (101). Concepts such as environmental sustainability, carbon accounting, and the avoidance of wasteful practices should be integrated into early medical education. Regular case-based discussions, similar to morbidity and mortality rounds, can focus on unnecessary testing or treatments, ultimately enhancing awareness of value in healthcare and minimizing waste. As part of the emergency medicine residency program curriculum, trainees may be required to complete environmentally related quality improvement projects. These initiatives serve to create a green culture in a bottom-up approach.

Limitations and future research

A significant barrier to implementing environmentally sustainable changes in healthcare is the lack of appropriate infrastructure (102). This challenge is particularly evident in older healthcare facilities, many of which were constructed before environmental sustainability became a priority. Retrofitting these facilities typically focuses on reducing energy consumption through energy efficiency measures, improving indoor environmental quality, and upgrading building envelopes. In contrast, newly constructed facilities are designed with sustainability in mind, often aiming for net-zero energy use or net-negative emissions (103).

There is a significant lack of education (104) and training on sustainable practices (105) in low- and middle-income countries. This is exemplified by inadequate medical waste management systems (105) in many healthcare establishments. Workers handling medical waste are frequently underpaid, operate in unsafe conditions, and lack adequate in-service training (102). Consequently, medical waste is frequently mixed with household waste and disposed of through incineration or in open landfills. Future research is necessary to improve waste management capacity, develop effective guidelines, and promote environmentally sustainable practices in these settings. The measurement of successful implementation in EDs and trade-offs with emergency care priorities would also be a direction for further studies.

Another challenge is the absence of standardized metrics to measure GHG emissions across countries, resulting in uncertainty in global healthcare-related emissions estimates. Assessing healthcare’s broader environmental degradation impacts, along with the direct and indirect health effects, adds further complexity. The structure of healthcare systems significantly influences the implementation of sustainable practices. A regional, decentralized model based on self-governance like in Germany, limits state control and complicates the execution of sustainability initiatives. Conversely, government-run systems, such as the tax-funded National Health Service in the UK, allow for more direct state involvement in policy execution (104). These contrasting governance models highlight the need for tailored sustainability strategies that align with the specific structure of each healthcare system.

The COVID-19 pandemic highlighted the trade-off between infection control and environmental sustainability. The increased use of single-use medical devices, such as personal protective equipment (PPE) and test kits has exacerbated healthcare waste management challenges (105). While reusable devices, biodegradable alternatives, and eco-friendly packaging are potential solutions, they require reliable sterilization infrastructure to prevent infection. In some contexts, single-use plastics remain indispensable for infection prevention (102). A balanced approach prioritizing patient safety while minimizing unnecessary waste is essential (106). Research and development efforts must focus on creating sustainable materials and technologies for medical applications.

Conclusions

The deleterious effects of climate change on human health are exponentially increasing. As the frontline of most healthcare systems, EDs bear the brunt of resultant increased attendances. Urgent actions by the emergency medicine fraternity are needed to understand and tackle the causes and consequences of climate change in tandem with environmental sustainability efforts to mitigate these issues.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-25-57/rc

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-25-57/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-25-57/coif). M.T.C. serves as an unpaid editorial board member of Annals of Translational Medicine from November 2024 to October 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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