Explainable Machine Learning Interpretations on New Zealand Random Forest Liquefaction Manifestation Predictions

Background Predicting the prognosis of patients with acute myocardial infarction (AMI) combined with diabetes mellitus (DM) is crucial due to high in-hospital mortality rates. This study aims to develop and validate a mortality risk prediction model for these patients by interpretable machine learning (ML) methods. Methods Data were sourced from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.2). Predictors were selected by Least absolute shrinkage and selection operator (LASSO) regression and checked for multicollinearity with Spearman’s correlation. Patients were randomly assigned to training and validation sets in an 8:2 ratio. Seven ML algorithms were used to construct models in the training set. Model performance was evaluated in the validation set using metrics such as area under the curve (AUC) with 95% confidence interval (CI), calibration curves, precision, recall, F1 score, accuracy, negative predictive value (NPV), and positive predictive value (PPV). The significance of differences in predictive performance among models was assessed utilising the permutation test, and 10-fold cross-validation further validated the model’s performance. SHapley Additive exPlanations (SHAP) and Local Interpretable Model-agnostic Explanations (LIME) were applied to interpret the models. Results The study included 2,828 patients with AMI combined with DM. Nineteen predictors were identified through LASSO regression and Spearman’s correlation. The Random Forest (RF) model was demonstrated the best performance, with an AUC of 0.823 (95% CI: 0.774–0.872), high precision (0.867), accuracy (0.873), and PPV (0.867). The RF model showed significant differences (p < 0.05) compared to the K-Nearest Neighbours and Decision Tree models. Calibration curves indicated that the RF model’s predicted risk aligned well with actual outcomes. 10-fold cross-validation confirmed the superior performance of RF model, with an average AUC of 0.828 (95% CI: 0.800–0.842). Significant Variables in RF model indicated that the top eight significant predictors were urine output, maximum anion gap, maximum urea nitrogen, age, minimum pH, maximum international normalised ratio (INR), mean respiratory rate, and mean systolic blood pressure. Conclusion This study demonstrates the potential of ML methods, particularly the RF model, in predicting in-hospital mortality risk for AMI patients with DM. The SHAP and LIME methods enhance the interpretability of ML models.

Air pollution in Macau has become a serious problem following the Pearl River Delta’s (PRD) rapid industrialization that began in the 1990s. With this in mind, Macau needs an air quality forecast system that accurately predicts pollutant concentration during the occurrence of pollution episodes to warn the public ahead of time. Five different state-of-the-art machine learning (ML) algorithms were applied to create predictive models to forecast PM2.5, PM10, and CO concentrations for the next 24 and 48 h, which included artificial neural networks (ANN), random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM), and multiple linear regression (MLR), to determine the best ML algorithms for the respective pollutants and time scale. The diurnal measurements of air quality data in Macau from 2016 to 2021 were obtained for this work. The 2020 and 2021 datasets were used for model testing, while the four-year data before 2020 and 2021 were used to build and train the ML models. Results show that the ANN, RF, XGBoost, SVM, and MLR models were able to provide good performance in building up a 24-h forecast with a higher coefficient of determination (R2) and lower root mean square error (RMSE), mean absolute error (MAE), and biases (BIAS). Meanwhile, all the ML models in the 48-h forecasting performance were satisfactory enough to be accepted as a two-day continuous forecast even if the R2 value was lower than the 24-h forecast. The 48-h forecasting model could be further improved by proper feature selection based on the 24-h dataset, using the Shapley Additive Explanations (SHAP) value test and the adjusted R2 value of the 48-h forecasting model. In conclusion, the above five ML algorithms were able to successfully forecast the 24 and 48 h of pollutant concentration in Macau, with the RF and SVM models performing the best in the prediction of PM2.5 and PM10, and CO in both 24 and 48-h forecasts.

Abstract. As air pollution is regarded as the single largest environmental health risk in Europe it is important that communication to the public is up to date and accurate and provides means to avoid exposure to high air pollution levels. Long- and short-term exposure to outdoor air pollution is associated with increased risks of mortality and morbidity. Up-to-date information on present and coming days' air quality helps people avoid exposure during episodes with high levels of air pollution. Air quality forecasts can be based on deterministic dispersion modelling, but to be accurate this requires detailed information on future emissions, meteorological conditions and process-oriented dispersion modelling. In this paper, we apply different machine learning (ML) algorithms – random forest (RF), extreme gradient boosting (XGB), and long short-term memory (LSTM) – to improve 1, 2, and 3 d deterministic forecasts of PM10, NOx, and O3 at different sites in Greater Stockholm, Sweden. It is shown that the deterministic forecasts can be significantly improved using the ML models but that the degree of improvement of the deterministic forecasts depends more on pollutant and site than on what ML algorithm is applied. Also, four feature importance methods, namely the mean decrease in impurity (MDI) method, permutation method, gradient-based method, and Shapley additive explanations (SHAP) method, are utilized to identify significant features that are common and robust across all models and methods for a pollutant. Deterministic forecasts of PM10 are improved by the ML models through the input of lagged measurements and Julian day partly reflecting seasonal variations not properly parameterized in the deterministic forecasts. A systematic discrepancy by the deterministic forecasts in the diurnal cycle of NOx is removed by the ML models considering lagged measurements and calendar data like hour and weekday, reflecting the influence of local traffic emissions. For O3 at the urban background site, the local photochemistry is not properly accounted for by the relatively coarse Copernicus Atmosphere Monitoring Service ensemble model (CAMS) used here for forecasting O3 but is compensated for using the ML models by taking lagged measurements into account. Through multiple repetitions of the training process, the resulting ML models achieved improvements for all sites and pollutants. For NOx at street canyon sites, mean squared error (MSE) decreased by up to 60 %, and seven metrics, such as R2 and mean absolute percentage error (MAPE), exhibited consistent results. The prediction of PM10 is improved significantly at the urban background site, whereas the ML models at street sites have difficulty capturing more information. The prediction accuracy of O3 also modestly increased, with differences between metrics. Further work is needed to reduce deviations between model results and measurements for short periods with relatively high concentrations (peaks) at the street canyon sites. Such peaks can be due to a combination of non-typical emissions and unfavourable meteorological conditions, which are rather difficult to forecast. Furthermore, we show that general models trained using data from selected street sites can improve the deterministic forecasts of NOx at the station not involved in model training. For PM10 this was only possible using more complex LSTM models. An important aspect to consider when choosing ML algorithms is the computational requirements for training the models in the deployment of the system. Tree-based models (RF and XGB) require fewer computational resources and yield comparable performance in comparison to LSTM. Therefore, tree-based models are now implemented operationally in the forecasts of air pollution and health risks in Stockholm. Nevertheless, there is big potential to develop generic models using advanced ML to take into account not only local temporal variation but also spatial variation at different stations.

This study focuses on using various machine learning (ML) models to evaluate the shear behaviors of ultra-high-performance concrete (UHPC) beams reinforced with glass fiber-reinforced polymer (GFRP) bars. The main objective of the study is to predict the shear strength of UHPC beams reinforced with GFRP bars using ML models. We use four different ML models: support vector machine (SVM), artificial neural network (ANN), random forest (R.F.), and extreme gradient boosting (XGBoost). The experimental database used in the study is acquired from various literature sources and comprises 54 test observations with 11 input features. These input features are likely parameters related to the composition, geometry, and properties of the UHPC beams and GFRP bars. To ensure the ML models' generalizability and scalability, random search methods are utilized to tune the hyperparameters of the algorithms. This tuning process helps improve the performance of the models when predicting the shear strength. The study uses the ACI318M-14 and Eurocode 2 standard building codes to predict the shear capacity behavior of GFRP bars-reinforced UHPC I-shaped beams. The ML models' predictions are compared to the results obtained from these building code standards. According to the findings, the XGBoost model demonstrates the highest predictive test performance among the investigated ML models. The study employs the SHAP (SHapley Additive exPlanations) analysis to assess the significance of each input parameter in the ML models' predictive capabilities. A Taylor diagram is used to statistically compare the accuracy of the ML models. This study concludes that ML models, particularly XGBoost, can effectively predict the shear capacity behavior of GFRP bars-reinforced UHPC I-shaped beams.

Optimisation and interpretation of machine and deep learning models for improved water quality management in Lake Loktak

ObjectiveThis study aimed to develop and validate interpretable machine learning (ML) models based on multi-dimensional fusion data for predicting positive surgical margins (PSM) in robot-assisted radical prostatectomy (RARP).MethodsPatients who underwent RARP at our institution between January 2016 and July 2025 were enrolled. Demographic, clinical, biopsy pathology data, and MRI-derived anatomical features (measured using ITK-SNAP on axial, sagittal, and coronal planes) were collected. Feature selection was performed using intraobserver and interobserver correlation coefficients (ICCs), low-variance filtering, univariable logistic regression, Spearman’s correlation analysis, the least absolute shrinkage and selection operator (LASSO) algorithm, and the Boruta algorithm. Six ML models were constructed, with performance evaluated using area under the curve (AUC), calibration curves, and decision curve analyses (DCA) to identify the optimal model. Five-fold and ten-fold cross-validation were used to assess the optimal model’s generalizability, and its interpretability was evaluated via Shapley Additive exPlanations (SHAP) analysis.ResultsA total of 347 patients were included, comprising a training set (n=193, January 2016–December 2024), validation set (n=84, January 2016–December 2024), and test set (n=70, January 2025–July 2025). From 164 initial features, 7 key features were retained through a four-step screening. The Random Forest (RF) model outperformed other models, achieving AUCs of 0.99 (95% CI: 0.97–1.00) in the training set, 0.88 (95% CI: 0.80–0.95) in the validation set, and 0.97 (95% CI: 0.94–1.00) in the test set. Calibration curve and decision curve analyses confirmed its strong clinical utility. Five-fold cross-validation for the RF model showed fold-specific AUCs of 0.82–0.92, with a mean AUC of 0.87 (95% CI: 0.84–0.90). Ten-fold cross-validation showed fold-specific AUCs of 0.80–0.99, with a mean AUC of 0.88 (95% CI: 0.83–0.93). SHAP analysis revealed five novel spatial anatomical features (such as Sagittal plane-posterior spatial anatomical structure index, Coronal plane-Left anatomical structure interval) were negatively associated with PSM risk, while the number of positive biopsy cores and clinical tumor stage were positively associations.ConclusionsMulti-dimensional fusion data combined with ML models improves PSM prediction accuracy in RARP. The RF model, with excellent performance and interpretability, shows promise for preoperative PSM risk stratification, facilitates optimized clinical decision-making, and supports personalized treatment discussions during preoperative planning, but requires prospective and external validation before clinical implementation.

ObjectivesThis study aims to build a machine learning (ML) model to predict the recurrence probability for postoperative non-lactating mastitis (NLM) by Random Forest (RF) and XGBoost algorithms. It can provide the ability to identify the risk of NLM recurrence and guidance in clinical treatment plan.MethodsThis study was conducted on inpatients who were admitted to the Mammary Department of Shuguang Hospital affiliated to Shanghai University of Traditional Chinese Medicine between July 2019 to December 2021. Inpatient data follow-up has been completed until December 2022. Ten features were selected in this study to build the ML model: age, body mass index (BMI), number of abortions, presence of inverted nipples, extent of breast mass, white blood cell count (WBC), neutrophil to lymphocyte ratio (NLR), albumin-globulin ratio (AGR) and triglyceride (TG) and presence of intraoperative discharge. We used two ML approaches (RF and XGBoost) to build models and predict the NLM recurrence risk of female patients. Totally 258 patients were randomly divided into a training set and a test set according to a 75%-25% proportion. The model performance was evaluated based on Accuracy, Precision, Recall, F1-score and AUC. The Shapley Additive Explanations (SHAP) method was used to interpret the model.ResultsThere were 48 (18.6%) NLM patients who experienced recurrence during the follow-up period. Ten features were selected in this study to build the ML model. For the RF model, BMI is the most important influence factor and for the XGBoost model is intraoperative discharge. The results of tenfold cross-validation suggest that both the RF model and the XGBoost model have good predictive performance, but the XGBoost model has a better performance than the RF model in our study. The trends of SHAP values of all features in our models are consistent with the trends of these features’ clinical presentation. The inclusion of these ten features in the model is necessary to build practical prediction models for recurrence.ConclusionsThe results of tenfold cross-validation and SHAP values suggest that the models have predictive ability. The trend of SHAP value provides auxiliary validation in our models and makes it have more clinical significance.

ObjectiveAnalyze the psychological and clinical factors of clinically significant tinnitus (THI score ≥38) in patients with hearing loss, construct predictive models based on four machine learning (ML) algorithms, and compare the predictive performance of different models.MethodsPatients with hearing loss who visited the Department of Otolaryngology at Qinghai University between August 2024 and May 2025 were enrolled in this study. Clinical data were retrieved from the hospital’s electronic medical record system. The study outcome was the occurrence of clinically significant tinnitus. Predictive variables were screened using univariate analysis, the least absolute shrinkage and selection operator (LASSO) regression, and the Boruta algorithm. Four ML algorithms—logistic regression (LR), random forest (RF), extreme gradient boosting (XGBoost), and support vector machine (SVM)—were applied to construct and validate predictive models. The area under the receiver operating characteristic curve (AUC) of each model in the validation set was compared using the DeLong test. Additionally, model performance metrics in the validation set were compared to identify the optimal model. Finally, the Shapley additive explanations (SHAP) algorithm was employed to interpret the best-performing model.ResultsNine key variables—age, hypertension, sleep disorder, anxiety, hearing loss severity, depression, noise exposure history, hearing side, and ototoxic drug use—were retained after LASSO and Boruta feature selection. Among the four ML models, the RF algorithm achieved the best predictive performance, with an AUC of 0.973 in the training set and 0.977 in the validation set, followed by XGBoost (AUC = 0.962 and 0.961, respectively). DeLong tests confirmed that RF significantly outperformed LR and SVM models (p < 0.001), while its difference from XGBoost was not significant. In the validation set, the RF model yielded the highest accuracy (0.923), sensitivity (0.929), specificity (0.914), precision (0.945), and F1-score (0.937). SHAP analysis indicated that hearing loss severity, age, and sleep disorder were the most influential predictors, suggesting that both auditory and non-auditory factors contribute substantially to the risk of clinically significant tinnitus.ConclusionThe RF model showed the best performance in predicting clinically significant tinnitus, with hearing loss severity, age, and sleep disorder identified as major predictors. Integrating auditory and psychological factors can improve early risk identification in patients with hearing loss.

The number of deaths from cardiovascular disease is projected to reach 23.3 million by 2030. As a contribution to preventing this phenomenon, this paper proposed a machine learning (ML) model to predict patients with arteriosclerotic heart disease (AHD). We also interpreted the prediction model results based on the ML approach and deployed modelagnostic ML methods to identify informative features and their interpretations. We used a hematology Electronic Health Record (EHR) with information on erythrocytes, hematocrit, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, leukocytes, thrombocytes, age, and sex. To detect and predict AHD, we explored random forest (RF), XGBoost, and AdaBoost models. We examined the prediction model results based on the confusion matrix and accuracy measures. We used the Shapley Additive exPlanations (SHAP) framework to interpret the ML model and quantify the contribution of features to predictions. Our study included data from 6,837 patients, with 4,702 records from patients diagnosed with AHD and 2,135 records from patients without an AHD diagnosis. AdaBoost outperformed RF and XGBoost, achieving an accuracy of 0.78, precision of 0.82, F1-score of 0.85, and recall of 0.88. According to the SHAP summary bar plot method, hemoglobin was the most important attribute for detecting and predicting AHD patients. The SHAP local interpretability bar plot revealed that hemoglobin and mean corpuscular hemoglobin concentration had positive impacts on AHD prediction based on a single observation. ML models based on real clinical data can be used to predict AHD.

12074 Background: Skeletal-related events (SREs) are detrimental clinical events in bone metastasis from advanced cancer, defined by pathologic fracture, spinal cord compression, and inevitable surgical or radiational intervention to the bone. Given their negative impact on quality of life and prognosis and interpatient heterogeneity in the SRE risk, accurate identification of patients with high SRE risk is critical. Methods: The patient-level data from three randomized clinical trials that administered zoledronic acid (ZA) to patients with bone-metastatic breast cancer, castration-resistant prostate cancer (CRPC), and other types of cancer were analyzed. (N = 460, 452, and 315, respectively) Machine learning (ML) models to predict SREs within 18 months (breast cancer), 12 months (CRPC), and 9 months (other cancers) were developed based on more than 40 baseline clinical and laboratory data. Seven ML algorithms and five feature selection methods were utilized to develop multiple models. The ML model with the best performance was identified based on the F1 score and the area under the receiver operating characteristic curve (AUC-ROC) for each cancer type and interrogated for important features with Shapley additive explanations. Lastly, the ML models’ ability to stratify patients by the cumulative SRE risk was evaluated by calculating hazard ratio (HR) with Cox-proportional hazards models. Results: Among the multiple ML models developed with different algorithms and feature selection methods, the model developed utilizing the random forests algorithm and the Boruta method for selecting features demonstrated the best performance in all types of cancer (F1 0.70, 0.67, and 0.67, and AUC-ROC 0.72, 0.68, and 0.73 for breast cancer, CRPC, and other cancers, respectively). In the ML model for breast cancer, performance status (PS), history of SRE, serum alkaline phosphatase (ALP), history of anti-neoplastic surgery, radiation therapy, and pathologic fracture were included as important features. Serum ALP, albumin, sodium, Gleason scores, and geographic regions were shown to be relevant in the CRPC model. For other cancers, serum ALP, albumin, total protein, phosphorus, red blood cell count, white blood cell count, visceral metastases, and history of arthritis were incorporated in the ML model. The ML model prediction successfully stratified the patients for cumulative SRE risk in all three cohorts. (HR with 95% confidence interval: 2.43 [1.86 – 3.18], 1.92 [1.51 – 2.45], and 3.06 [2.29 – 4.09] for breast cancer, CRPC, and other types of cancer, respectively). Conclusions: ML models incorporating baseline clinical and laboratory data can identify patients with bone metastasis on ZA harboring a high SRE risk.

Development and validation of an explainable machine learning model for mortality prediction among patients with infected pancreatic necrosis.

Introduction: Heart failure (HF) may induce bowel hypoperfusion, leading to hypoxia of the villa of the bowel wall and the occurrence of Clostridioides difficile infection (CDI). However, the risk factors for the development of CDI in HF patients have yet to be fully illustrated, especially because of a lack of evidence from real-world data. Methods: Clinical data and survival situations of HF patients with CDI admitted to ICU were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. For developing a model that can predict 28-day all-cause mortality in HF patients with CDI, the Recursive Feature Elimination with Cross-Validation (RFE-CV) method was used for feature selection. And nine machine learning (ML) algorithms, including logistic regression (LR), decision tree, Bayesian, adaptive boosting, random forest (RF), gradient boosting decision tree, XGBoost, light gradient boosting machine, and categorical boosting, were applied for model construction. After training and hyperparameter optimization of the models through grid search 5-fold cross-validation, the performance of models was evaluated by the area under curve (AUC), accuracy, sensitivity, specificity, precision, negative predictive value, and F1 score. Furthermore, the SHapley Additive exPlanations (SHAP) method was used to interpret the optimal model. Results: A total of 526 HF patients with CDI were included in the study, of whom 99 cases (18.8%) experienced death within 28 days. Eighteen of the 57 variables were selected for the model construction algorithm for model construction. Among the ML models considered, the RF model emerged as the optimal model achieving the accuracy, F1-score, and AUC values of 0.821, 0.596, and 0.864, respectively. The net benefit of the model surpassed other models at 16%–22% threshold probabilities based on decision curve analysis. According to the importance of features in the RF model, red blood cell distribution width, blood urea nitrogen, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, and white blood cell count were highlighted as the five most influential variables. Conclusions: We developed ML models to predict 28-day all-cause mortality in HF patients associated with CDI in the ICU, which are more effective than the conventional LR model. The RF model has the best performance among all the ML models employed. It may be useful to help clinicians identify high-risk HF patients with CDI.

Endoscopic disease activity monitoring is important for the long-term management of patients with ulcerative colitis (UC), there is currently no widely accepted non-invasive method that can effectively predict endoscopic disease activity. We aimed to develop and validate machine learning (ML) models for predicting it, which are desired to reduce the frequency of endoscopic examinations and related costs. The patients with a diagnosis of UC in two hospitals from January 2016 to January 2021 were enrolled in this study. Thirty nine clinical and laboratory variables were collected. All patients were divided into four groups based on MES or UCEIS scores. Logistic regression (LR) and four ML algorithms were applied to construct the prediction models. The performance of models was evaluated in terms of accuracy, sensitivity, precision, F1 score, and area under the receiver-operating characteristic curve (AUC). Then Shapley additive explanations (SHAP) was applied to determine the importance of the selected variables and interpret the ML models. A total of 420 patients were entered into the study. Twenty four variables showed statistical differences among the groups. After synthetic minority oversampling technique (SMOTE) oversampling and RFE variables selection, the random forests (RF) model with 23 variables in MES and the extreme gradient boosting (XGBoost) model with 21 variables in USEIS, had the greatest discriminatory ability (AUC = 0.8192 in MES and 0.8006 in UCEIS in the test set). The results obtained from SHAP showed that albumin, rectal bleeding, and CRP/ALB contributed the most to the overall model. In addition, the above three variables had a more balanced contribution to each classification under the MES than the UCEIS according to the SHAP values. This proof-of-concept study demonstrated that the ML model could serve as an effective non-invasive approach to predicting endoscopic disease activity for patients with UC. RF and XGBoost, which were first introduced into data-based endoscopic disease activity prediction, are suitable for the present prediction modeling.

PurposeThe aim of this study was to develop and validate a machine learning (ML) based prediction model for sentinel lymph node metastasis in breast cancer to identify patients with a high risk of sentinel lymph node metastasis.MethodsIn this machine learning study, we retrospectively collected 225 female breast cancer patients who underwent sentinel lymph node biopsy (SLNB). Feature screening was performed using the logistic regression analysis. Subsequently, five ML algorithms, namely LOGIT, LASSO, XGBOOST, RANDOM FOREST model and GBM model were employed to train and develop an ML model. In addition, model interpretation was performed by the Shapley Additive Explanations (SHAP) analysis to clarify the importance of each feature of the model and its decision basis.ResultsCombined univariate and multivariate logistic regression analysis, identified Multifocal, LVI, Maximum Diameter, Shape US, Maximum Cortical Thickness as significant predictors. We than successfully leveraged machine learning algorithms, particularly the RANDOM FOREST model, to develop a predictive model for sentinel lymph node metastasis in breast cancer. Finally, the SHAP method identified Maximum Diameter and Maximum Cortical Thickness as the primary decision factors influencing the ML model’s predictions.ConclusionWith the integration of pathological and imaging characteristics, ML algorithm can accurately predict sentinel lymph node metastasis in breast cancer patients. The RANDOM FOREST model showed ideal performance. With the incorporation of these models in the clinic, can helpful for clinicians to identify patients at risk of sentinel lymph node metastasis of breast cancer and make more reasonable treatment decisions.

ObjectivePostoperative complications remain a major concern in laryngeal cancer surgery, often requiring invasive interventions or intensive care. This study aimed to develop and validate an interpretable machine learning (ML) model to preoperatively predict Clavien-Dindo Grade ≥ III complications and support risk-informed perioperative decision-making.MethodsWe conducted a retrospective study using a temporally split cohort of laryngeal cancer patients. Postoperative complications were graded using the Clavien-Dindo (CD) classification. Eight ML algorithms were trained and evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Model interpretability was assessed using SHapley Additive exPlanations (SHAP). A web-based calculator was deployed for clinical use.ResultThe random forest (RF) model achieved the best performance, with an area under the curve (AUC) of 0.935 in the training set and 0.842 in the test set. The model demonstrated robust sensitivity and specificity for both surgical and medical complications. Calibration curves indicated strong agreement between predicted and actual outcomes. SHAP analysis identified eight key predictors—such as vocal cord mobility, tumor subsite, and nutritional status—that contributed most to risk estimation. A user-friendly web calculator was developed and is accessible at: https://qilushiny.shinyapps.io/qilupredicate/.ConclusionWe developed a clinically interpretable ML model that accurately predicts major postoperative complications in patients undergoing laryngeal cancer surgery. This tool provides individualized risk assessments that can guide surgical planning, optimize perioperative strategies, and enhance shared decision-making. Prospective multicenter validation is needed to confirm its utility in routine practice.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12893-025-03213-z.