Keratosis conjunctiva of unknown significance: a case report

Keratosis conjunctiva of unknown significance: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Keratosis conjunctiva of unknown significance: a case report lihong huang, Dazheng Zhang, Jing Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4386239/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Cutaneous hornis a relatively uncommon neoplasm of the eyelid skin, frequently observed in exposed areas such as the extremities, head, and face. However, its etiology remains incompletely elucidated. Case presentation We report the case of a 32-year-old Asian female patient who presented with corneal mass of right eye of 10 years duration. She was examined and underwent excision, with biopsy showing cornea cutaneous horn. Conclusion The mass is benign and exhibits a slow growth pattern. However, post-removal, the mass demonstrated recurrent enlargement. It is hypothesized that the disease may bear resemblance to solar keratosis. Consequently, the etiology remains uncertain and further investigation is warranted. Cutaneous horn cornea mass recurrent proliferation solar keratosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction The cutaneous horn is a frequently encountered clinical condition that typically manifests as a skin lesion. The disease was officially recognized as a medical disorder in the late eighteenth century by London surgeons Everard Home and his brother-in-law John Hunter, thereby establishing its characterization within the realm of medicine[1]. We report the case of cornea cutaneous horn in a 32-year-old Asian female patient presenting with corneal mass. Case Presentation A 32-year-old Asian female patient who presented with the inner corner of the right eye has been growing for 10 years. She was admitted to our hospital in October 2023. Seven months ago, the growth of a white mass in the inner canthus of the right eye, approximately the size of a grain of rice, resulted in its extension onto the cornea. Consequently, surgical excision was performed on the lesion involving both conjunctiva and superficial sclera at an external hospital. One month postoperatively, a recurrent white mass with identical shape and size reappeared at the original site. Following consultation with a physician, part of the mass was successfully excised by gentle swabbing under slit-lamp examination. However, 18 days later, another white mass with similar characteristics resurfaced. The patient did not exhibit any visual impairment, redness of the eyes, ocular pain, photophobia-induced tearing or other discomfort. There was no increase in secretions observed. Furthermore, there was no history of ocular trauma or surgery reported by the patient. Systemic examination revealed no abnormalities and ophthalmological specialist examination indicated a visual acuity of 1.0 with intraocular pressure (IOP) measured at 15mmHg in the right eye. In the right eye, there was an irregularly shaped mass measuring approximately 3mm*3mm*4mm found on the nasal conjunctiva, which infiltrated into the corneal limbus by around 1 mm. The mass displayed a slightly raised appearance with a wide base and white coloration, indicating an uneven surface and clearly defined borders (Figure1). There was no evidence of conjunctival congestion or presence of nourishing vessels or neovascularization observed. The cornea maintained its transparency without any abnormalities noted. Anterior segment optical coherence tomography (OCT) demonstrated that this lesion extended into the intranasal limbus by 1 mm and reached up to the stromal layer (Figure 2). Clinical diagnosis: Treatment process: In February 2023, after local infiltration at the outer hospital, conjunctival and superficial sclera lesions were surgically excised. (Specific details are unavailable due to missing cases). In October 2023, following relevant examinations at our hospital, a cotton swab was gently applied to the mass site under the slit lamp. The mass partially detached with a brittle consistency and no bleeding was observed at its base (Figure 3). Pathological analysis revealed minimal keratinized powder and corneal mass in the right eye (Figure 4). The patient reported experiencing other ocular discomfort. The patient declined pharmacotherapy and surgical intervention. After 18 days of wiping, the tumor regenerated while maintaining its original shape (Figure 5). Subsequently, another round of slit-lamp wiping was performed on the patient (Figure6), who continued to refuse further treatment options. One month later, during a follow-up visit to our clinic, it was observed that the tumor had regrown with identical characteristics as before (Figure 7). Due to strong personal preferences expressed by the patient, further examination at subsequent stages was declined. Discussion Cutaneous horns are infrequent neoplasms found on the skin of the eyelids, constituting approximately 4% of all eyelid mass[2][3]. They typically manifest in sun-exposed regions like the extremities, head, and face but rarely occur on the trunk or limbs. Moreover, they exhibit a male predominance. This mass can develop from extensive epidermal lesions and comprise concentric layers of cortical epithelial cells lacking bony nuclei which differentiate them from true horns. However, despite continuous research endeavors, their precise pathogenesis remains incompletely elucidated. Particularly noteworthy was its exceptional presentation within the conjunctiva of a young Asian woman documented in this case study. Associated lesions encompass keratosis sebum accumulation verrucae (warts), trichilemmal cysts Bowen's disease (squamous cell carcinoma in situ) invasive squamous cell carcinoma malignant melanoma as well as basal cell carcinoma[4]. The clinical presentation of solar keratosis [5-7] is characterized by a flat and slightly raised lesion with clear boundaries, appearing white or yellowish white in color. It is a non-invasive tumor that typically affects only one eye. The development of actinic keratosis (AK) in the conjunctiva remains controversial, with various potential factors implicated such as ultraviolet light exposure, chronic inflammation, surface microtrauma, and HPV infection[8][9]. Its pathological features include hyperplasia and squamous metaplasia of the conjunctival epithelium, hyperkeratosis or hyperkeratosis of surface cells, absence of granular layer, acanthosis thickening and basal cell proliferation, solar elastic fibrosis, as well as infiltration of lymphocytes and plasma cells. In this case study, the patient's occupational characteristics involved prolonged computer use. Despite resection of the lesion tissue, continuous proliferation was observed along with histopathological findings indicating keratinization. Therefore, it is suggested that this disease may share similarities with solar keratosis. Conclusion We present an exceptionally rare case of aggressive conjunctival keratosis involving the cornea in young Asian women who have been exposed to prolonged indoor work conditions. Despite resection, the tumor exhibits persistent growth at the original site, posing challenges for local treatments and surgical interventions. Importantly, no similar lesions have been identified on other areas of the skin. This report provides valuable insights into the epidemiological and pathological characteristics of solar keratosis. Declarations Acknowledgements We would like to express our gratitude to the patient for granting us consent to utilize the various images, which we believe will shed light on this exceptional medical condition. Additionally, we extend our appreciation to the hospital for authorizing the publication of this paper. This case report obtained the informed consent of the patient and received the ethical review of Hospital. Author contributions All authors contributed to the review and analysis of various articles. Huang was responsible for writing the case presentation and drafting the initial version of the case report, Zhang performed the surgical procedure on the patient and compiled relevant articles related to the case, while Zhou finalized and authored the comprehensive case report, also providing ongoing patient follow-up. The final manuscript was read and approved by all authors. Funding Not applicable. Availability of data and materials All data and materials are available upon request by the Editor-in-Chief. Declarations Ethics approval and consent to participate. Both ethical clearance and informed consent were obtained from the institutional review board of the Department of Ophthalmology for this case report. Consent for publication The patient provided written informed consent for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests Not applicable. References E. Home, “VI. observations on certain horny excrescences of the human body,” Philosophical Transactions of the Royal Society of London , vol. 81, pp. 95–105, 1791. Yu, R. C. H., Pryce, D. W., Macfarlane, A. W., & Stewart, T. W. (1991). A histopathological study of 643 cutaneous horns. British Journal of Dermatology , 124 (5), 449-452. Kumaresan, M., Kumar, P., & Pai, M. V. (2008). Giant cutaneous horn. Indian journal of dermatology , 53 (4), 199-200. Bondeson, Jan M.D., Ph.D. Everard Home, John Hunter, and Cutaneous Horns: A Historical Review. The American Journal of Dermatopathology 23(4):p 362-369, August 2001. Roewert‐Huber, J., Stockfleth, E., & Kerl, H. (2007). Pathology and pathobiology of actinic (solar) keratosis–an update. British Journal of Dermatology , 157(s2), 18-20. Frost, C. A., & Green, A. C. (1994). Epidemiology of solar keratoses. British Journal of Dermatology, 131(4), 455-464. Ackerman, A. B., & Mones, J. M. (2006). Solar (actinic) keratosis is squamous cell carcinoma. British Journal of Dermatology , 155 (1), 9-22. Woods M, Chow S, Heng B, Glenn W, Whitaker N, Waring D, et al.Detecting human papillomavirus in ocular surface diseases. Invest Ophthalmol Vis Sci 2013; 54: 8069–8078. McDonnell JM, Mayr AJ, Martin WJ. DNA of human papillomavirus type 16 in dysplastic and malignant lesions of the conjunctiva and cornea. N Engl J Med 1989; 320: 1442–1446. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4386239","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":302337158,"identity":"9dec8ba9-838c-4919-bbf1-c81d8ee4d0ac","order_by":0,"name":"lihong huang","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"lihong","middleName":"","lastName":"huang","suffix":""},{"id":302337159,"identity":"013644a6-42ea-458a-92dc-b0c76442e868","order_by":1,"name":"Dazheng 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The disease was officially recognized as a medical disorder in the late eighteenth century by London surgeons Everard Home and his brother-in-law John Hunter, thereby establishing its characterization within the realm of medicine[1]. We report the case of cornea cutaneous horn in a 32-year-old Asian female patient presenting with corneal mass.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e32-year-old Asian female patient who presented with the inner corner of the right eye has been growing for 10 years. She was admitted to our hospital in October 2023. Seven months ago, the growth of a white mass in the inner canthus of the right eye, approximately the size of a grain of rice, resulted in its extension onto the cornea. Consequently, surgical excision was performed on the lesion involving both conjunctiva and superficial sclera at an external hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne month postoperatively, a recurrent white mass with identical shape and size reappeared at the original site. Following consultation with a physician, part of the mass was successfully excised by gentle swabbing under slit-lamp examination. However, 18 days later, another white mass with similar characteristics resurfaced. The patient did not exhibit any visual impairment, redness of the eyes, ocular pain, photophobia-induced tearing or other discomfort. There was no increase in secretions observed. Furthermore, there was no history of ocular trauma or surgery reported by the patient. Systemic examination revealed no abnormalities and ophthalmological specialist examination indicated a visual acuity of 1.0 with intraocular pressure (IOP) measured at 15mmHg in the right eye. In the right eye, there was an irregularly shaped mass measuring approximately 3mm*3mm*4mm found on the nasal conjunctiva, which infiltrated into the corneal limbus by around 1 mm. The mass displayed a slightly raised appearance with a wide base and white coloration, indicating an uneven surface and clearly defined borders (Figure1). There was no evidence of conjunctival congestion or presence of nourishing vessels or neovascularization observed. The cornea maintained its transparency without any abnormalities noted. Anterior segment optical coherence tomography (OCT) demonstrated that this lesion extended into the intranasal limbus by 1 mm and reached up to the stromal layer (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical diagnosis: Treatment process: In February 2023, after local infiltration at the outer hospital, conjunctival and superficial sclera lesions were surgically excised. (Specific details are unavailable due to missing cases). In October 2023, following relevant examinations at our hospital, a cotton swab was gently applied to the mass site under the slit lamp. The mass partially detached with a brittle consistency and no bleeding was observed at its base (Figure 3). Pathological analysis revealed minimal keratinized powder and corneal mass in the right eye (Figure 4). The patient reported experiencing other ocular discomfort. The patient declined pharmacotherapy and surgical intervention. After 18 days of wiping, the tumor regenerated while maintaining its original shape (Figure 5). Subsequently, another round of slit-lamp wiping was performed on the patient (Figure6), who continued to refuse further treatment options. One month later, during a follow-up visit to our clinic, it was observed that the tumor had regrown with identical characteristics as before (Figure 7). Due to strong personal preferences expressed by the patient, further examination at subsequent stages was declined.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCutaneous horns are infrequent neoplasms found on the skin of the eyelids, constituting approximately 4% of all eyelid mass[2][3]. They typically manifest in sun-exposed regions like the extremities, head, and face but rarely occur on the trunk or limbs. Moreover, they exhibit a male predominance. This mass can develop from extensive epidermal lesions and comprise concentric layers of cortical epithelial cells lacking bony nuclei which differentiate them from true horns. However, despite continuous research endeavors, their precise pathogenesis remains incompletely elucidated. Particularly noteworthy was its exceptional presentation within the conjunctiva of a young Asian woman documented in this case study. Associated lesions encompass keratosis sebum accumulation verrucae (warts), trichilemmal cysts Bowen's disease (squamous cell carcinoma in situ) invasive squamous cell carcinoma malignant melanoma as well as basal cell carcinoma[4]. \u003c/p\u003e\n\u003cp\u003eThe clinical presentation of solar keratosis\u003csup\u003e[5-7]\u003c/sup\u003eis characterized by a flat and slightly raised lesion with clear boundaries, appearing white or yellowish white in color. It is a non-invasive tumor that typically affects only one eye. The development of actinic keratosis (AK) in the conjunctiva remains controversial, with various potential factors implicated such as ultraviolet light exposure, chronic inflammation, surface microtrauma, and HPV infection[8][9]. Its pathological features include hyperplasia and squamous metaplasia of the conjunctival epithelium, hyperkeratosis or hyperkeratosis of surface cells, absence of granular layer, acanthosis thickening and basal cell proliferation, solar elastic fibrosis, as well as infiltration of lymphocytes and plasma cells. In this case study, the patient's occupational characteristics involved prolonged computer use. Despite resection of the lesion tissue, continuous proliferation was observed along with histopathological findings indicating keratinization. Therefore, it is suggested that this disease may share similarities with solar keratosis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe present an exceptionally rare case of aggressive conjunctival keratosis involving the cornea in young Asian women who have been exposed to prolonged indoor work conditions. Despite resection, the tumor exhibits persistent growth at the original site, posing challenges for local treatments and surgical interventions. Importantly, no similar lesions have been identified on other areas of the skin. This report provides valuable insights into the epidemiological and pathological characteristics of solar keratosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe would like to express our gratitude to the patient for granting us consent to utilize the various images, which we believe will shed light on this exceptional medical condition. Additionally, we extend our appreciation to the hospital for authorizing the publication of this paper.\u003c/em\u003e\u003cem\u003e\u0026nbsp;This case report obtained the informed consent of the patient and received the ethical review of Hospital.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors contributed to the review and analysis of various articles. Huang was responsible for writing the case presentation and drafting the initial version of the case report, Zhang performed the surgical procedure on the patient and compiled relevant articles related to the case, while Zhou finalized and authored the comprehensive case report, also providing ongoing patient follow-up. The final manuscript was read and approved by all authors.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNot applicable.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll data and materials are available upon request by the Editor-in-Chief.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDeclarations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval and consent to participate.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBoth ethical clearance and informed consent were obtained from the institutional review board of the Department of Ophthalmology for this case report.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe patient provided written informed consent for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNot applicable.\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eE. Home, \u0026ldquo;VI. observations on certain horny excrescences of the human body,\u0026rdquo; \u003cem\u003ePhilosophical Transactions of the Royal Society of London\u003c/em\u003e, vol. 81, pp. 95\u0026ndash;105, 1791.\u003c/li\u003e\n\u003cli\u003eYu, R. C. H., Pryce, D. W., Macfarlane, A. W., \u0026amp; Stewart, T. W. (1991). A histopathological study of 643 cutaneous horns. \u003cem\u003eBritish Journal of Dermatology\u003c/em\u003e, \u003cem\u003e124\u003c/em\u003e(5), 449-452.\u003c/li\u003e\n\u003cli\u003eKumaresan, M., Kumar, P., \u0026amp; Pai, M. V. (2008). Giant cutaneous horn. \u003cem\u003eIndian journal of dermatology\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(4), 199-200.\u003c/li\u003e\n\u003cli\u003eBondeson, Jan M.D., Ph.D. Everard Home, John Hunter, and Cutaneous Horns: \u003cem\u003eA Historical Review. \u003c/em\u003eThe American Journal of Dermatopathology 23(4):p 362-369, August 2001.\u003c/li\u003e\n\u003cli\u003eRoewert‐Huber, J., Stockfleth, E., \u0026amp; Kerl, H. (2007). Pathology and pathobiology of actinic (solar) keratosis\u0026ndash;an update. \u003cem\u003eBritish Journal of Dermatology\u003c/em\u003e, 157(s2), 18-20.\u003c/li\u003e\n\u003cli\u003eFrost, C. A., \u0026amp; Green, A. C. (1994). Epidemiology of solar keratoses. British Journal of Dermatology, 131(4), 455-464.\u003c/li\u003e\n\u003cli\u003eAckerman, A. B., \u0026amp; Mones, J. M. (2006). Solar (actinic) keratosis is squamous cell carcinoma. \u003cem\u003eBritish Journal of Dermatology\u003c/em\u003e, \u003cem\u003e155\u003c/em\u003e(1), 9-22.\u003c/li\u003e\n\u003cli\u003eWoods M, Chow S, Heng B, Glenn W, Whitaker N, Waring D, et al.Detecting human papillomavirus in ocular surface diseases. \u003cem\u003eInvest Ophthalmol Vis\u003c/em\u003e Sci 2013; 54: 8069\u0026ndash;8078.\u003c/li\u003e\n\u003cli\u003eMcDonnell JM, Mayr AJ, Martin WJ. DNA of human papillomavirus type 16 in dysplastic and malignant lesions of the conjunctiva and cornea. N Engl J Med 1989; 320: 1442\u0026ndash;1446.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cutaneous horn, cornea mass, recurrent proliferation, solar keratosis","lastPublishedDoi":"10.21203/rs.3.rs-4386239/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4386239/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCutaneous hornis a relatively uncommon neoplasm of the eyelid skin, frequently observed in exposed areas such as the extremities, head, and face. However, its etiology remains incompletely elucidated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report the case of a 32-year-old Asian female patient who presented with corneal mass of right eye of 10 years duration. She was examined and underwent excision, with biopsy showing cornea cutaneous horn.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mass is benign and exhibits a slow growth pattern. However, post-removal, the mass demonstrated recurrent enlargement. It is hypothesized that the disease may bear resemblance to solar keratosis. Consequently, the etiology remains uncertain and further investigation is warranted.\u003c/p\u003e","manuscriptTitle":"Keratosis conjunctiva of unknown significance: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-20 19:00:14","doi":"10.21203/rs.3.rs-4386239/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed84dc8e-de95-4b89-ac19-c9404a36306e","owner":[],"postedDate":"May 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-26T22:23:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-20 19:00:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4386239","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4386239","identity":"rs-4386239","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}