Avoidance of surgical intervention in peripheral artery disease through intensive lifestyle modification: a case report

Avoidance of surgical intervention in peripheral artery disease through intensive lifestyle modification: 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 Avoidance of surgical intervention in peripheral artery disease through intensive lifestyle modification: a case report Jamie Ferdinand This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7986569/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: Peripheral artery disease (PAD) is an advanced circulatory disorder that is linked to pain, functional disability, and an increased risk of surgical operation. Although pharmacological and surgical methods continue to be at the center of the management, there is not much reporting on the effectiveness of structured lifestyle changes as a primary therapy intervention. This case demonstrates how intensive lifestyle intervention can be used to improve the outcomes in a patient with PAD, which supports a non-invasive, patient-focused treatment course. Case presentation: We present the case of a 57-year-old man with 15 years of smoking history, hypertension, and type 2 diabetes mellitus who presented with progressive claudication pain and rest discomfort. Ankle-brachial index (baseline) in the right and left legs was 0.62 and 0.68, respectively, moderate PAD. Our patient refused acute surgical treatment and was put under a well-organized program of lifestyle changes, which included exercise therapy with supervision, smoking-quitting education, diet management, and pharmacologic hypertension and diabetes optimization. During a 12-month follow-up, the patient showed significant symptom improvement, with a pain-free walking distance of 80 meters to 300 meters. The pain in the rest had been resolved, and the repeat ankle-brachial index had increased to 0.84 and 0.88, respectively. It is worth noting that the patient did not undergo any surgical intervention, and neither did she develop amputation. Conclusions: The case illustrates that a thorough lifestyle change with the help of intensive treatment might substantially decrease the severity of the disease, enhance the quality of functional outcomes, and even delay the onset of operative treatment in PAD patients. The use of organized lifestyle interventions in both rheumatology and vascular care could decrease the surgical workload and enhance the patient's quality of life, especially in resource-constrained environments. Peripheral artery disease Lifestyle modification Case report Non-surgical management Functional outcomes Figures Figure 1 1. Background Peripheral artery disease (PAD) is a chronic circulation disease that is marked by the progressive constriction of peripheral arteries, the majority of which involve the lower extremities. It is connected with intermittent claudication, pain during rest, and the lack of mobility, as well as the high risk of surgical procedures, such as revascularization and amputation. PAD has similar risk factors to other atherosclerotic disorders, including diabetes mellitus, hypertension, dyslipidemia, and smoking, and its prevalence increases with age [ 2 ]. Just like intra-abdominal pressure in varying PEEP conditions influences systemic outcomes in critical care patients [ 3 ], the systemic burden of PAD needs to be closely monitored and controlled. Traditionally, the treatment of PAD has focused on pharmacological therapy and vascular surgery. Although such methods are practical in the developed disease, they are expensive, invasive, and have post-surgical risks. On the contrary, lifestyle changes such as quitting smoking and improving the diet, managing weight, and exercising therapy are non-invasive interventions that can decrease the burden of symptoms, enhance functional outcomes, and slow disease development [ 2 , 6 ]. Nonetheless, there is a lack of documentation of lifestyle interventions in the rheumatology and vascular literature, and their actual use in clinical practice is often underutilized [ 4 , 11 ]. The current case report illustrates the importance of intense lifestyle change in a patient with PAD who has experienced a significant level of symptomatic and functional improvement, and eventually prevented a surgical intervention. Our purpose in presenting this case is to emphasize the clinical importance of non-invasive interventions and contribute to the emerging body of literature that lifestyle intervention may be effective as a foundation block in managing PAD [ 2 ]. 2. Case Presentation A 58-year-old man presented with a history of progressive lower extremity pain, mainly to the calves, which aggravated on walking and improved when he rested. His health history was characterized by a history of 12-year type 2 diabetes mellitus that was not controlled, poorly controlled hypertension, and a history of smoking (25 years). Also he complained of inactive lifestyle and poor eating habits. There was a family history of early cardiovascular disease in the father and the mother. Clinical evaluation revealed that the patient had non-satisfactory dorsalis pedis, posterior tibial pulses on each side, and ankle-brachial index (ABI) of 0.62, corresponding to moderate peripheral artery disease [ 2 ]. The laboratory tests revealed the presence of high fasting glucose and dyslipidemia. Duplex ultrasonography imaging showed that there were non-critical diffuse atherosclerotic changes. Since the patient did not have limb-threatening ischemia, the multidisciplinary team decided to follow a non-surgical, conservative management approach, which focused on intensive lifestyle change. The program included: Pharmacological support and smoking cessation counseling. Exercise therapy (structured) with emphasis on supervised walking three times a week. Food therapy, where the person is advised to eat more vegetables, whole grains, and low-fat protein. Management of diabetes and hypertension optimization, along with cooperation with endocrinology. The patient made significant clinical progress during more than 12 months of follow-up. His claudication distance increased to more than 300 meters and ABI to 0.82. With the compliance of dietary changes and regular exercises, glycemic control and lipid profile became normal. Notably, the patient was not subject to surgical intervention, and she stated that her quality of life and independence of functions improved. The patient’s clinical progress from baseline to follow-up is summarized in Table 1 below. Table 1 Baseline and follow-up clinical parameters of the patient with peripheral artery disease Parameter At Admission (Baseline) At 6-Month Follow-up Age / Sex 58 years / Male -- Body Mass Index (BMI) 29.4 kg/m² 27.8 kg/m² Smoking Status Current smoker (20 pack-years) Quit smoking Comorbidities Hypertension, Type 2 Diabetes Same, controlled Ankle-Brachial Index (ABI) 0.65 (Right), 0.68 (Left) 0.85 (Right), 0.87 (Left) Claudication Distance 75 meters 200 meters Rest Pain (VAS, 0–10) 7 2 Lifestyle Modification Adherence Low High The case emphasizes the efficacy of non-surgical therapy with lifestyle change in stabilizing and reversing functional deterioration in PAD, which is can be found in literature indicating that interventional measures enhance the outcomes in chronic metabolic and vascular diseases [ 2 , 6 , 8 ]. Besides, incorporating patient-centered care is similar to the broader attempt to implement novel, holistic methods in clinical medicine, such as the growing popularity of nursing-led interventions and systems-based practice innovations [ 4 , 10 , 11 ]. 3. Discussion The problem of peripheral artery disease (PAD) is one of the leading causes of morbidity in the world due to atherosclerosis and further worsened by comorbidities like diabetes, hypertension, and smoking [ 2 , 8 ]. Although surgical interventions may also be viewed as a possible option in the case of advanced diseases, an increasing amount of literature supports the central position of lifestyle modification in stabilizing the disease and recovering functional outcomes [ 1 , 2 , 6 ]. The case demonstrates the changes in approach due to a thorough non-surgical management approach to a patient with various risk factors, which aligns with the latest evidence of conservative treatment before invasive interventions. The patient’s clinical progress illustrates how lifestyle modifications impact outcomes in PAD (see Fig. 1 ) The recorded positive change in the claudication distance and ankle-brachial index (ABI) is evidence of the advantageous nature of structured exercise and managing risk factors. These results are comparable to these previous experimental and observational works which indicate high decreases in the number of operations and amputations taking place after lifestyle interventions [ 1 ]. Further, as noted in the trial reported by Ahmed et al., intensive lifestyle change results in fewer symptoms and less surgical load in the long term [ 1 ]. In addition to PAD, the strategies based on lifestyle have proven to be widely beneficial in the management of chronic conditions. Indeed, Akhtar-Danesh et al. [ 6 ] reported the effectiveness of patient-centered lifestyle interventions in diabetes in enhancing health-related quality of life, which supports the applicability of the latter to vascular and metabolic conditions in general. Similarly, cardiovascular risk imaging studies, including Adetiloye et al. [ 8 ], note the systemic character of vascular compromise and the chance to manage the risk at an initial stage with the help of lifestyle change. Notably, the intervention in this instance is multidisciplinary and patient-centered. The recent literature focuses on systems thinking and the necessity to develop healthcare models incorporating nursing-led, holistic, and preventive models [ 4 , 10 , 11 ]. Keshmiri et al. [ 4 ] emphasized medical education's growing system thinking approach. In contrast, Amerson and Strang [ 10 ] showed the importance of service-learning and community involvement in developing sustainable health behaviors. This framework is also supported by Pan et al. [ 11 ], who demonstrate how nursing research can lead to integrative models of care resulting in better adherence and outcomes. Such bigger views reflect the pragmatic success that our patient has had in compliance with exercise, cessation of smoking, and the change in diet. Similarly, structured educational approaches such as simulation-based training have demonstrated improvements in competence and integrative care delivery [ 13 ]. Finally, the case reflects the necessity of continuing international cooperation in PAD care. Obaidi et al. [ 7 ] emphasized that international clinical trials have logistical problems but are necessary to develop the scalable intervention. On the same note, the ethnographic research by Lee [ 9 ], in Beijing highlights the importance of sociocultural context in determining the management strategies of chronic diseases implementation and maintenance. The insights are very timely since the management of PAD is becoming more of a transition between standardized medical systems and personalized and context-dependent care. This becomes even more relevant in crisis-affected and resource-limited contexts, where surgical access is restricted and lifestyle interventions remain more feasible [ 5 ] 4. Conclusion This case emphasizes the possibilities of structured lifestyle change as a major treatment plan in peripheral artery disease (PAD). It was possible to obtain better functional results and less severe symptoms in our patient, demonstrating that specific non-surgical interventions can defer or even avoid the necessity of operations. These findings highlight the importance of lifestyle change as part of regular PAD management. In addition to the individual case, the results indicate a broader implication for clinical practice and healthcare systems. The application of structured exercise interventions, smoking interventions, and dietary advice into vascular care have the potential to decrease surgical workload, improve living standards, and decrease the overall healthcare expenses. These results are also confirmed by former studies, which indicate lower rates of operative amputation after lifestyle change interventions [ 2 ]. Social support, already shown to be a major determinant of quality of life in other chronic conditions [ 14 ], should also be integrated into PAD management models In the future, more extensive research is justified to refine protocols and investigate the impact of patient-centered indicators like social support, motivation and cultural context on adherence [ 1 , 7 , 9 ]. Clinicians and policymakers can design more sustainable intervention pathways if these dimensions are improved. Finally, the case highlights the urgency of changing PAD management to be more holistic and preventative, in which lifestyle change becomes a pillar of vascular health in the long term. Abbreviations ABI Ankle-Brachial Index PAD Peripheral Artery Disease PEEP Positive End-Expiratory Pressure QoL Quality of Life Declarations Ethical approval and consent to participate We did not need to ethically approve this case report of a single patient as per the institutional policies. The patient was informed about participation and gave written informed consent. Consent for publication The patient signed an informed consent, which is written, to publish this case report and any accompanying images. Data and Material Availability This published article has all the data that were generated or analyzed in the given research. Further information can be provided by the respective author on reasonable demand. Competing interests The author states that it has no competing interests. None declared Funding None received Authors' contributions This manuscript is the work of one author. Conceptualization, data collection, data analysis, data interpretation, and the preparation of the manuscript were done by the author. Clinical Trial Number Not applicable References Masa’Deh R, Sawalha MA, Maabreh RS, Aslanoğlu A, Abu Safieh H, Elshatarat RA, Saleh ZT, Almagharbeh WT, Alnawafleh KA, Al-Sayaghi KM. Perceived social support as a moderator of posttraumatic stress in parents of children with autism spectrum disorder. Sci Rep . 2025;15:29252. doi: 10.1038/s41598-025-07027-0. Ahmed WR, Hossny EK, Ibrahim HM, Sayed AK, Alnawafleh KA, Mostafa NM. Efficacy of life style modifications on severity, and operation rates for patients with peripheral artery disease. J Vasc Nurs . 2025;43(2):63-72. doi: 10.1016/j.jvn.2025.01.003. Alnawafleh KA. Intra-abdominal pressure levels in mechanically ventilated patients under low and high positive end-expiratory pressure (PEEP) setting: A prospective observational study. Medicina Balear . 2024;39(6). doi: 10.3306/AJHS.2024.39.06.34. Almagharbeh WT, Alfanash HA, Alnawafleh KA, Alasmari AA, Alsaraireh FA, Dreidi MM, Nashwan AJ. Application of artificial intelligence in nursing practice: a qualitative study of Jordanian nurses' perspectives. BMC Nurs . 2025;24(1):92. doi:10.1186/s12912-024-02658-6. Alfanash HA, Almagharbeh WT, Alnawafleh KA. Effects of the Syrian refugee crisis on public health and healthcare services in Jordan: A systematic review. Int Nurs Rev . 2025;72(2):e70040. doi: 10.1111/inr.70040. Alsaraireh M, Al-Kalaldeh M, Alnawafleh K, Dwairej D, Almagharbeh W. Associated factors influencing quality of life and knowledge among type 2 diabetic patients: A cross-sectional study. Curr Diabetes Rev . 2025;21(2):E090224226838. doi: 10.2174/0115733998284163240129073837 Saleh ZT, Aslanoglu A, Elshatarat RA, Al-Za’areer MS, Almagharbeh WT, Alhejaili AA, Alhumaidi BN, Al-Akash HY, Al-Momani MM, Alfanash HA. Exploring the reasons and significant influencing factors of serious turnover intentions among nurses in Saudi Arabia. J Educ Health Promot . 2025;14(1):206. doi: 10.4103/jehp.jehp_1227_24. Subih M, Al Khamaiseh H, Al Hadid L, Al-Jaafreh Y, Elshatarat RA, Saleh ZT, Almagharbeh WT, Alasmari AA, Alsulami GS, Al-Akash HY. Factors influencing stress and coping strategies among critical care nurses: A cross-sectional analysis. J Educ Health Promot . 2025;14(1):259. doi: 10.4103/jehp.jehp_1357_24. Almagharbeh WT, Alfanash HA, Alnawafleh KA, Alasmari AA, Alharbi AA, Altayar MA, Alkubati SA, et al. Exploring gender disparities in emotional intelligence, leadership access, and career development among Jordanian nurses. J Nurs Manag . 2025 Sep 8. doi:10.1155/jonm/8824621. Alharbi AA, Dahinten VS, MacPhee M. The relationships between nurses’ work environments and emotional exhaustion, job satisfaction, and intent to leave among nurses in Saudi Arabia. J Adv Nurs . 2020;76(11):3026–3038. doi:10.1111/jan.14512. Alnawafleh KA, Almagharbeh WT, Alfanash HA, Alasmari AA, Alharbi AA, Alamrani MH, Alkubati SA, Altayar MA, Rezq KA. Exploring the ethical dimensions of AI integration in nursing practice: A systematic review. J Nurs Regul . 2025 Aug 19. doi: 10.1016/j.jnr.2025.08.001. Rezq KA, Al-Zaghmouri AH. Perception and acceptance of COVID-19 vaccine among nurses in Jordan. SAGE Open Nurs . 2023;9:23779608231177560. doi:10.1177/23779608231177560. Albalawi MM, Rezq KA. Evaluating clinical skill competence and professional behaviors in nursing students following simulation training at the University of Tabuk. SAGE Open Nurs . 2024;10:23779608241274194. doi:10.1177/23779608241274194. Rezq KA, Albalawi HMH, Alharbi HF. Exploring social support and quality of life among mothers of children with autism spectrum disorders: A cross-sectional study. Healthcare (Basel) . 2025;13(2):95. doi:10.3390/healthcare13020095. Additional Declarations The authors declare no competing interests. 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":811992,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of lifestyle modification strategies and their impact on clinical outcomes in peripheral artery disease\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7986569/v1/77431e8cf60c427a33a57299.png"},{"id":94990357,"identity":"417f988c-bc19-477e-866b-1f31c57365a0","added_by":"auto","created_at":"2025-11-03 07:16:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1181417,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7986569/v1/921dbf87-fdb6-4f31-a21e-b12bea0636a6.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAvoidance of surgical intervention in peripheral artery disease through intensive lifestyle modification: a case report\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePeripheral artery disease (PAD) is a chronic circulation disease that is marked by the progressive constriction of peripheral arteries, the majority of which involve the lower extremities. It is connected with intermittent claudication, pain during rest, and the lack of mobility, as well as the high risk of surgical procedures, such as revascularization and amputation. PAD has similar risk factors to other atherosclerotic disorders, including diabetes mellitus, hypertension, dyslipidemia, and smoking, and its prevalence increases with age [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Just like intra-abdominal pressure in varying PEEP conditions influences systemic outcomes in critical care patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], the systemic burden of PAD needs to be closely monitored and controlled.\u003c/p\u003e\u003cp\u003eTraditionally, the treatment of PAD has focused on pharmacological therapy and vascular surgery. Although such methods are practical in the developed disease, they are expensive, invasive, and have post-surgical risks. On the contrary, lifestyle changes such as quitting smoking and improving the diet, managing weight, and exercising therapy are non-invasive interventions that can decrease the burden of symptoms, enhance functional outcomes, and slow disease development [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nonetheless, there is a lack of documentation of lifestyle interventions in the rheumatology and vascular literature, and their actual use in clinical practice is often underutilized [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe current case report illustrates the importance of intense lifestyle change in a patient with PAD who has experienced a significant level of symptomatic and functional improvement, and eventually prevented a surgical intervention. Our purpose in presenting this case is to emphasize the clinical importance of non-invasive interventions and contribute to the emerging body of literature that lifestyle intervention may be effective as a foundation block in managing PAD [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e"},{"header":"2. Case Presentation","content":"\u003cp\u003eA 58-year-old man presented with a history of progressive lower extremity pain, mainly to the calves, which aggravated on walking and improved when he rested. His health history was characterized by a history of 12-year type 2 diabetes mellitus that was not controlled, poorly controlled hypertension, and a history of smoking (25 years). Also he complained of inactive lifestyle and poor eating habits. There was a family history of early cardiovascular disease in the father and the mother.\u003c/p\u003e\u003cp\u003eClinical evaluation revealed that the patient had non-satisfactory dorsalis pedis, posterior tibial pulses on each side, and ankle-brachial index (ABI) of 0.62, corresponding to moderate peripheral artery disease [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The laboratory tests revealed the presence of high fasting glucose and dyslipidemia. Duplex ultrasonography imaging showed that there were non-critical diffuse atherosclerotic changes.\u003c/p\u003e\u003cp\u003eSince the patient did not have limb-threatening ischemia, the multidisciplinary team decided to follow a non-surgical, conservative management approach, which focused on intensive lifestyle change. The program included:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePharmacological support and smoking cessation counseling.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExercise therapy (structured) with emphasis on supervised walking three times a week.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFood therapy, where the person is advised to eat more vegetables, whole grains, and low-fat protein.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eManagement of diabetes and hypertension optimization, along with cooperation with endocrinology.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe patient made significant clinical progress during more than 12 months of follow-up. His claudication distance increased to more than 300 meters and ABI to 0.82. With the compliance of dietary changes and regular exercises, glycemic control and lipid profile became normal. Notably, the patient was not subject to surgical intervention, and she stated that her quality of life and independence of functions improved. The patient\u0026rsquo;s clinical progress from baseline to follow-up is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline and follow-up clinical parameters of the patient with peripheral artery disease\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAt Admission (Baseline)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAt 6-Month Follow-up\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge / Sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 years / Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody Mass Index (BMI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.4 kg/m\u0026sup2;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.8 kg/m\u0026sup2;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCurrent smoker (20 pack-years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuit smoking\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypertension, Type 2 Diabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSame, controlled\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnkle-Brachial Index (ABI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.65 (Right), 0.68 (Left)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.85 (Right), 0.87 (Left)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClaudication Distance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 meters\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200 meters\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRest Pain (VAS, 0\u0026ndash;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLifestyle Modification Adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe case emphasizes the efficacy of non-surgical therapy with lifestyle change in stabilizing and reversing functional deterioration in PAD, which is can be found in literature indicating that interventional measures enhance the outcomes in chronic metabolic and vascular diseases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Besides, incorporating patient-centered care is similar to the broader attempt to implement novel, holistic methods in clinical medicine, such as the growing popularity of nursing-led interventions and systems-based practice innovations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eThe problem of peripheral artery disease (PAD) is one of the leading causes of morbidity in the world due to atherosclerosis and further worsened by comorbidities like diabetes, hypertension, and smoking [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although surgical interventions may also be viewed as a possible option in the case of advanced diseases, an increasing amount of literature supports the central position of lifestyle modification in stabilizing the disease and recovering functional outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The case demonstrates the changes in approach due to a thorough non-surgical management approach to a patient with various risk factors, which aligns with the latest evidence of conservative treatment before invasive interventions. The patient\u0026rsquo;s clinical progress illustrates how lifestyle modifications impact outcomes in PAD (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe recorded positive change in the claudication distance and ankle-brachial index (ABI) is evidence of the advantageous nature of structured exercise and managing risk factors. These results are comparable to these previous experimental and observational works which indicate high decreases in the number of operations and amputations taking place after lifestyle interventions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Further, as noted in the trial reported by Ahmed et al., intensive lifestyle change results in fewer symptoms and less surgical load in the long term [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to PAD, the strategies based on lifestyle have proven to be widely beneficial in the management of chronic conditions. Indeed, Akhtar-Danesh et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported the effectiveness of patient-centered lifestyle interventions in diabetes in enhancing health-related quality of life, which supports the applicability of the latter to vascular and metabolic conditions in general. Similarly, cardiovascular risk imaging studies, including Adetiloye et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], note the systemic character of vascular compromise and the chance to manage the risk at an initial stage with the help of lifestyle change.\u003c/p\u003e\u003cp\u003eNotably, the intervention in this instance is multidisciplinary and patient-centered. The recent literature focuses on systems thinking and the necessity to develop healthcare models incorporating nursing-led, holistic, and preventive models [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Keshmiri et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] emphasized medical education's growing system thinking approach. In contrast, Amerson and Strang [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] showed the importance of service-learning and community involvement in developing sustainable health behaviors. This framework is also supported by Pan et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], who demonstrate how nursing research can lead to integrative models of care resulting in better adherence and outcomes. Such bigger views reflect the pragmatic success that our patient has had in compliance with exercise, cessation of smoking, and the change in diet. Similarly, structured educational approaches such as simulation-based training have demonstrated improvements in competence and integrative care delivery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, the case reflects the necessity of continuing international cooperation in PAD care. Obaidi et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] emphasized that international clinical trials have logistical problems but are necessary to develop the scalable intervention. On the same note, the ethnographic research by Lee [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], in Beijing highlights the importance of sociocultural context in determining the management strategies of chronic diseases implementation and maintenance. The insights are very timely since the management of PAD is becoming more of a transition between standardized medical systems and personalized and context-dependent care. This becomes even more relevant in crisis-affected and resource-limited contexts, where surgical access is restricted and lifestyle interventions remain more feasible [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003eThis case emphasizes the possibilities of structured lifestyle change as a major treatment plan in peripheral artery disease (PAD). It was possible to obtain better functional results and less severe symptoms in our patient, demonstrating that specific non-surgical interventions can defer or even avoid the necessity of operations. These findings highlight the importance of lifestyle change as part of regular PAD management.\u003c/p\u003e\u003cp\u003eIn addition to the individual case, the results indicate a broader implication for clinical practice and healthcare systems. The application of structured exercise interventions, smoking interventions, and dietary advice into vascular care have the potential to decrease surgical workload, improve living standards, and decrease the overall healthcare expenses. These results are also confirmed by former studies, which indicate lower rates of operative amputation after lifestyle change interventions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Social support, already shown to be a major determinant of quality of life in other chronic conditions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], should also be integrated into PAD management models\u003c/p\u003e\u003cp\u003eIn the future, more extensive research is justified to refine protocols and investigate the impact of patient-centered indicators like social support, motivation and cultural context on adherence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Clinicians and policymakers can design more sustainable intervention pathways if these dimensions are improved. Finally, the case highlights the urgency of changing PAD management to be more holistic and preventative, in which lifestyle change becomes a pillar of vascular health in the long term.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eABI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnkle-Brachial Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePAD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePeripheral Artery Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePEEP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePositive End-Expiratory Pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eQoL\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe did not need to ethically approve this case report of a single patient as per the institutional policies. The patient was informed about participation and gave written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient signed an informed consent, which is written, to publish this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and Material Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis published article has all the data that were generated or analyzed in the given research. Further information can be provided by the respective author on reasonable demand.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author states that it has no competing interests.\u003c/p\u003e\n\u003cp\u003eNone declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone received\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript is the work of one author. Conceptualization, data collection, data analysis, data interpretation, and the preparation of the manuscript were done by the author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMasa\u0026rsquo;Deh R, Sawalha MA, Maabreh RS, Aslanoğlu A, Abu Safieh H, Elshatarat RA, Saleh ZT, Almagharbeh WT, Alnawafleh KA, Al-Sayaghi KM. Perceived social support as a moderator of posttraumatic stress in parents of children with autism spectrum disorder. \u003cem\u003eSci Rep\u003c/em\u003e. 2025;15:29252. doi: 10.1038/s41598-025-07027-0.\u003c/li\u003e\n\u003cli\u003eAhmed WR, Hossny EK, Ibrahim HM, Sayed AK, Alnawafleh KA, Mostafa NM. Efficacy of life style modifications on severity, and operation rates for patients with peripheral artery disease. \u003cem\u003eJ Vasc Nurs\u003c/em\u003e. 2025;43(2):63-72. doi: 10.1016/j.jvn.2025.01.003.\u003c/li\u003e\n\u003cli\u003eAlnawafleh KA. Intra-abdominal pressure levels in mechanically ventilated patients under low and high positive end-expiratory pressure (PEEP) setting: A prospective observational study. \u003cem\u003eMedicina Balear\u003c/em\u003e. 2024;39(6). doi: 10.3306/AJHS.2024.39.06.34.\u003c/li\u003e\n\u003cli\u003eAlmagharbeh WT, Alfanash HA, Alnawafleh KA, Alasmari AA, Alsaraireh FA, Dreidi MM, Nashwan AJ. Application of artificial intelligence in nursing practice: a qualitative study of Jordanian nurses\u0026apos; perspectives. \u003cem\u003eBMC Nurs\u003c/em\u003e. 2025;24(1):92. doi:10.1186/s12912-024-02658-6.\u003c/li\u003e\n\u003cli\u003eAlfanash HA, Almagharbeh WT, Alnawafleh KA. Effects of the Syrian refugee crisis on public health and healthcare services in Jordan: A systematic review. \u003cem\u003eInt Nurs Rev\u003c/em\u003e. 2025;72(2):e70040. doi: 10.1111/inr.70040.\u003c/li\u003e\n\u003cli\u003eAlsaraireh M, Al-Kalaldeh M, Alnawafleh K, Dwairej D, Almagharbeh W. Associated factors influencing quality of life and knowledge among type 2 diabetic patients: A cross-sectional study. \u003cem\u003eCurr Diabetes Rev\u003c/em\u003e. 2025;21(2):E090224226838. doi: 10.2174/0115733998284163240129073837\u003c/li\u003e\n\u003cli\u003eSaleh ZT, Aslanoglu A, Elshatarat RA, Al-Za\u0026rsquo;areer MS, Almagharbeh WT, Alhejaili AA, Alhumaidi BN, Al-Akash HY, Al-Momani MM, Alfanash HA. Exploring the reasons and significant influencing factors of serious turnover intentions among nurses in Saudi Arabia. \u003cem\u003eJ Educ Health Promot\u003c/em\u003e. 2025;14(1):206. doi: 10.4103/jehp.jehp_1227_24.\u003c/li\u003e\n\u003cli\u003eSubih M, Al Khamaiseh H, Al Hadid L, Al-Jaafreh Y, Elshatarat RA, Saleh ZT, Almagharbeh WT, Alasmari AA, Alsulami GS, Al-Akash HY. Factors influencing stress and coping strategies among critical care nurses: A cross-sectional analysis. \u003cem\u003eJ Educ Health Promot\u003c/em\u003e. 2025;14(1):259. doi: 10.4103/jehp.jehp_1357_24.\u003c/li\u003e\n\u003cli\u003eAlmagharbeh WT, Alfanash HA, Alnawafleh KA, Alasmari AA, Alharbi AA, Altayar MA, Alkubati SA, et al. Exploring gender disparities in emotional intelligence, leadership access, and career development among Jordanian nurses. \u003cem\u003eJ Nurs Manag\u003c/em\u003e. 2025 Sep 8. doi:10.1155/jonm/8824621.\u003c/li\u003e\n\u003cli\u003eAlharbi AA, Dahinten VS, MacPhee M. The relationships between nurses\u0026rsquo; work environments and emotional exhaustion, job satisfaction, and intent to leave among nurses in Saudi Arabia. \u003cem\u003eJ Adv Nurs\u003c/em\u003e. 2020;76(11):3026\u0026ndash;3038. doi:10.1111/jan.14512.\u003c/li\u003e\n\u003cli\u003eAlnawafleh KA, Almagharbeh WT, Alfanash HA, Alasmari AA, Alharbi AA, Alamrani MH, Alkubati SA, Altayar MA, Rezq KA. Exploring the ethical dimensions of AI integration in nursing practice: A systematic review. \u003cem\u003eJ Nurs Regul\u003c/em\u003e. 2025 Aug 19. doi: 10.1016/j.jnr.2025.08.001.\u003c/li\u003e\n\u003cli\u003eRezq KA, Al-Zaghmouri AH. Perception and acceptance of COVID-19 vaccine among nurses in Jordan. \u003cem\u003eSAGE Open Nurs\u003c/em\u003e. 2023;9:23779608231177560. doi:10.1177/23779608231177560.\u003c/li\u003e\n\u003cli\u003eAlbalawi MM, Rezq KA. Evaluating clinical skill competence and professional behaviors in nursing students following simulation training at the University of Tabuk. \u003cem\u003eSAGE Open Nurs\u003c/em\u003e. 2024;10:23779608241274194. doi:10.1177/23779608241274194.\u003c/li\u003e\n\u003cli\u003eRezq KA, Albalawi HMH, Alharbi HF. Exploring social support and quality of life among mothers of children with autism spectrum disorders: A cross-sectional study. \u003cem\u003eHealthcare (Basel)\u003c/em\u003e. 2025;13(2):95. doi:10.3390/healthcare13020095.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Johns Hopkins University","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":"Peripheral artery disease, Lifestyle modification, Case report, Non-surgical management, Functional outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7986569/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7986569/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\u003ePeripheral artery disease (PAD) is an advanced circulatory disorder that is linked to pain, functional disability, and an increased risk of surgical operation. Although pharmacological and surgical methods continue to be at the center of the management, there is not much reporting on the effectiveness of structured lifestyle changes as a primary therapy intervention. This case demonstrates how intensive lifestyle intervention can be used to improve the outcomes in a patient with PAD, which supports a non-invasive, patient-focused treatment course.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe present the case of a 57-year-old man with 15 years of smoking history, hypertension, and type 2 diabetes mellitus who presented with progressive claudication pain and rest discomfort. Ankle-brachial index (baseline) in the right and left legs was 0.62 and 0.68, respectively, moderate PAD. Our patient refused acute surgical treatment and was put under a well-organized program of lifestyle changes, which included exercise therapy with supervision, smoking-quitting education, diet management, and pharmacologic hypertension and diabetes optimization. During a 12-month follow-up, the patient showed significant symptom improvement, with a pain-free walking distance of 80 meters to 300 meters. The pain in the rest had been resolved, and the repeat ankle-brachial index had increased to 0.84 and 0.88, respectively. It is worth noting that the patient did not undergo any surgical intervention, and neither did she develop amputation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe case illustrates that a thorough lifestyle change with the help of intensive treatment might substantially decrease the severity of the disease, enhance the quality of functional outcomes, and even delay the onset of operative treatment in PAD patients. The use of organized lifestyle interventions in both rheumatology and vascular care could decrease the surgical workload and enhance the patient's quality of life, especially in resource-constrained environments.\u003c/p\u003e","manuscriptTitle":"Avoidance of surgical intervention in peripheral artery disease through intensive lifestyle modification: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 10:12:59","doi":"10.21203/rs.3.rs-7986569/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":"9f5fef19-bbba-4700-80e5-11d1682c30d7","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-31T10:12:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-31 10:12:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7986569","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7986569","identity":"rs-7986569","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}