Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital
Jabbour et al. World Journal of Emergency Surgery
Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital
Gaby Jabbour 2
Ayman El-Menyar 0 1
Ruben Peralta 4
Nissar Shaikh 3
Husham Abdelrahman 4
Insolvisagan Natesa Mudali 3
Mohamed Ellabib 4
Hassan Al-Thani 4
0 Clinical Medicine, Weill Cornell Medical School , Doha , Qatar
1 Clinical Research, Trauma Surgery, Hamad General Hospital , Doha , Qatar
2 Department of Surgery, Hamad General Hospital (HGH) , Doha , Qatar
3 Surgical Intensive Care Unit , HGH, Doha , Qatar
4 Trauma Surgery Section, Hamad General Hospital , Doha , Qatar
Background: Necrotizing fasciitis (NF) is a fatal aggressive infectious disease. We aimed to assess the major contributing factors of mortality in NF patients. Methods: A retrospective study was conducted at a single surgical intensive care unit between 2000 and 2013. Patients were categorized into 2 groups based on their in-hospital outcome (survivors versus non-survivors). Results: During a14-year period, 331 NF patients were admitted with a mean age of 50.8 ± 15.4 years and 74 % of them were males Non-survivors (26 %) were 14.5 years older (p = 0.001) and had lower frequency of pain (p = 0.01) and fever (p = 0.001) than survivors (74 %) at hospital presentation. Diabetes mellitus, hypertension, and coronary artery disease were more prevalent among non-survivors (p = 0.001). The 2 groups were comparable for the site of infection; except for sacral region that was more involved in non-survivors (p = 0.005). On admission, non-survivors had lower hemoglobin levels (p = 0.001), platelet count (p = 0.02), blood glucose levels (p = 0.07) and had higher serum creatinine (p = 0.001). Non-survivors had greater median LRINEC (Laboratory Risk Indicator for NECrotizing fasciitis score) and Sequential Organ Failure Assessment (SOFA) scores (p = 0.001). Polybacterial and monobacterial gram negative infections were more evident in non-survivors group. Monobacterial pseudomonas (p = 0.01) and proteus infections (p = 0.005) were reported more among non-survivors. The overall mortality was 26 % and the major causes of death were bacteremia, septic shock and multiorgan failure. Multivariate analysis showed that age and SOFA score were independent predictors of mortality in the entire study population. Conclusion: The mortality rate is quite high as one quarter of NF patients died during hospitalization. The present study highlights the clinical and laboratory characteristics and predictors of mortality in NF patients.
Necrotizing fasciitis; Predisposing factors; Presentation; Management; Mortality
Necrotizing fasciitis (NF) is a rare infectious disease
which is rapidly progressive and potentially fatal in
nature . Despite the advanced medical treatment, the
rate of mortality remains as high as 24-34 %; posing a
challenge for the diagnosis and management . The
mortality in NF patients primarily depends upon the
time of the medical and surgical interventions and
extent of spread of infection to the primary site
(subcutaneous tissue, fasciae, skin or muscles) . NF
patients with streptococcal infection are associated
with increased risk of complications and mortality (up
to 80 %) . There are various predisposing factors
for NF such as advanced age, diabetes mellitus,
peripheral vascular disease, obesity, chronic renal failure
and trauma . Therefore, early recognition of these
predisposing factors might help in the early definitive
management . Moreover, early surgical debridement
is a known contributor to improve outcomes in NF
To date, the most appropriate tool for diagnosis and
discrimination of NF is the LRINEC (Laboratory Risk
Indicator for NECrotizing fasciitis score) scoring system
proposed by Wong et al. . It is based on laboratory
parameters that are readily available for scoring in most
institutions to predict survival and discriminate
necrotizing from non-necrotizing infections. In addition, various
predictors of mortality based on predisposing factors
have been reported by different investigators. Previous
studies have identified advanced age (>60 years),
aeromonas and vibrio infection, liver cirrhosis, cancer,
hypotension, band polymorphonuclear neutrophils
(PMN) >10 %, and serum creatinine >2 mg/dL to be
independent predictors of mortality in NF cases [8, 9].
Despite the fact that mortality depends upon the time of
diagnosis, and management, the predisposing factors also
play an important role in the outcome. The present study
aims to determine the various predisposing and
prognostic factors associated with mortality in NF patients.
All consecutive patients admitted to the surgical
intensive care at Hamad General Hospital (HGH) with a
diagnosis of necrotizing fasciitis were retrospectively
included in this analysis between January 2000 and
December 2013. Patients were categorized into 2 groups
according to their hospital mortality (survivors versus
non-survivors). The present study included patients for
which the operative notes and or histopathological
findings indicate NF. Data included age, sex, presentation
and duration of symptoms, predisposing factors, risk
factors, causative microbiological organisms, on-admission
laboratory parameters, the Sequential Organ Failure
Assessment (SOFA) and LRINEC score, number of
operative debridement, length of intensive care and
hospital stay, recurrence and in-hospital mortality. The
anatomic site of infection was classified as extremity
(upper and lower limbs), abdominal/groin, chest/breast,
neck/facial, sacral and perineum. Exclusion criteria
included patients not admitted in the ICU (uncomplicated
mild forms of NF and were managed in the regular
ward), patients with cellulitis or superficial infection not
requiring aggressive debridement or antibiotics), and
The ratio of partial pressure of arterial oxygen and
fraction of inspired oxygen (PaO2/FiO2), platelets count,
bilirubin level, Glasgow coma score, mean arterial
pressure (MAP), vasopressor use, creatinine level and urine
output were used to calculate SOFA score . The
laboratory parameters such as C-reactive protein (CRP),
WBC, hemoglobin, sodium level, creatinine
concentration and glucose level were used to calculate the
LRINEC score . The various recorded parameters were
analyzed according to the final outcome. This study was
approved by the medical research center at HMC, Qatar
Data were presented as proportions, median (range) or
mean (± standard deviation), as appropriate. Baseline
demographic characteristics, laboratory findings, clinical
presentation, bacteriology and predisposing factors were
compared between non-survivors and survivors.
Analyses were conducted using Student-t test for
continuous variables and Pearson chi-square (χ2) test for
categorical variables; Fisher’s exact test was used, if
the expected cell frequencies were below 5. A 2-tailed
p < 0.05 was considered significant. Multivariate
logistic regression analysis was performed to look for
the predictors of mortality in the overall NF cohort
along with the odd ratio and 95 % confidence
interval. Data analysis was carried out using the Statistical
Package for Social Sciences version 18 (SPSS Inc,
During the 14-year study period, a total of 331
admissions were recorded for NF; 74 % were males and the
mean age was 50.8 ± 15.4 years. Among them, 246 were
survivors (74.3 %) and 85 (25.7 %) were non-survivors.
Non-survivors were 14.5 years older (61.6 ± 14.3 vs.
47 ± 14 years, p = 0.001) than survivors and the two
groups were comparable for gender. Moreover, higher
proportion of Qatari nationals (50.6 % vs. 27.2 %; p =
0.001) died due to NF as compared to non-Qatari
(Arabs) (Table 1).
On admission, the most common symptoms were local
swelling (78 %), pain/tenderness (68 %) and fever (67 %).
At presentation, non-survivors had significantly lower
frequency of pain (57 % vs. 72 %; p = 0.01) and fever (48
% vs. 73 %; p = 0.001) than survivors. The frequency of
diabetes mellitus (64 % vs. 47 %; p = 0.007),
hypertension (53 % vs. 29 %; p = 0.001), renal impairment (30 %
vs. 10 %; p = 0.001), coronary artery disease (25 % vs.
11 %; p = 0.001) and cerebrovascular accidents (8 %
vs. 1 %; p = 0.001) were significantly higher among
non-survivors as compared to survivor group.
However, traumatic injuries (18 % vs. 8 %; p = 0.04) were
observed more among survivors than non-survivors.
Site of infection
The most frequent site of infection was lower limb/thigh
(53 %) followed by perineum (25 %), abdominal/groin
region (11.5 %) and neck/facial region (6.3 %). Although,
the 2 groups were comparable for the site of infection;
sacral region had significantly higher frequency in
nonsurvivors (4.7 % vs. 0.4 %; p = 0.005) than survivors.
Non- survivors (n = 85)
61.6 ± 14.3
The initial blood investigations such as hemoglobin,
leukocyte count, serum sodium, bilirubin and C-reactive
protein were comparable among survivors and
nonsurvivors. However, non-survivors had lower levels of
hemoglobin (10.1 ± 2.6 vs. 11.4 ± 2.7; p = 0.001), platelet
count (230 ± 158 vs. 273 ± 141; p = 0.02), blood glucose
levels (10.7 ± 5.4 vs. 12.5 ± 8.4; p = 0.07) and had higher
serum creatinine [135 (
) vs. 91 (
); p =
0.001] as compared to survivors. The median
procalcitonin levels were non-significantly higher in non-survivors
[9.8 (0.1-182) vs. 3.3 (0.07-303); p = 0.28] than that of
survivors. In addition, non-survivors had significantly
higher median LRINEC [7 (
) vs. 5 (
); p =
0.001] and SOFA scores [12 (
) vs. 9 (
); p =
0.001] in comparison to the survivors group. Also,
non-survivors were less likely to receive combination
of antibiotics (>2 antibiotics) than survivors (28.2 %
vs. 49.3 %; p = 0.001).
Table 2 represents the involvement of microorganisms
in the pathogenesis of NF. Monobacterial gram positive
(42 %) were the most frequent organisms identified
followed by polybacterial (34 %) and monobacterial gram
negative (12.5 %). Among gram positive bacteria,
streptococcus (38 %) and staphylococcus (37 %) were
the most commonly identified organisms. Bacteriodes
(22 %) and E-Coli (11 %) were the predominant gram
negative microorganisms. Fungal infection was observed
in 30 (10.2 %) cases. Among them 22 (73.3 %) cases were
positive for tissue culture, 7 (23.3 %) were positive for
tissue as well as blood culture and one (3.4 %) case was
positive for blood culture alone. The frequency of
polybacterial (38 % vs. 32.5 %, p = 0.002) and monobacterial
gram negative infections (15.5 % vs. 11.3 %, p = 0.002)
were more evident in non-survivors; while
monobacterial gram positive organisms were commonly identified
among survivors (47.9 % vs. 25.4 %; p = 0.002) compared
Pseudomonas (14.5 % vs. 5.4 %; p = 0.01) and Proteus
infections (5.3 % vs. 0.5 %; p = 0.005) were the most
commonly associated microorganisms among
Management and outcomes
The median number of surgical debridements performed
was 2 (ranged 1–8) and the hospital length of stay was
) days. The number of debridements was
comparable in the 2 groups. The median ICU stay [9 (
vs. 5 days (
); p = 0.002], overall hospital stay [20.5
) vs. 15 (
) days; p = 0.02] and the frequency
of septic shock (48 % vs. 20 %; p = 0.001) were
significantly higher in non-survivors than the survivor group.
Recurrent admissions for NF were required for 13 (4 %)
patients; of whom 11 patients were admitted twice and
two patients required three admissions. A total of 85
patients died in the present study with an overall
mortality rate of 26 %. Table 3 shows the major causes of
mortality which mainly involved septic shock alone and a
combination of bacteremia and multiorgan failure.
Table 4 shows multivariate analysis for the major
predictors of mortality. SOFA scoring followed by age were
the independent predictors of mortality in the present
study cohort. The proportion of mortality based on the
bacteriology results is given in Table 5.
None of the co-morbidities showed significant
association with types of microorganisms and combination of
antibiotics used except coronary heart disease (CHD).
Significantly higher frequency of CHD patients were
prescribed more than two antibiotic combinations (p =
0.009). Table 6 compares the co-morbidities with
microbiological data and antibiotics used.
The association of high morbidity and mortality in
necrotizing fasciitis (NF) patients urges the need for early
diagnosis and identification of potential risk factors of
worse outcomes. The present study is interestingly large
series of NF cases from a Middle Eastern small
Positive blood and
population country that assesses various contributing
factors to mortality. NF is a fulminant life-threatening
infection of the musculoskeletal soft tissues
characterized with rapid progression that typically requires urgent
surgical interventions [11, 12]. The classic and frequent
manifestations associated with NF usually include a triad
27 (38 %)
18 (25.4 %)
of pain, tender local swelling, and fever [13, 14].
Consistent with earlier reports, this triad was more frequently
observed among survivors in the current series.
Moreover, out of proportion pain on physical examination
and unresolved cellulitis are major diagnostic clues for
NF, however, these clinical features often appear later in
the disease course . Therefore, delayed diagnosis is
usually associated with high mortality (up to 25 %)
among young adults which could even reach 44 % in
elderly population [9, 15]. The number of in-hospital
deaths in the present study is 26 % which is consistent
with earlier studies.
The current literature suggests that NF could occur at
any age but is mostly reported within the age range of
32 to 57 years [16, 17]. In the present study, the mean
age was 51 years and the non-survivors were 14.5 years
older than the survivors at the time of presentation. The
reason of the frequently observed association of NF with
advanced age could be explained in part by the
preexisting co-morbidities and immunosuppression. In this
context, Golger et al.  reported advanced age,
streptococcal toxic shock syndrome and
immunocompromised status to be independent predictors of
mortality in NF patients.
The frequently associated co-morbidities in NF are
diabetes mellitus, malignancy, chronic cardiac disease,
peripheral vascular disease, chronic renal disease, and
immune-suppression . Other predisposing factors
include traumatic injuries, smoking, history of muscular
injection and paraplegia. Diabetes mellitus, hypertension,
and renal impairment were the most frequent
comorbidities associated with mortality in the current
series. Diabetes mellitus remains the main co-morbidity
in NF patients which is associated with prolonged
hospitalization and increased mortality [13, 20]. In this
study, patients with a history of diabetes mellitus showed
considerably rapid progress of the severity of NF and
mortality. This finding could be attributed in part to the
hyperglycemic status that compromises the immunity
status and fosters bacterial growth. However, the initial
readings of serum sugar in the study cohort were
nonsignificantly lower in non-survivors. Unfortunately, the
current database did not include HbA1c to explain
inpart this finding. The other common comorbidity in the
present study was hypertension, which might cause
disruption of the microvascular supply and reduction of
tissue oxygenation and antimicrobial delivery. The
frequency of hypertension was significantly higher in the
non-survivors group. Consistently, Huang et al. 
demonstrated a high association of hypertension among NF
non-survivors. Earlier studies have also outlined the
increased risk of NF in the presence of the
abovementioned pathologies [21, 22]. Furthermore, elderly
patients with such co-morbidities who are suspected to
have NF should be evaluated thoroughly to rule out NF,
even in the absence of the usual hard manifestations.
Although, NF might affect any part of the body, earlier
studies have reported frequent involvement of the
extremities, perineum, head & neck and truncal regions
. In the current series, the most frequent sites of
infection included lower limbs, perineum, abdominal/
groin and neck/facial regions. The site of infection and
its expansion also affect mortality. It has been suggested
that affection of the head and neck region is associated
with higher mortality as accounted for the proximity
with various vital anatomical structures . Mao et al.
 analyzed the craniocervical NF cases with and
without thoracic extension and observed a poor survival with
thoracic extension as compared to non-thoracic
extension. An earlier study reported a lower rate of mortality
in extremity infection in comparison to abdominal and
perineal infections . Urschel  suggested that NF
infection extending proximally to pelvis or trunk might
have worse prognosis. Therefore, early and aggressive
treatment aimed at restriction of the infection with
repeated surgical debridement could be useful in
achieving better survival rates.
Unfortunately, the first stage of NF disease is frequently
masked by non-specific manifestations, which prevents
effective and timely specific therapy . Therefore, early
identification and diagnosis is mandatory and should not
rely only on the clinical signs alone . Consequently,
prognostic indicators such as laboratory markers and
specific patient characteristics obtained from the medical
history would assist in the early diagnosis, risk
stratification and decision making . Earlier studies identified
some laboratory findings such as anemia, elevated
creatinine, and increased white cell count to be non-specifically
associated with NF which might affect prognosis. In the
present series, non-survivors had significantly lower levels
of hemoglobin and platelet count and had higher serum
creatinine as compared to survivors. Similarly, an earlier
study observed that non-survivors had significantly lower
levels of hemoglobin and platelet and presented with
higher levels of serum glucose and creatinine than the
survivors . An earlier study reported that aeromonas
infection, advanced age, band PMNs >10 %, serum
creatinine (>2.0 mg/dL), and an activated prothrombin time
(>60 s) were found to be the independent predictors of
mortality in NF patients . In the present study the
major predictors of mortality were age and SOFA scoring.
SOFA score is a useful tool to assess the severity of NF
based on the involvement of major organ systems. In the
present series, non-survivors had significantly higher
median SOFA scores which are in accordance with the
current literature. The initial increase in SOFA score
during the first two days of ICU admission successfully
predicts high rates of mortality (50-95 %) . This
finding could be used as an alarming indictor and encourages
physicians to refer those patients as early as possible to
the tertiary care centers for the appropriate intensive care.
Therefore, the use of validated prognostic factors in daily
clinical practice, especially for initial diagnosis in
emergency departments, would help physicians for timely
management and obtaining better outcomes.
It has been suggested that bacteremia is one of the
frequent complications of NF which has been associated
with higher risk of mortality . In the current study,
21 % of the patients had positive blood and tissue
cultures and subsequently had higher mortality rate in
comparison to those who had negative blood culture.
Similarly, Huang et al.  observed four-fold increased
rate of mortality in patients with positive blood cultures
than those who had negative cultures.
Consistent with previous reports , gram positive
microorganisms, mainly streptococcus and
staphylococcus organism, were frequently identified in the present
study cohort. On the other side, bacteriodes and E-coli
were the predominant gram negative organisms. In the
present study, monobacterial infections with
pseudomonas and proteus were the most commonly associated
microorganisms among non-survivors. However, earlier
Twenty-five (30 %) patients Independent predictors of mortality include
died, 17 (68 %) within 72 h congestive heart failure (P = 0.033) and a
of admission. Total n = 82 history of gout (P = 0.037)
Independent predictors of mortality were
skin necrosis on the initial clinical
examination (OR = 15.48; 95 % CI = 2.02–
118.91) and acute renal failure
(OR = 118.91; 95 % CI 7.66–5135.79)
Total n = 89
The overall mortality
rate was 16.9 % (total
n = 166)
satisfied the inclusion
criteria. Overall mortality
was 20 %
The crude hospital
mortality rate was 11.1 %
(total n = 216)
a24/128 (19 %)
Mortality rates varied
between 6 hospitals
from 9 % to 25 %
(n = 296)
Overall mortality was
12.1 % (n = 57/472) and
the 30 day mortality was
11.0 % (n = 52/472)
Overall mortality was 28 %
(total n = 29)
Predictors of mortality
The extent of the infection (P = 0.0234) was
the only significant, independent predictor
A delay in surgery of > 24 h was correlated
with increased mortality (p < 0.05; RR = 9.4)
Independent predictors of mortality included
WBC > 30 000 × 103/μL, creatinine level >
2 mg/dL (176.8 μmol/L), and heart disease at
A poor WBC response, high serum urea and
creatinine, and low haemoglobin level were
the predictors for mortality
Advanced age (OR, 1.04; 95 % CI, 1.01 to 1.08;
p = 0.012), streptococcal toxic shock syndrome
(OR, 10.54; 95 % CI, 2.80 to 39.44; p < 0.001),
and immunocompromised status (OR, 3.97;
95 % CI, 1.04 to 15.19; p = 0.044) were
independent predictors of mortality
Patients aged > or =44 years at the time of
admission were 5 times as likely to die in the
hospital than patients who were aged
< or =43 years (adjusted RR 5.08, P = 0.03)
Aeromonas infection, Vibrio infection, cancer,
hypotension, and band form WBC > 10 % were
independent positive predictors of mortality
(P < 0.05). Presence of hemorrhagic bullae was
a negative predictor of mortality (P < 0.05)
Predictors of mortality included advanced age,
class C liver cirrhosis, ascites, higher serum
creatinine, and lower hemoglobin and platelet
The presence of hemorrhagic bullous skin
lesions/necrotizing fasciitis, primary septicemia,
a greater severity of illness, absence of
leukocytosis, and hypoalbuminemia were the
significant risk factors for mortality
Patient age and severity of disease (reflected
by shock requiring vasopressors and renal
failure postoperatively) were the main
predictors of mortality
Eight independent predictors of mortality :
liver cirrhosis, soft tissue air, Aeromonas
infection, age > 60 years, band
polymorphonuclear neutrophils >10 %,
activated partial thromboplastin time >60 s,
bacteremia, and serum creatinine >2 mg/dL
Renal and liver failure, thrombocytopenia,
initial proximal involvement, and hypotension
on admission were predictors of mortality in
UL NF. The ALERTS (Abnormal Liver function,
Extent of infection, Renal impairment,
Thrombocytopenia, and Shock) score with a
cutoff of 3 appeared to predict mortality.
Diabetes mellitus, obesity, and renal failure
were significantly associated with NF-related
death. However, age, sex, and race were
independently associated with the rate of
Clinically significant difference based on the
timing of surgical intervention (< or > 6 h)
(17.5 % in late vs. 7.5 % in early intervention
group), however no statistical significance
Khamnuan P et al. 
Khamnuan P et al. 
studies reported clostridial , beta-streptococci ,
aeromonas and vibrio  infections to be associated
with poor outcomes.
Prompt and aggressive debridement is important for
the management of NF. The debridement aims to
remove all necrotic tissue until the local infectious process
is treated. There is a positive correlation between the
survival rate and early diagnosis with appropriate
surgical debridement in NF patients . In the present
study, the median number of debridement procedures
performed per patient was two interventions, and these
were comparable for both non-survivors as well as
survivors. Data suggested that early surgical intervention is
crucial in reducing morbidity and mortality in NF
patients . However, there is still a lack of clear
definition on ‘How early should we be’. Kobayashi et al.
showed significantly lower mortality in the early
intervention group (within 12 h after diagnosis) . Delay of
surgical treatment of >12 h was associated with an
increased number of surgical debridement, septic
shock and acute renal failure . Hadeed et al. 
reported outcomes of earlier surgical treatment
(within the first 6 h) and found that although there
was no statistically significantly difference in mortality
between the study groups, higher mortality among
late intervention group was clinically significant.
Moreover, the outcomes in terms of the duration of
hospital and intensive care unit stay were in favor of
early intervention .
The appropriate and early antibiotic use and intensive
care measures significantly appear to affect patients’
outcomes. In the past decades, patients with NF have higher
mortality rates (up to 70 %), however, currently with
improved surgical and intensive care treatment, mortality
rates have declined to less than 30 % [37, 38]. Not only
delayed diagnosis and surgical intervention influences
in-hospital mortality, but also, the development of
secondary complications has unfavorable impact . The
major complications that significantly related to
mortality in the present series were bacteremia, septic shock
and multiorgan failure. Therefore, appropriate
prevention and management of such complications are vital for
improving the outcome in these vulnerable patients .
Table 7 summarizes the published studies of mortality
in NF and NSTI worldwide between 2000 and 2016.
There is no consensus for specific predictors of mortality
between these 20 studies including the current study.
The design and objectives of studies as well as the
availability of clinical and laboratory data are the main reason
of the diversity of predictors of mortality among these
studies. The present study has several limitations. It is
retrospective in nature. It lacks information regarding
the exact time of commencing antibiotics, delay in
diagnosis, the timing of surgical debridement and the type of
surgery performed post diagnosis. Also, the sensitivity
and minimum inhibitory concentration of the bacteria
and percentage of multi drug resistant strains is not
available . Data describing the empiric antibiotic
treatment in the emergency room is also not available for
analysis. Moreover, procalcitonin has been introduced
recently at HGH; therefore not all the NF in the past
underwent procalcitonin assessment at admission.
Further prospective studies are required to determine
the time interval between the diagnosis and treatment
which could possibly influence the mortality among
The mortality rate is quite high as one quarter of NF
patients died in the hospital. The present study
highlights the clinical characteristics and predictors of
mortality in NF patients. It is important to have a high index
of suspicion at initial presentation. Use of prognostic
tools in the daily clinical practice will help physicians for
the proper on-time management. The present study
provides useful information on the severity and outcome of
NF patients that will inform institutional guidelines for
the on-time treatment of NF.
CRP, C-reactive protein; LRINEC, laboratory risk indicator for necrotizing
fasciitis score; MAP, mean arterial pressure; NF, necrotizing fasciitis;
NSAID, non-steroidal anti-inflammatory drug; SOFA, sequential organ
We thank all the surgical intensive care unit staff, Hamad General Hospital,
Doha, Qatar. All the authors have read and approved the manuscript, and
all have no financial issue to disclose.
This research did not receive any specific grant from any funding agency in
the public, commercial or not-for-profit sector.
Availability of data and materials
Data supporting the present findings can be obtained, if needed, after
getting permission from the medical research center (MRC) at HMC
(). A waiver of consent (IRB # 14066/14) was granted for
this study from MRC as there was no direct contact with patients and all
data were retrieved retrospectively under full confidentiality to protect
GJ: acquisition of data, writing manuscript and review of manuscript; AE:
conception and design of the study, interpretation of data, writing
manuscript and critical review of manuscript; RP: study design, helped to
draft manuscript and review of manuscript; NS: acquisition of data, writing
manuscript and critical review of manuscript; HA: study design, acquisition
of data and critical review of manuscript; INM: acquisition of data, writing
manuscript and review of manuscript; ME: acquisition of data, writing
manuscript and critical review of manuscript; HA: conception and design
of the study, writing manuscript and critical review of manuscript. All authors
read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Ethical approval was obtained from the Medical Research Center
(IRB# 14066/14) and waiver consent was approved for this retrospective
study by the Hamad Medical Corporation, Doha, Qatar.
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