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Homoeopathy in the management of sub-clinical hypothyroidism: Two evidence-based case reports
*Corresponding author: Dr. Azizul Islam Khadim, Department of Case Taking and Repertory, Nehru Homoeopathic Medical College and Hospital, New Delhi, India. azizulislamkhadim786786@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Shil RC, Khadim AI. Homoeopathy in the management of sub-clinical hypothyroidism: Two evidence-based case reports. J Integr Stand Homoeopath. 2026;9:44-54. doi: 10.25259/JISH_106_2024
Abstract
Subclinical hypothyroidism (SCH) is characterised by elevated serum thyroid-stimulating hormone (TSH) levels, while serum T3 and T4 concentrations remain within normal. There is growing interest in alternative therapies, including homoeopathy, for managing SCH. Here, we present two cases where individualised homoeopathic treatment improved the serum thyroid profile of patients with SCH without side effects, in a shorter duration, while also enhancing their quality of life. Two patients presented at the outpatient department of a government homoeopathic college and hospital with symptoms of SCH and were treated with individualised homeopathic medicines. The cases were diagnosed and assessed using the TSH value and Zulewski’s clinical score. The response to homeopathic medicine was assessed through the modified Naranjo Criteria for Homeopathy Causal Attribution Inventory. These case reports suggest a positive role of individualised homoeopathic medicine in the management of SCH without any adverse effects. However, further research, including more documented cases and scientific research, is needed on this topic.
Keywords
Calcarea Carb
Homoeopathy
Kali carb
Subclinical hypothyroidism
Zulewski’s clinical score
INTRODUCTION
Hypothyroidism, characterised by insufficient thyroid function, is the most prevalent thyroid condition and one of the lifestyle metabolic disorders that negatively affects society.[1] Thyroid disease is often unrecognised, undetected, incorrectly diagnosed and untreated.[2] Compared to men, women are 4–8 times more likely to develop hypothyroidism. The risk is greatest immediately following childbirth and throughout menopause; it rises with age.[3] Subclinical hypothyroidism (SCH) is a condition characterised by elevated serum thyroid-stimulating hormone (TSH) levels, while serum T3 and T4 concentrations remain at the lower or normal end of the reference range. When thyroid hormones do not function properly, various physiological processes in the body are affected. This condition may persist for many years, with a risk of progression to overt thyroid failure. The overall prevalence of SCH is 4–10% in the general population and up to 20% in women, particularly those with thyroid autoimmunity and those older than 40 years.[4,5] The incidence of SCH in India is 11%, compared with 2% in the UK and 4–6% in the USA.[6,7] The euthyroid state is defined as a TSH level of 0.45–4.49 mIU/L, and SCH as TSH 4.5–19.9 mIU/L.[6,7] According to age, the upper limit of normal serum TSH is 3.5 mIU/L in individuals 20–29 years old, 4.5 mIU/L in those 50–59 years old and 7.5 mIU/L in those older than 80 years.[7,8] In younger individuals, thyroid problems are often latent or asymptomatic; symptoms often emerge as age increases. Clinical manifestations range from asymptomatic to severe symptoms. Weight gain, weakness, weariness, cold intolerance, constipation, hoarseness of voice, dry skin or irregular menstruation are among the usual symptoms, but clinical presentation can vary with age, sex or other factors.[9] SCH may resolve spontaneously within 2 years, particularly in patients with TSH values between 4 and 6 mIU/L, with or without thyroxine or levothyroxine therapy. The rate of progression to overt hypothyroidism (TSH ≥6.5 mIU/L) is 33–55% over 10–20 years. Thyroxine or levothyroxine therapy, along with vitamin D3 supplementation, may help improve the serum lipid profile and maintain adequate D3 levels for bone health.[10] Levothyroxine sodium is the primary treatment for hypothyroidism.[11] Unfortunately, it has several adverse effects, including anxiety, depression, headache, heat sensitivity, vomiting, diarrhoea, muscle cramps and chronic pain.[12,13] Therefore, many patients choose homoeopathy due to its effectiveness, minimal adverse effects and low cost. However, evidence supporting homoeopathic treatment of hypothyroidism is scarce; the majority of available evidence is anecdotal. The most frequently prescribed homoeopathic medicines for hypothyroidism are: Natrum mur, Kali carb, Thyroidinum, Calcarea Carb, Iodium, Calcarea iod, Thuja occidentalis, Sepia officinalis and Silica.[14,15]
In homoeopathy, there is no specific remedy for hypothyroidism. The medicine is selected using an individualistic approach; the physical, mental, emotional and social background of the patient. The two cases included in this manuscript describe the management of hypothyroidism with the help of individualised homoeopathic medicine.[16]
CASE REPORT
Case 1
Patient information
A 24-year-old married woman visited our outpatient department (OPD) on 07 May 2021 with pain and numbness in the lower limbs for the past 10 months. The complaints aggravated during cold and exertion and were ameliorated at rest. She also had throat pain, which was aggravated by changes in the weather and during menses. Her menstruation was irregular and profuse. She had consulted different physicians for effective treatment. On advice from an endocrinologist, she underwent a thyroid profile on 01 March 2021 and was found to have TSH 7.24 μIU/mL and diagnosed with hypothyroidism. Her problems subsided after using conventional medications, but she felt weak, exhausted and her appetite was diminished. In addition, after starting the medications, the duration and amount of her menstrual flow increased. This led her to stop taking the medications and seek homoeopathic treatment.
Medical history
She had typhoid at the age of 12 years, which subsided with allopathic treatment.
Family history
Her father was hypertensive and her mother had diabetes for the past 3 years and was taking allopathic treatment for it.
Analysis of the case
She was married 2 years prior and had no sexual desire. Her menarche was at 13 years of age with a normal menstrual cycle until past 8 months. Now, her menstrual cycle was irregular with profuse bright red blood, lasting for 6–8 days.
She was a healthy, educated, career-focused young woman, but since the complaints began a year prior, her mental serenity has been disrupted. She was very anxious about her future and this condition made her more anxious and fearful. She generally had no interest in sex; in fact, it agitated her. Her appetite was moderate with normal thirst. She had dryness in her mouth. She had a desire for salty things. Her stool was constipated and hard, passed at 1–2 day intervals with much difficulty. Her urine was normal and clear. She had sound sleep for around 7–8 h/day. Her skin was dry with a burning sensation.
Clinical examination
Her weight was 69 kg and her height was 160 cm. Her pulse rate and blood pressure were 78 beats/min and 112/78 mm of Hg, respectively. She had no anaemia, jaundice or cyanosis; her lymph nodes were not palpable.
Local examination
She looked flabby, had an earthy complexion and with slight puffiness on her face. Her skin was dry.
Diagnosis and assessment
The case was diagnosed based on the patient’s history, physical examination, symptomatology, Zulewski’s clinical score (ZCS) and TSH level [Figure 1].
- Thyroid-stimulating hormone (TSH) Case 1 before treatment.
The ZCS was used every month to assess the clinical symptoms. This scoring system contains seven subjective symptoms and five physical signs of hypothyroidism. Each symptom or sign, if present gets 1 point and if absent, gets 0 points.[17] The scores at baseline and after the end of treatment were eight and one, respectively [Figure 2]. The causal attribution was ascertained using the modified Naranjo criteria for homeopathy (MONARCH), which suggested a possible causal attribution between the medicine and outcome.[18]
- Zulewski’s clinical score Case 1.
Therapeutic intervention
The patient’s symptoms were analysed and evaluated, after which the totality was constructed. The following characteristic symptoms were considered for repertorisation:
Fear of disease
Irritability after coition
Anxiety about the future
Dryness of mouth
Desires for salty things
Skin was dry with a burning sensation
Throat pain was aggravated in the change of weather and during menses
Pain with numbness felt in the lower limbs and aggravated from exertion.
The pertorisation was performed using Kent’s repertory in the Hompath Classic Homoeopathic software (Version 8.0 premium, Mumbai) [Figure 3].[19] Calcarea Carb (25/10), Phosphorus (19/8), Natrummur (13/7) and Nux vomica (13/6) received the highest grades. Calcarea Carb (25/10) covered all the rubrics and had the highest marks. Furthermore, the patient’s most prominent symptoms, throat pain aggravated in change of weather and during menses, were found in Calcarea Carb. Hence, Calcarea Carb was selected after referring to the Materia Medica.[20,21]
- Repertorisation Case 1.
Follow-up and outcome
The patient was followed up every 15 days, during which gradual improvement was noted. During the follow-up, the potency, dose and repetition were modified according to homoeopathic philosophy [Table 1 and Figure 4]. No adverse events were observed during the treatment. The causal attribution was also ascertained through MONARCH. The score was 8, which suggested a possible causal attribution between the medicine and outcome [Table 2].
| Date of visit | Symptoms | Prescription | Justification |
|---|---|---|---|
| Baseline of prescription | She had fear of disease, irritability after coition, she was very anxious about her future, dryness of mouth, desires for salty things, her skin was dry with burning sensation, throat pain was aggravated in change of weather and during menses and she felt pain with numbness in the lower limbs and aggravated from exertion. | Calcarea carb 200/1 dose, followed by placebo | Baseline prescription based on totality of symptoms and referring to Materia Medica |
| May 24, 2021 | Pain in both legs and numbness was slightly better. Hoarseness of voice and pain in throat was aggravated. | Placebo | Improvement has started so interference is not required. |
| June 10, 2021 | Complaints reduced gradually, but pain in throat increased; she felt overall better. | Placebo | To wait and allow the medicine to act. |
| June 28, 2021 | Pain and numbness were occasional. Throat pain was reduced. Puffiness of face was slightly reduced. Menses were irregular but profuse in quantity, lasts 6 days (LMP June 18, 2021). Patient was overall much better. | Placebo. Advised to check serum TSH level. | To wait and allow the medicine to act. |
| June 05, 2021 | For the past few days, intensity of pain in the both legs as well as throat increased, but her sleep, bowel movement and appetite were normal. | Calcarea carb 200/1 dose followed by placebo | Intensity of the complaints was increased; hence same medicine repeated with same potency. |
| June 26, 2021 | Pain decreased and she could perform regular activity; she felt overall better and her skin looked normal | Placebo | To wait and allow the medicine to act. |
| July 16, 2021 | Complaints of mild rise of temperature with sneezing and pain in head, due to exposure to rain. Prior complaints were better | Rhustox 30/6 dose BD for 3 days | On the basis of acute totality. |
| August 02, 2021 | Improvement remained same, no changes overall. No fever, sneezing and pain in head which was complaining in the previous visit. LMP: 24 July 2021 (bright red colour, moderate amount of bleeding and lasts 5 days) | Calcarea carb 1M/1 dose followed by placebo for 15 days | Condition remained same, hence next higher potency prescribed. |
| August 20, 2021 | Moderate improvement noticed, no puffiness of face was seen; throat pain was also reduced. Since the last few visits, she has been more open about sharing her thoughts and feelings, which was missing when starting treatment. | Placebo | No new complaints with moderate improvement |
| September 08, 2021 | From last 2 weeks, no pain, tingling sensation was felt; all generals were normal. She felt very happy. LMP: 26 August 2021 (bright red colour, moderate amount and lasts 5 days) | Placebo | Marked improvement was noticed |
| September 24, 2021 | Marked improvement, no complaints and she could perform all her household duties. The patient’s husband was happy with the improvement in her health and behaviour. | Placebo. Advised to check serum TSH level. | Marked improvement was noticed. No new or old complaints were observed |
| October 11, 2021 | No new or old complaints. In addition, TSH level was found to be normal (2.01 μIU/mL) | Placebo and also advised to visit if any recurrence of symptoms | Advised to visit once in every 6 months |
| Till May, 2023 | No new or old complaints were observed and this was confirmed based on the ZCS. However, due to financial constraints, TSH, T3 and T4 levels were not measured during the follow-up. | Advised both the patients to report in case of recurrence of symptoms |
TSH: Thyroid-stimulating hormone, ZCS: Zuleswki’s clinical score, LMP: Last menstrual period, BD: Twice in a day
| S. No. | Domains | Yes | No | Not sure or not available | Case-1 | Case-2 |
|---|---|---|---|---|---|---|
| 1. | Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed? | +2 | −1 | 0 | +2 | +2 |
| 2. | Did the clinical improvement occur within a plausible timeframe relative to the drug intake? | +1 | −2 | 0 | +1 | +1 |
| 3. | Was there an initial aggravation of symptoms? | +1 | 0 | 0 | 0 | +1 |
| 4. | Did the effect encompass more than the main symptom or condition (i.e., were other symptoms ultimately improved or changed)? | +1 | 0 | 0 | +1 | +1 |
| 5. | Did overall well-being improve? (suggest using a validated scale or mention about changes in physical, emotional and behavioural elements) | +1 | 0 | 0 | +1 | +1 |
| 6. | Direction of cure: Did some symptoms improve in the opposite order of the development of symptoms of the disease? | +1 | 0 | 0 | 0 | 0 |
| 7. | Direction of cure: Did at least two of the following aspects apply to the order of improvement of symptoms From organs of more importance to those of less importance? From deeper to more superficial aspects of the individual? From the top downwards? |
+1 | 0 | 0 | 0 | 0 |
| 8. | Did “old symptoms” (defined as non-seasonal and noncyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement? | +1 | 0 | 0 | 0 | 0 |
| 9. | Are there alternate causes (other than the medicine) that with a high probability could have caused the improvement? (consider known course of disease, other forms of treatment and other clinically relevant interventions) | -3 | +1 | 0 | +1 | +1 |
| 10. | Was the health improvement confirmed by any objective evidence? (e.g. laboratory test and clinical observation) | +2 | 0 | 0 | +2 | +2 |
| 11. | Did repeat dosing, if conducted, create similar clinical improvement? | +1 | 0 | 0 | 0 | 0 |
| Total score | 8 | 9 | ||||
- Thyroid-stimulating hormone (TSH) Case 1 after treatment.
Case 2
Patient information
A 42-year-old woman visited our OPD on 05 July 2021 with complaints of hair fall and numbness in the right lower limb for 15 months. The numbness was aggravated while sitting; she often self-medicated with analgesics. The numbness had aggravated in the past 6 months and was affecting her work, due to which she finally sought treatment. Along with hair fall, she also reported easy breakage of hair.
The patient ascribed her complaints to her stressful life. On our advice, she underwent a thyroid profile on 09 July 2021 and was found to have TSH 10.94 μIU/mL, confirming hypothyroidism.
Medical history
She had dengue 6 years prior and was treated with conventional medicines and recovered well.
Family history
Her mother had osteoarthritis and her father had respiratory trouble. Both were treated with conventional medicine.
Analysis of the case
She was married 7 years prior and had two daughters. Her menarche was at 14 years of age and her cycle was irregular, with moderate bleeding, lasting for 5–6 days.
According to her husband, she was initially mentally stable and jovial. However, for 8–9 months, he noticed a change in her behaviour. Her moods fluctuated between happy and affectionate and very angry. Furthermore, she always wants company and feels uncomfortable when alone. Moreover, during the case taking, we noticed occasional confusion while detailing her complaints.
Her appetite was slightly decreased, with moderate thirst. She had a significant aversion to meat. Her bowel was irregular, hard and unsatisfactory. Her sleep was quite disturbed and unrefreshing. Despite her efforts, she could sleep for only 3–4 h at night; moreover, after midnight, she could not sleep at all. She had profuse perspiration, especially on her upper body. She felt worse in the cold. Her menstruation was irregular, with moderate bleeding and lasting for 5–6 days with mild pain in the lower abdomen (LMP: June 16, 2021).
Clinical examination
The patient had slight pallor, somewhat dry skin and was obese. Her body mass index was 29.2 kg/m2 and blood pressure 110/90 mm of Hg. There was no peripheral oedema, but slight puffiness of the face was noted. There was no anaemia, jaundice or cyanosis; her lymph nodes were not palpable.
Local examination
No swelling or mass was palpable on the neck on empty swallowing and no abnormalities of other systems were detected.
Diagnosis and assessment
The case was diagnosed based on patient history, physical examination, symptomatology, ZCS and TSH level [Figure 5].
- Thyroid-stimulating hormone (TSH) Case 2 before treatment. LFT: Liver function test
The SCH was used every month to assess the clinical symptoms. The scores at baseline and after the end of treatment were seven and two, respectively [Figure 6]. The causal attribution was ascertained using MONARCH, which suggested a possible causal attribution between the medicine and outcome.[18]
- Zulewski’s clinical score Case 2.
Therapeutic intervention
The patient’s symptoms were analysed and evaluated; the prominent mental and physical generals and particulars were used to formulate the totality. The following characteristics and symptoms were considered for repertorisation:
Desire for company.
Confusion of mind.
Changeability of mood.
Aversion to meat.
Perspiration mainly occurs on the upper part of the body.
She felt worse generally in cold weather.
Sleeplessness, especially after midnight.
Hair easily falls out and breaks easily.
Numbness in the right lower limbs, aggravated while sitting.
The pertorisation was done using Kent’s repertory in the Hompath classic Homoeopathic software (Version 8.0 premium, Mumbai) by considering several rubrics [Figure 7].[19] On repertorial analysis, Kali carb (27/11), Sepia officinalis (20/9), Silica (19/8), Arsenicum album (18/8) and Lycopodium clavatum (18/8) were the highest graded medicines. Kali carb (27/11) covered all the rubrics and with highest marks. Furthermore, in Kent’s repertory, the patient’s most prominent symptom, that is, numbness in the right lower limbs, included only Kali carb. After referring to the Materia Medica, Kali carb was selected as the remedy.[20,21]
- Repertorisation Case 2.
Follow-up and outcome
The patient was followed up every 15 days, during which there was a gradual improvement noted. During the follow-up, the potency, dose and repetition were modified based on the principles of homoeopathic philosophy. The details of the follow-ups are provided in Table 3 and Figure 8. No adverse events were observed during the treatment. The causal attribution was also ascertained through MONARCH [Table 2].
- Thyroid-stimulating hormone Case 2.
| Date of visit | Symptoms | Prescription | Justification |
|---|---|---|---|
| Baseline of prescription | Desire for company; confusion; changeability of mood; aversion to meat; heavy perspiration, mainly on the upper body; aggravated in cold weather; sleeplessness after midnight; hair easily falls out and breaks and numbness in the right lower limb aggravated while sitting | Kali carb 200/1 dose followed by placebo | Baseline prescription based on totality of symptoms and referring to Materia medica |
| July 16, 2021 | Numbness was increased along with pain from last week; she experienced more hair fall; but she felt generally better, appetite was normal and her sleep was good since 5–6 days. | Placebo | Aggravation of the presenting complaints, but the patient was overall better. Medicine was allowed to act. |
| August 02, 2021 | Complaints reduced with mild pain, but not troublesome; no change in hair fall; she felt overall better | Placebo | To wait and allow the medicine to act |
| August 20, 2021 | Pain and numbness were occasional; hair fall reduced slightly along with mild puffiness of face; constipation present; sleep improved. Menses were irregular but moderate in quantity with mild pain in the lower abdomen and lasting 6 days (LMP August 10, 2021). Patient felt overall much better. | Placebo | To wait and allow the medicine to act. |
| September 10, 2021 | Since the last few days, intensity of complaints (numbness and pain of right lower limbs) increased; she required analgesics for the pain; hair fall reduced but hair breaks easily and her sleep, bowel movement and appetite were normal. | Kali carb 200/1 dose followed by placebo | Intensity of the complaints was increased; hence same medicine repeated with same potency |
| September 28, 2021 | Complaints decreased in frequency; dryness of skin reduced; not happy with her bowel movement and overall she felt better. No puffiness of face seen. She had an injury on her right hand due to fall. LMP: September 16, 2021(Bright red in colour with normal bleeding and lasts for 5 days) | Arnica Montana 30/4 dose followed by placebo | Due to injury |
| October 18, 2021 | Improvement constant. Stool passed daily but hard and unsatisfactory. Occasional numbness in the lower limb; overall she felt better. The hand injury had healed. | Kali carb 1M/1 dose followed by placebo for 15 days | Condition remained same, hence next higher potency prescribed on the basis of acute totality |
| November 05, 2021 | Occasional numbness if she sits for a long time. Bowel movements easier now. No confusion noted while she was relating her follow-up. LMP 27 October 2021 (Bright red with mild pain and normal bleeding lasts 4 days) | Placebo | No new complaints; mild improvement occurs |
| November 26, 2021 | Moderate improvement noticed. Hair fall and breakage reduced. Overall, she felt better. | Placebo. Advised to check serum TSH level. | No new complaints with moderate improvement |
| December 16, 2021 | Since 2 weeks, no pain or numbness; all generals were normal. She felt very happy. Her husband was also happy with her behaviour towards his family. The TSH level normalised (3.71 μIU/mL) LMP 30 November 2021 (Bright red colour, moderate amount and lasts 5 days) | Placebo | Marked improvement was noticed. No new or old complaints were observed |
| December 30, 2021 | No complaints and could perform all her regular activities. All the generals were normal | Placebo and also advised to visit if any recurrence of symptoms | Advised to visit once every 6 months |
| Till May, 2023 | No new or old complaints were observed, and this was confirmed using the ZCS. However, due to financial constraints, TSH, T3 and T4 levels were not measured during the follow-up. | Advised to contact if symptoms recur |
TSH: Thyroid-stimulating hormone, ZCS: Zulewski’s clinical score
DISCUSSION
Hypothyroidism represents the tip of an iceberg; due to its subtle signs and symptoms, it needs extra caution regarding early detection and prompt treatment. If untreated, hypothyroidism poses a serious risk of morbidity and mortality. Both cases showed the classical symptoms of hypothyroidism and were treated with individualised homoeopathic medicines. The potency, dose and repetition were determined following homoeopathic principles, the patient’s susceptibility and the second principle of Kent’s philosophy.[22-24] Both patients showed progressive improvement in general and particular symptoms along with normalisation of TSH levels within 6–8 months. Case 1 exhibited significant improvement in anxiety, irritability and menstrual irregularities, while Case 2 demonstrated better emotional stability, sleep and hair quality. Notably, both patients experienced gradual weight reduction, reflecting improved metabolism and endocrine balance. The marked improvement in mental and physical spheres indicates that individualised homoeopathic therapy can positively influence both subjective and objective parameters in hypothyroid states. These observations highlight how potency and remedy repetition can influence not only objective symptoms, that is, weight loss but also subjective symptoms such as changeability of mood which provides a deeper understanding of the homeopathic intervention and its outcomes.
Few studies provide substantial evidence for the effectiveness of homoeopathy in treating hypothyroidism. At present, 22 studies on hypothyroidism have been published in different peer-reviewed journals.[25] A randomised clinical study was carried out by Sangita to assess the role of the homoeopathic remedy Thyroidinum 3X for treating hypothyroidism. The remedy yielded beneficial effects, with remarkable weight loss, symptomatic relief and no adverse events.[26] An observational study by Arora and Goel reported a marked reduction in TSH value after treatment with homoeopathic medicine.[27] Several case reports highlight the positive role of homoeopathy in the management of SCH.[28-31]
The strength of our case study lies in the pathological findings and clinical diagnosis through the ZCS, ensuring a comprehensive assessment of SCH. Both patients were systematically monitored and followed up. Both patients’ well-being was monitored using clinical and biochemical parameters; the TSH normalised within 6–8 months, indicating a significant therapeutic response. The curative effect of homeopathic medicine was assessed using MONARCH, further strengthening the validity of our findings. One limitation of our study was the lack of anti-thyroid peroxidase [TPO] antibody testing, which could have helped determine whether the cases were autoimmune (e.g., Hashimoto’s thyroiditis). We acknowledge the importance of this test in identifying the underlying aetiology. For future research, we strongly recommend incorporating autoimmune markers (anti-TPO and anti-thyroglobulin) to explore the potential role of homeopathy across different hypothyroid aetiologies. This would help determine whether homeopathic treatment exerts an immunomodulatory effect in autoimmune thyroid disorders or primarily aids in functional recovery. Despite this limitation, our study provides valuable evidence of the role of homoeopathy in managing SCH, with well-documented clinical and biochemical improvements.
The scope and effectiveness of homoeopathic remedies need to be explored with well-planned, documented case reports or randomised clinical studies.
CONCLUSION
The utility of homoeopathic medicine in the management of Schwas observed in both cases; both did not require thyroid replacement therapy. More documented cases and randomised studies are required to provide further evidence on the usefulness of homoeopathic medicines in managing SCH.
Acknowledgement:
The authors thank the patients for their active co-operation and participation.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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