, Antonella Amendola 7, Gaetano Ferrara 8, Gabriele Caggianelli 9,§, Fabio Petrelli 10,§
1 Unit of Diabetology, Asur Marche—Area Vasta 4 Fermo, 63900 Fermo, Italy
2 Department of Nursing, Polytechnic University of Ancona, 60121 Ancona, Italy
3 Department of Pharmacy, Health and Nutritional Sciences (DFSSN), University of Calabria, 87036 Rende, Italy
4 Department of Nursing, A.O. Polyclinic San Martino Hospital, 16132 Genova, Italy
5 Units of Psychiatry, Ast Fermo, 63900 Fermo, Italy
6 IRCCS Humanitas Research Hospital via Manzoni 56, 20089 Rozzano, Italy
7 Department of Health Sciences, Università degli Studi di Milano, 20122 Milan, Italy
8 Nephrology and Dialysis Unit, Ramazzini Hospital, 41012 Carpi, Italy
9 Azienda Ospedaliera San Giovanni Addolorata, 00184 Rome, Italy
10 School of Pharmacy, Polo Medicina Sperimentale e Sanità Pubblica “Stefania Scuri”, 62032 Camerino, Italy
†These authors contributed equally.
§These authors contributed equally.
Abstract
Pressure injuries (PIs) are a significant issue for international healthcare systems. Particularly common among older adults with reduced mobility, PIs represent a considerable socio-healthcare burden, which deeply impacts the psychological well-being of patients. Malnutrition is one of the main risk factors for the development of PIs, as malnutrition hinders healing and increases the risk of complications. For these reasons, implementing appropriate nutritional interventions, often underestimated in clinical practice, is crucial to manage PIs effectively. This study primarily aimed to identify and synthesize the best scientific evidence on nutritional interventions to prevent, facilitate, or improve the healing of PIs in an adult population. Additionally, both qualitative and quantitative outcomes were analyzed.
A narrative literature review was conducted using the PubMed–Medline, Scopus, and Google Scholar databases to potentially include potential studies. The scientific validity of the study was ensured using the Scale for the Assessment of Narrative Review Articles (SANRA) and the pre-registration of the OSF database was performed using the PICOS method, which is employed in numerous studies of this type. Randomized controlled trials (RCTs) published within the last 10 years and in English were included.
Out of the 1507 records identified, 8 RCTs were included, published between May 2014 and May 2023. One study focused on patient education and self-care in nutrition related to PIs, while the remaining seven focused on intensive nutritional interventions or the administration of dietary supplements to treat PIs directly. Positive therapeutic effects were observed using collagen peptides, vitamin C, and arginine. Furthermore, the topical application of fish oil showed a protective effect.
This study found that targeted nutritional interventions have a direct positive impact on PIs and an indirect effect on care, reducing complications and the duration of intensive care and healing times for PIs. Future systematic studies are recommended to broaden the understanding of the studied care framework.
Keywords
- nutrition
- pressure injuries
- fragile population
- public health
Pressure injuries (PIs) are localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Tissue tolerance to pressure and shear may also be influenced by factors such as microclimate, nutrition, perfusion, comorbidities, and the condition of the soft tissue [1, 2]. PIs have a significant impact on individuals, communities, and the healthcare system overall [3]. Their prevalence remains alarmingly high, especially among people with chronic diseases, often associated with aging [4, 5, 6], with approximately 3 million new cases worldwide each year [7]. According to recent reports, the global burden of PIs continues to rise, particularly in aging populations and those with mobility impairments, making their prevention and treatment a priority in healthcare settings [4, 5]. In the United States and Europe, prevalence ranges from 4.6% to 27%, making PIs the third most costly pathological condition after cancer and cardiovascular diseases [8]. In the United Kingdom, the estimated cost for the management and treatment of PIs ranges from £1.4 to £2.1 billion (
Fig. 1. Summary of vitamins support for pressure injuries (PIs).
Fig. 2. Nutrient-specific mechanistic pathways for PIs healing.
This study employs a narrative review methodology, supported by the Scale for the Assessment of Narrative Review Articles (SANRA) qualitative support for conduction [31] (SANRA checklist; Supplementary File 1), aiming to provide a quantitative and qualitative synthesis of the existing literature on the relationship between nutrition and PIs healing in an adult population.
The research questions that guided this narrative review are as follows:
• In adult patients at risk of PIs, do specific nutritional interventions, compared to no intervention or another intervention, reduce the incidence of PIs?
• In adult patients with PIs, is the administration of nutritional supplements, compared to no intervention or another intervention, more effective in improving or healing PIs?
This research was developed using the PICOS framework [32], already established in previous studies [11, 21, 33], to ensure a structured and scientifically valid approach to the identified topic:
P (Population): Adult patients at risk of or with PIs without a declared primary chronic condition;
I (Intervention): nutritional intervention (nutritional or educational support);
C (Comparison): no nutritional intervention or alternative intervention;
O (Outcome): qualitative and quantitative outcomes;
S (Study Type): Randomized Controlled Trial (RCT).
This review aimed to thoroughly examine the relationships between nutrition and PIs healing to provide solid evidence for clinical and public health practice in managing this complication.
The study included a preliminary registration in the OSF database with the code https://doi.org/10.17605/OSF.IO/NGEZT. The search strategy was conducted using the PubMed-Medline and Scopus databases, aiming to select RCTs published in the last 10 years. After the initial search to identify the total number of records, a blinded screening process was carried out independently by two reviewers (GCan and FS). In case of disagreement between the two, and to reach the necessary consensus for inclusion, a third researcher (SM) was involved in the selection process. EndNote 20 (© 2024 Clarivate, London, UK) [34] was used for bibliographic management of the analyzed records, and specific search strings were applied with Boolean operators (Search Strategy: Supplementary File 2). Exclusion criteria: all studies not aligned with the selected review model (e.g., cohort studies), in incomplete editorial formats (such as conferences and editorials), and that did not meet the PICOS framework selected and discussed in point 2.2 of this manuscript.
The selected studies underwent a rigorous two-phase analysis. Initially, they were categorized based on various criteria: first author/period/location, cohort, intervention, bias, and primary outcomes. This categorization ensured a structured approach to synthesizing the identified literature. Subsequently, a comprehensive narrative synthesis was conducted, integrating the results of the selected RCTs and providing an overall perspective on the topic, while also highlighting the unique features and complexities of each included study.
The risk of bias and methodological quality of the studies included in this review were independently assessed by two researchers to ensure a comprehensive and objective evaluation. To achieve this, the researchers utilized the Critical Appraisal Skills Programme (CASP) checklists [35], which are widely recognized tools for assessing the quality of both qualitative and quantitative studies. The use of the CASP checklist allowed for a systematic examination of key elements such as study design, methodology, sample size, data collection processes, and the validity of the conclusions drawn. The assessment aimed to identify potential sources of bias and limitations within the studies, ensuring that the findings presented in the review were based on high-quality, reliable evidence (Supplementary File 3).
The search strategy yielded a total of 1507 records from the PubMed-Medline and Scopus databases. After removing 20 duplicates and excluding 1250 articles based on title, 235 articles were selected for abstract screening. Of these, 214 were deemed irrelevant. Subsequently, 23 full-text articles were evaluated for eligibility, and 15 were excluded due to irrelevance or not meeting methodological requirements. As a result, eight RCTs were included in the final narrative review (Fig. 3, Table 1, Table 2 (Ref. [36, 37, 38, 39, 40, 41, 42, 43])).
Fig. 3. Prisma flow chart.
| Characteristic | Frequency (n = 8) | Percentage | |
| Publication year | |||
| 2023 | 2 | 25.0% | |
| 2021 | 1 | 12.5% | |
| 2017 | 1 | 12.5% | |
| 2016 | 2 | 25.0% | |
| 2015 | 1 | 12.5% | |
| 2014 | 1 | 12.5% | |
| Cohort | |||
| EG | 355 | 51.82% | |
| CG | 330 | 48.18% | |
| Quality of studies | |||
| Positive | 7 | 87.5% | |
| Negative | 0 | 0% | |
| Unknowns | 1 | 12.5% | |
CG, control group; EG, experimental group.
| Author/Period/Location | Sample | Main intervention | Main biases | Main results |
| Sadeghi SS et al. [36] 2023/Iran | 34 EG, 31 CG, 37 Placebo group | Topical use of fish oil to prevent wounds | Unclear randomization | Higher risk of PIs in CG vs EG and placebo; EG 2.7 times lower (p = 0.023); placebo 11.9 times lower (p = 0.132) |
| Banks MD et al. [37] 2023/Australia | 42 intensive intervention, 43 supplements 46 CG | Intensive nutritional intervention or with supplements of Arg, VIT-C, and Zinc | Reduced sample, knowledge of the intervention known to patients | 91% enriched diet; only 26.7% and 33.6% meet energy/protein requirements; variations in PUSH score (−2.9 |
| Mehl AA et al. [38] 2021/Brazil | 15 EG, 15 CG | Specialized ONS in EG; standard ONS in CG | Heterogeneous sample, short duration (4 weeks) | Difference in percentage reduction of wound area: CG 34.0% |
| Yamanaka H et al. [39] 2017/Japan | 22 CP, 22 Arg, 22 CG | Standard care, with supplementation of CP or Arg | Reduced sample, stringent inclusion/exclusion criteria | Improvement in DESIGN-R score for the CP group (10.9 |
| Banks MD et al. [40] 2016/Australia | 25 EG, 25 CG | Intensive nutritional care in EG; standard care in CG | Assignment of notes to patients and nurses, reduced sample | High correlation between intensive care and improvements in PUSH scores and in the area of PIs |
| Robert S et al. [41] 2016/Australia | 39 EG, 41 CG | Education and participation in nutritional self-care | Exclusion of patients with cognitive deficits or illiteracy; knowledge of nutritional monitoring in the CG | Satisfaction of: recruitment rates (81.6%), number of subjects who completed the study (87.5%) and number of subjects who performed at least part of the intervention (100%); energy/protein needs improved by 27% and 42% in EG vs 1% and 18% in CG; no negative feedback |
| Cereda E et al. [42] 2015/Italy | 101 EG, 99 CG | Nutritional formula with Arg, zinc, antioxidants in EG; standard formula in CG | Exclusion of normonutrient patients; inclusion only of patients who can drink ONS | Reduction of PIs size by 60.9% in EG vs 45.2% in CG; complete healing better at 4 weeks in EG (16.9%) vs CG (9.7%) |
| Wong A et al. [43] 2014/Singapore | 12 EG, 14 CG | Mixture with amino acids in EG; placebo in CG | Heterogeneity of PIs, short study (2 weeks), small sample | Reduction of wound area by 37.5% in CG vs 27.5% in EG; decrease in PUSH scores from 12.25 |
EG, experimental group; CG, control group; ONS, Oral Nutritional Supplements; PIs, Pressure Injuries; PUSH, Pressure Ulcers Scale for Healing; CP, collagen peptide; VIT-C, Vitamin C; Arg, Arginine; DESIGN-R, Depth, Exudate, Size, Inflammation/Infection, Granulation Tissue, Necrotic Tissue – rating score; p, p value.
Of the 8 included RCTs [36, 37, 38, 39, 40, 41, 42, 43], three were conducted in Australia [37, 40, 41], and one each in Iran [36], Brazil [38], Japan [39], Italy [42], and Singapore [43]. A total of 355 subjects were included in the experimental group (EG) and 330 in the control group (CG). The largest experimental cohort included 102 cases, while the smallest had 12. The quality of the study design was high in 7 out of 8 studies, with only one not reaching the same standard.
The analyzed studies emphasize how the integration of topical and nutritional interventions plays a crucial role in the prevention of PIs, highlighting both clinical efficacy and improvement in patient conditions (Fig. 4.).
Fig. 4. Preventive nutritional interventions for PIs.
Sadeghi SS et al. [36] conducted a clinical study involving 102 patients admitted to the Intensive Care Unit at Besat Hospital (Iran), assigned to either the control group (CG) (N = 31), the placebo group (N = 37), or the experimental group (EG) (N = 34). Baseline data were collected on demographics, clinical variables, level of consciousness, Braden scale, and nutritional status. The intervention group received topical fish oil (2 cc) applied to the sacrum daily for 5 days, while the placebo group received soybean oil, and the CG received routine care. Daily assessments of the incidence of PIs were conducted for 6 days. Results showed a significantly lower incidence of PIs in the fish oil group compared to the control group (p = 0.023), demonstrating the preventive efficacy of topical fish oil. Similarly, the pilot study by Roberts S et al. [41] evaluated the effectiveness of nutritional education in the prevention of PIs. Patients participated in nutritional self-care sessions and were interviewed about the acceptability of the intervention. The survey was conducted on 80 at-risk patients in 3 hospital wards in Queensland, Australia, with a 3-day intervention. The EG (n = 39) showed an improvement of 27% and 42% in energy and protein requirements, compared to marginal improvements (1% and 18%) observed in the CG (n = 41). Recruitment and retention rates were high (81.6% and 87.5%, respectively), and 100% of participants took part in at least part of the intervention. No negative feedback was reported.
Studies on the management of PIs highlight how specific nutritional interventions and personalized care programs can significantly improve healing processes. Various strategies have been explored, ranging from intensive nutritional regimens to enriched supplementation, all showing promising outcomes.
In 2023, Banks MD et al. [37] conducted a multicenter study at public and private hospitals in Australia. A total of 131 malnourished adult patients with PIs were recruited, followed for 14 days, and assigned to three groups: CG (n = 46) with standard nutrition, intensive nutritional intervention conducted by nutritionists and dietitians (n = 42), and enriched supplements with trace elements such as Arginine (Arg), Vitamin C (VIT-C), and Zinc (n = 43). The majority (91%) received an enriched diet, but the estimated energy/protein requirements were met by only 26.7% and 33.6%, respectively. There were changes in the Pressure Ulcers Scale for Healing (PUSH) score in the intensive experimental group (–2.9
The review highlighted the crucial role of nutrition in the management of PIs among adults, emphasizing that targeted nutritional strategies can significantly enhance the healing process. These approaches not only support tissue repair but also help reduce the pain and discomfort associated with PIs, ultimately improving patients’ quality of life [44, 45]. Despite the growing body of evidence supporting the efficacy of nutritional interventions, their implementation in routine clinical practice remains inconsistent. Barriers such as limited awareness among healthcare professionals, inadequate training, and limited integration into clinical guidelines hinder the widespread adoption of these strategies. The emerging data confirm that adequate nutritional interventions can positively impact tissue repair, reducing complications and accelerating recovery. Furthermore, several international studies have demonstrated the effectiveness of these interventions in the management of other common chronic conditions, including type 2 diabetes, cancer, respiratory, hepatic, allergic, neurodegenerative, and kidney diseases [46, 47, 48, 49, 50, 51, 52, 53, 54]. This suggests that a broader application of nutritional strategies in chronic disease management could also enhance PI prevention and treatment. Conversely, poor nutrition can promote the development of such conditions. For example, it has been documented that a high consumption of ultra-processed foods increases the risk of developing diabetes by 31% [55]. A key aspect identified is the importance of nutritional education. Although educational programs have been shown to be well-received by patients, improving awareness regarding the prevention of PIs [41], previous studies [53] indicate that nutritional knowledge remains limited, even when patients benefit from specific professional consultations. Munoz et al. [22] and Langer et al. [23] emphasized that while nutritional interventions show clear benefits, their success largely depends on patient adherence and healthcare provider engagement. Therefore, educational strategies should not only target patients but also be incorporated into training programs for nurses and clinicians to ensure better long-term implementation. Consequently, it is essential to implement integrated educational strategies, also through digital platforms and social media, to enhance nutritional literacy a promote healthier behaviors [56, 57, 58]. The active participation of the patient, promoting greater awareness of the link between nutrition and health, represents a fundamental lever to improve therapeutic compliance and clinical outcomes [59]. In this context, the adoption of artificial intelligence (AI) could amplify the effectiveness of nutritional strategies, offering personalized recommendations based on the specific needs of the patient. However, its use raises legal and ethical issues, requiring careful regulation, which is already common practice in numerous branches of medicine for chronic diseases [60, 61, 62]. Recent advancements in AI-driven nutritional guidance have demonstrated potential in optimizing dietary interventions for chronic wound healing. Implementing AI-based decision-support systems in hospitals and long-term care facilities could enhance the precision of nutritional plans and improve patient outcomes [57, 58, 59]. Nevertheless, further research is needed to validate the effectiveness of these approaches specifically in the context of PIs. Another decisive element that emerged from the review concerns the effectiveness of specific nutritional interventions compared to standard care. Recent studies [63, 64, 65] confirm that the use of nutritional supplements, including formulas enriched with proteins, micronutrients, and antioxidants, plays a fundamental role in improving clinical outcomes. For example, specialized ONS containing energy, proteins, and vitamins have been shown to accelerate the healing process of PIs, with noticeable improvements observed as early as two weeks from the start of treatment [38]. Moreover, the use of these supplements in community settings is associated with a significant reduction in complications, such as infections, post-operative problems, and insufficient healing [66]. However, it is important to note that not all studies have demonstrated a direct causal link between micronutrient supplementation and PI prevention. Several studies have reported variable responses, highlighting the need for personalized approaches that consider individual patient factors such as comorbidities, baseline nutritional status, and severity of PIs [67, 68]. The use of arginine, zinc, and other micronutrients has been widely studied and has proven promising in promoting wound repair [36, 37, 38, 39, 40, 42, 43]. Arginine, for example, stimulates the synthesis of proline and nitric oxide, both essential for tissue repair, while zinc plays a key role in maintaining immune function [69]. To strengthen the proposed mechanisms and reduce the excessive reliance on correlational data, it is essential to integrate translational evidence, such as in vitro collagen synthesis assays, which can provide more concrete and direct evidence of the biological pathways involved [70, 71]. Furthermore, it is crucial to understand the underlying biological mechanisms that link nutrient status and intake to pressure ulcer healing. Specific nutrients, such as arginine and zinc, play a direct role in the biological processes involved in tissue repair. Arginine, for instance, stimulates the synthesis of proline and nitric oxide [72], two molecules essential for wound healing. Zinc is critical for supporting immune function and regulating cellular metabolism [73]. Additionally, vitamins, particularly vitamin C and vitamin A, are vital for collagen synthesis and for modulating the inflammatory response [74]. Although previous studies, have already demonstrated the positive effects of nutritional interventions in PIs management [22, 23] this review adds value by offering a comprehensive synthesis of recent clinical evidence with a particular focus on implementation challenges and future research directions. Unlike earlier systematic reviews that primarily assessed efficacy, this study highlights the barriers preventing nutritional strategies from becoming standard practice in PIs care. Furthermore, it discusses the importance of interdisciplinary collaboration and emerging technologies, such as AI and digital health tools, in optimizing nutritional interventions. By emphasizing these aspects, our work contributes to bridging the gap between research findings and real-world clinical application. However, some studies [67, 68, 69, 70, 71, 75] have not demonstrated a direct causal link between the intake of these micronutrients and the prevention of PIs, suggesting the need for further studies to clarify these associations. A more standardized approach to nutritional supplementation is also required to define optimal dosages and administration protocols tailored to PIs patients. Future trials should focus on defining the most effective combinations of nutrients and evaluating their long-term effects. In addition to nutritional interventions, educational modalities play a critical role in the management of PIs particularly in community setting [76, 77, 78]. Patient education on self-care practices, including proper nutrition, skin care, and repositioning techniques, is essential for preventing and managing PIs effectively [79, 80] Studies have shown that well-structured educational programs can empower patients to actively engage in their care, improving compliance with nutritional strategies and reducing the risk of complications [81, 82]. Healthcare professionals, specially nurse, are key in delivering this education, ensuring that patients are equipped with the necessary knowledge to optimize their healing process and overall well-being [76, 77, 78, 79, 80, 81, 82].
There are several promising directions for future research in the field of nutrition applied to the management of PIs. For instance, AI and technological support in healthcare could be leveraged to generate personalized nutritional recommendations. These technologies enable continuous and real-time monitoring of patient needs. Moreover, the advancement of digital nutrition platforms and social media opens new perspectives for developing more effective methods of food promotion. Nutritional mobile apps, already successfully used in other conditions such as chronic kidney disease, also show promise in the prevention of PIs [83]. Additionally, future research should explore the cost-effectiveness of large-scale nutritional interventions for PI prevention. Economic analyses comparing standard wound care with nutrition-focused strategies could provide valuable insights for policymakers and healthcare administrators. Studies have confirmed the effectiveness of these supports in improving patients’ motivation, self-efficacy, knowledge, and attitudes, enhancing the therapeutic education offered by healthcare professionals between clinical and social care [84]. Another important research direction involves evaluating the impact of interdisciplinary collaboration in PI care. Integrating dietitians into wound care teams could improve the identification of malnutrition-related risks and ensure timely nutritional interventions. Interdisciplinary collaboration between nursing and engineering disciplines is crucial for the development of these innovative solutions, which not only improve patient outcomes but also transform healthcare practice [85]. Finally, future studies should investigate the potential benefits of specific dietary patterns, such as the Mediterranean or high-protein diets, in PI prevention and treatment. These approaches, which have shown promising results in other chronic conditions, could offer alternative, patient-friendly strategies for PI management. It is essential to evaluate the long-term effectiveness of such nutritional interventions to understand their impact on patients’ quality of life and healthcare costs. These advancements in research and implementation of healthcare technologies allow for the improvement of therapeutic and preventive strategies, fostering a future of excellence in global healthcare.
This review presents some limitations that affect its interpretation. Firstly, many of the included studies have small sample sizes, which reduce the statistical power and robustness of the results. Furthermore, the heterogeneity among patient groups, resulting from different comorbidities, makes direct comparison between studies difficult. Factors such as short follow-up durations, often caused by early patient discharge, also limit the ability to assess the long-term effectiveness of interventions. Another critical limitation is the marked heterogeneity in the demographics and clinical profiles of the included populations. The analyzed studies involved diverse groups, including critically ill patients, individuals with diabetes, and elderly people with varying degrees of frailty. For instance, Cereda et al. [42] did not stratify patients based on diabetes status, which may have influenced wound healing outcomes. This variability hinders the generalizability of the results and underscores and underscores the need for future trials to adopt more standardized inclusion criteria and stratification methods to improve comparability across studies. Additionally, the methodological quality of the included studies was moderate, as reflected in the SANRA score score of 10 out of 12. A major concern was the lack of blinding in most randomized controlled trials (7 out of 8), as highlighted in the CASP Checklist (Supplementary File 3). This limitation raises concerns about potential bias in outcome assessment, especially when relying on subjective measures such as wound healing scores. Furthermore, many studies failed to report key statistical indicators, such as confidence intervals, which weakens the reliability of the findings and limits the generalizability of results. Another important limitation concerns the incomplete reporting of critical parameters in some studies, such as the exact dosage, duration, and administration details of interventions like fish oil. These omissions make it difficult to replicate the interventions or apply them in clinical practice. Despite these limitations, the main strength of this review lies in its rigorous and well-structured methodological approach, which ensures a high level of validity for a narrative review. Future research should adhere to more robust methodological and reporting standards, such as the CONSORT guidelines, to improve transparency, reproducibility, and clinical applicability.
This study provides an in-depth overview of the importance of nutritional interventions in the management of PIs in adults, an aspect often underestimated in routine clinical practice. Nutritional education has proven essential in improving patient engagement and promoting informed dietary choices, while nutritional supplements, aimed at tissue repair, have shown a significant positive impact on wound healing. The implementation of these strategies not only optimizes clinical outcomes but also contributes to the overall improvement of patient well-being, promoting more effective integration within care pathways. However, the collected data suggest the need for further research, especially regarding larger sample sizes and the analysis of the long-term effectiveness of nutritional interventions. Future studies should also explore the benefits derived from specific dietary patterns and evaluate the impact of nutritional education by healthcare providers, particularly nurses, on clinical outcomes. Moreover, it would be valuable to assess the effectiveness of these interventions in high-risk populations, such as individuals in community or long-term care settings, to determine their preventive impact in vulnerable groups.
The datasets used and analyzed during the current study are available from Giovanni Cangelosi on reasonable request.
GCan, AA, GCag and FS designed the research study. GCan, FS, SM, SMP and MS performed the research. FB and SMP provided help and advice. GF and FB analyzed the data. GCag, FS, SM, SMP, AA, FB and FP wrote the manuscript. GCag FB, SMP, AA and FP supervision. GCan, AA, GCag, SM and FP responsability and direction. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.
Not applicable.
Not applicable.
This research received no external funding.
The authors declare no conflict of interest.
Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.31083/IJVNR36342.
References
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