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The approval covered the retrospective secondary analysis of routinely collected electronic health records generated at AFHSR between January 2017 and April 2025 and remains valid for five years. No data were prospectively collected for research purposes prior to ethics approval. The Research Ethics Committee waived the requirement for individual informed consent because the study involved retrospective analysis of anonymized clinical data, posed minimal risk to participants, and did not involve any direct patient contact. All data were extracted from the hospital electronic health record system and fully anonymized prior to analysis, with no access to personal identifiers. The study was conducted in accordance with the principles of the Declaration of Helsinki and complied with applicable institutional policies and national regulations governing the secondary use of health data in Saudi Arabia, including relevant guidance from the Saudi Ministry of Health on informed consent and data protection.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1163"}}