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Artificial neural network-based determination of denoised optical properties in double integrating spheres measurement

    https://doi.org/10.1142/S1793545823500128Cited by:0 (Source: Crossref)

    Abstract

    Accurate determination of the optical properties of biological tissues enables quantitative understanding of light propagation in these tissues for optical diagnosis and treatment applications. The absorption (μa) and scattering (μs) coefficients of biological tissues are inversely analyzed from their diffuse reflectance (R) and total transmittance (T), which are measured using a double integrating spheres (DIS) system. The inversion algorithms, for example, inverse adding doubling method and inverse Monte Carlo method, are sensitive to noise signals during the DIS measurements, resulting in reduced accuracy during determination. In this study, we propose an artificial neural network (ANN) to estimate μa and μs at a target wavelength from the R and T spectra measured via the DIS to reduce noise in the optical properties. Approximate models of the optical properties and Monte Carlo calculations that simulated the DIS measurements were used to generate spectral datasets comprising μa, μs, R and T. Measurement noise signals were added to R and T, and the ANN model was then trained using the noise-added datasets. Numerical results showed that the trained ANN model reduced the effects of noise in μa and μs estimation. Experimental verification indicated noise-reduced estimation from the R and T values measured by the DIS with a small number of scans on average, resulting in measurement time reduction. The results demonstrated the noise robustness of the proposed ANN-based method for optical properties determination and will contribute to shorter DIS measurement times, thus reducing changes in the optical properties due to desiccation of the samples.

    1. Introduction

    A quantitative understanding of light propagation in biological tissues is essential in the field of biomedical optics for diagnostic and therapeutic applications.1 Light propagation in biological tissues is mainly characterized by two optical parameters: the absorption coefficient μa and the scattering coefficient μs.2 The values of μa and μs are determined using a combination of spectroscopic measurements and inversion algorithms.3 To date, several methods have been developed to determine the μa and μs characteristics of various bio-tissues.4 In the spectroscopic measurements, a double integrating sphere (DIS) system allows the diffuse reflectance R and the total transmittance T to be measured simultaneously at the same point in a sample with high accuracy.5,6 The combination of the DIS system with inversion algorithms is regarded as the gold standard for measurement of these optical properties.7

    Several inversion techniques for μa and μs from the R and T characteristics measured by the DIS system have been established; examples include inverse adding doubling (IAD),8 the inverse Monte Carlo (IMC) method,9 lookup tables (LTs),10 and artificial neural network (ANN)11,12 based methods. The IAD method, which is based on numerical solution of the radiation transport equation, offers high-speed inversion.13 The IMC method is based on an iterative calculation performed with the Monte Carlo (MC) model of light transport in tissues and calculates the optical properties accurately for a wide range of absorption and scattering coefficients.14 In the LT and ANN methods, the iterative processes required in the IAD and IMC methods are avoided and the calculation time can then be reduced significantly.10,11,12 Although these methods have been used previously, the estimated μa and μs values are affected by the measurement noise signals of both R and T.11

    The conventional approaches estimate μa and μs values from measured R and T for each wavelength. The measured R and T values include random noise signals in the DIS measurements. These measurement noise signals thus affect the estimation of both μa and μs and reduce the accuracy of their determination. This measurement noise is unavoidable, and the effect increases as the measurement time for R and T decreases. Longer measurement times often lead to issues due to changes in the dryness of the bio-tissue, which lead to changes in the optical properties in the DIS measurement. To ensure that the μa and μs values are determined accurately, a noise-resistant inversion technique is required.

    In this work, we propose an ANN model with multiple wavelength inputs (mwANN) to determine the μa and μs values of tissues with high noise robustness. The mwANN is based on the fact that the μa and μs spectra are theoretically defined as continuous functions in wavelength.2 The measurement noise is reduced by using the continuity of the μa and μs values between the target and neighboring wavelengths. The mwANN accepts the measured spectra of R and T for the target and neighboring wavelengths and outputs noise-reduced μa and μs values at the target wavelength. To date, several ANN models have been demonstrated to provide a fast technique for determination of μa and μs and consideration of the wavelength-dependent anisotropy factor g and the refractive index n.12 In addition to these functions, the mwANN enables noise-reduced estimation of both μa and μs. This improvement to the inversion process can shorten the DIS measurement time because of its high noise robustness, leading to measurements that can reduce the effects of sample desiccation and degeneration over time. This offers an advantage in providing accurate estimation without the need for equipment improvements for reducing the noise levels.

    2. Materials and Methods

    2.1. Neural network model

    Figure 1 shows a schematic illustration of the mwANN that is proposed to determine the noise-reduced μa and μs values at a target wavelength. The measured R and T values include measurement noise signals that depend on the DIS system and the measurement conditions. The measured R and T values at the target wavelength and several neighboring wavelengths are input into the mwANN model. The mwANN model reduces the estimation noise for both μa and μs at the target wavelength by learning the relevance and the continuity of these spectra. Estimated μa and μs spectra were obtained by varying the target wavelength.

    Fig. 1.

    Fig. 1. (Color online) Schematic diagram of ANN model for determination of noise-reduced μa and μs values at a target wavelength. Measured R and T values for the target wavelength (blue circles) and at several neighboring wavelengths (red triangles) are input. Estimated μa and μs values (blue squares) are then output.

    The mwANN model, which has three hidden layers that incorporate batch normalization and a rectified linear unit (ReLU) function for activation, was then prepared. The mwANN model was tuned independently according to the noise conditions of the DIS system. The codes were implemented in Python and TensorFlow with the Keras module was used as the deep learning toolkit. Training was performed using Adam optimization. The mean squared error was then minimized as a loss function.

    2.2. Dataset preparation

    To construct a dataset, μa and μs spectra were generated using an approximation model and expressed as a function of the wavelength λ [nm]. Several μa spectra for biological tissues, denoted by μa(λ), can be modeled using the μa spectra of oxyhemoglobin (μa,HbO2(λ)), deoxyhemoglobin (μa,Hb(λ)), water (μa,W(λ)) and melanin (μa,Mel(λ)), as shown below2:

    μa(λ)=SB×{α×μa,HbO2(λ)+(1α)×μa,Hb(λ)}+SW×μa,W(λ)+SM×μa,Mel(λ)[mm1],(1)
    where SB, SW and SM are scaling factors that indicate the blood, water and melanin volume fractions, respectively. α is the percentage of HbO2 in the blood. μa,Mel(λ) is calculated using the following equation15 :
    μa,Mel(λ)=6.6×1010×λ3.33[mm1].(2)
    μs(λ) is calculated using the following equation with constants a,b,c and d, which vary for different tissues16 :
    μs(λ)=a×λb+c×λd[mm1].(3)
    To simulate the measured R(λ) and T(λ) values, 15,000 sets of μa(λ) and μs(λ) were generated within the 370–800nm wavelength range. The scaling factors and the constants in Eqs. (1) and (3) were assigned randomly from the ranges given in Table 1 to cover a wide range of optical properties. The ranges of these factors were determined based on values from the literature.16,17,18 To match the sampling pitch of the wavelength in the DIS measurements, the generated sets of μa(λ) and μs(λ) were interpolated using quadratic splines. The interpolated μa(λ) and μs(λ) were used after their spectral shapes were confirmed to be identical before and after the interpolation. From each set of these interpolated μa(λ) and μs(λ) values, the corresponding R(λ) and T(λ) values were then calculated using a Monte Carlo model of steady-state light transport in multi-layered tissues (MCML).19 The light propagation calculations were executed using CUDAMCML, which is graphics processing unit (GPU)-accelerated MCML software.20 In the MCML calculations, the biological sample was assumed to be sealed between two glass slides to perform the DIS measurement.7 The values of n and g for the sample were set at 1.385 and 0.9, respectively, according to the literature.21 The thickness of the glass slide was set at 1.0mm. The n value of the glass slides was 1.524. The number of photon packets used in the MCML calculations was 1×106. The sample thickness was set at 0.5mm in the numerical demonstration according to the literature22 or at an appropriate measured value in the experimental verification.

    Table 1. Ranges of sample parameters used to generate training datasets.

    ParameterMinMax
    SB0.0010.04
    α0.51
    SW0.50.8
    SM00.04
    a1 ×1081.2 ×1011
    b24
    c280
    d0.150.7

    Notes: Sb: blood volume fraction; SW: water volume fraction; Sm: melanosome volume fraction; α: percentage of HbO2 in the blood; a, b, c and d: constants that control the spectral variation in each tissue.

    To simulate the measurement noise signals, noise signals based on the assumption of DIS measurement were added to the interpolated R(λ) and T(λ) values. R(λ) and T(λ) are obtained via three optical measurements, comprising a white light reference measurement, a dark reference measurement and a sample measurement, using the DIS system. The dark reference measurements for R(λ) or T(λ) were taken experimentally 20 times over the wavelength range of the dataset to obtain the variance at each wavelength as the detection noise signals. The detection noise distributions were assumed to be Gaussian noise. The noise variance of R(λ), denoted by σnoise2(R), and that of T(λ), denoted by σnoise2(T), were calculated via error propagation using the variances of the detection noise signals. Gaussian noise signals with variances of σnoise2(R) and σnoise2(T) were generated randomly and then added to the interpolated R(λ) and T(λ) values. Therefore, a database consisting of 15,000 sets of μa(λ), μs(λ), noise-added R(λ) and noise-added T(λ) values was constructed. Several databases were prepared by changing σnoise2(R) and σnoise2(T) during the evaluation of the noise robustness.

    For a training dataset, target wavelengths were assigned randomly for each set in the constructed database. The μa(λ) and μs(λ) values at the assigned target wavelengths and the continuous noise-added R(λ) and T(λ) sequences with the same number of wavelengths as the mwANN inputs were then extracted. The training dataset, which consisted of 15,000 pairs of inputs and outputs from the mwANN shown in Fig. 1, was thus constructed. For the test dataset, 1,000 sets of μa(λ), μs(λ), noise-added R(λ) and T(λ) values were generated using the same procedure that was used for the database for the training dataset.

    2.3. Accuracy evaluation

    To evaluate the noise reduction performance, the signal-to-noise ratio (SNR) was used. The SNRs of the estimated μa and μs values were calculated independently using the following equation23 :

    SNR=10log10σx2σe2,(4)
    where σx2 is the variance of the true μa(λ) and μs(λ) values. σe2 is the variance of the estimation error, which is described as the absolute error between the true and estimated μa(λ) and μs(λ) values.

    Comparisons of the noise robustness of the proposed mwANN to the IMC method, a one-wavelength ANN (owANN) and a combination of a Gaussian filter (GF) and the owANN were performed. In the IMC method, μa(λ) and μs(λ) were determined using the methodology presented in the literature.24 In the IMC method, n and g were assumed to be constant at all wavelengths and were set at 1.385 and 0.9. In the owANN, 12,000 sets of a meshed training dataset of μa, μs, R and T were used for training, as described in the literature.11 To have the same ranges for the optical properties that were used as the training dataset for the mwANN, the ranges of μa and μs were 0–3 mm1 and 0–120 mm1, respectively, and the intervals for μa and μs were 0.03 mm1 and 1 mm1, respectively. For the combination of the GF and owANN, R and T values that had been denoised using a GF were input to the owANN, and the values of μa and μs were estimated. Within the parameter ranges, the μa and μs values were divided into each interval size and all possible different combinations were then generated.

    2.4. Sample measurement using DIS system

    To measure R(λ) and T(λ), a DIS system was used. Our DIS experimental setup was previously described in detail.24 Briefly, a xenon lamp (L2273 and C8849, Hamamatsu Photonics, Japan) was used as the white light source. The light was focused onto the sample surface into a 1mm diameter spot. The sample was placed between the reflectance and transmittance spheres (CSTM-3P-GPS-033SL, Labsphere). The integrating spheres had ports with a diameter of 10mm. The diffusely reflected and transmitted light was detected through an optical fiber (CUSTOM-PATCH-2243142, Ocean Optics) connected to a spectrometer (MAYP10161, Maya2000-Pro, Ocean Optics).

    Chicken breast tissue was prepared for the measurements. Frozen chicken breast tissue was cut into thin slices with dimensions of approximately 1cm × 1cm to cover the ports of the integrating spheres. The thickness of the chicken breast tissue was 2.0mm. The sample thickness was measured at three points using a micrometer (MDE-25MX, Mitutoyo, Japan) and averaged. The sample was then sandwiched between two glass slides using spacers to minimize any change in the optical properties due to compression. The tissue was then sealed with glue to prevent desiccation from occurring during the measurements. The above procedures had been completed within 10min and the measurement was performed immediately after sample preparation. To compare the performance of IMC and the mwANN, a single sample was prepared. The exposure time was set at 500ms and the number of scans averaged in the measurement was set at 1 or 100.

    3. Results

    3.1. Noise reduction in determination of absorption and scattering coefficients

    To demonstrate the noise reduction, the μa(λ) and μs(λ) values were estimated by the trained mwANN, which accepted 31 wavelengths from the simulated R(λ) and T(λ) spectra measured using the DIS system. Initially, μa(λ) and μs(λ) spectra generated in the same manner shown in Sec. 2.2 were defined as the true values. From the generated μa(λ) and μs(λ) spectra, the simulated R(λ) and T(λ) spectra were obtained. Figure 2(a) shows a set of the simulated R(λ) and T(λ) spectra. The σnoise2(R) and σnoise2(T) values were determined to be 2.10×105 and 3.32×105, respectively. Figure 2(b) shows the μa(λ) and μs(λ) spectra calculated using the IMC and mwANN methods. When compared with the μa(λ) and μs(λ) spectra obtained by the IMC method, the results from the mwANN method showed good agreement with the true values. The spectra estimated by the IMC method showed less accuracy, particularly at wavelengths around 400nm, where light absorption by the hemoglobin was notably strong. This led to the small values that were determined for both R(λ) and T(λ) within this wavelength range.25 In contrast, the spectra estimated via the mwANN method showed high accuracy with almost no dispersions. Figures 3(a) and 3(b) show the estimation errors for the IMC and mwANN methods, respectively. The average estimation errors for the μa(λ) and μs(λ) spectra were 0.013mm1 and 1.59mm1 for the IMC method and 0.010mm1 and 0.48mm1 for the mwANN method, respectively. The accuracy of the optical properties estimated from the noised R and T values was improved.

    Fig. 2.

    Fig. 2. (a) Simulated spectra of (i) R and (ii) T. (b) Spectra of (i) μa and (ii) μs estimated by both the mwANN and IMC methods.

    Fig. 3.

    Fig. 3. Absolute error distributions for (i) μa and (ii) μs determined by (a) the IMC method and (b) the mwANN.

    3.2. Evaluation of the number of input wavelengths

    To evaluate the relationships between the SNR and the number of input wavelengths, simulated measured R(λ) and T(λ) spectra were prepared by assuming that the number of scans to be averaged in the DIS measurement was 1 or 100. For the number of scans to be averaged of 1, σnoise2(R) and σnoise2(T) were 1.58×104 and 2.10×104, respectively. For the number of scans to be averaged of 100, σnoise2(R) and σnoise2(T) were 2.46×106 and 3.28×106, respectively. Figure 4 illustrates the relationship between the SNR and the number of input wavelengths. When the neighboring wavelengths were not taken into account (i.e., one wavelength was input), the SNR was low for both measurement conditions, indicating that the noise reduction procedure had not functioned. In contrast, as the number of input wavelengths increased, the SNR was observed to improve for both μa(λ) and μs(λ). This improvement occurred because use of a greater number of input wavelengths meant that more spectral shape changes could be trained and used for the estimation process. The use of multiple wavelengths as inputs is useful as an approach to noise reduction for the optical properties. For numbers of input wavelengths greater than 11, the SNRs of the μa and μs values estimated from the measurement with one scan exceeded the SNR obtained when 100 scans were averaged without consideration of the neighboring wavelengths (i.e., when one wavelength was input), thus indicating the feasibility of reducing the measurement time by applying the DIS.

    Fig. 4.

    Fig. 4. SNR characteristics of estimated (a) μa(λ) and (b) μs(λ) with varying numbers of input wavelengths. The SNRs were obtained from the simulated R and T spectra while assuming that the numbers of scans to be averaged were 1 and 100. Each estimation process was conducted three times and the error bars show the standard deviations.

    3.3. Evaluation of noise robustness

    To evaluate the noise robustness of the proposed method, the estimation accuracies obtained for each noise level when using the IMC method, the owANN method, the GF method and the mwANN method with 51 input wavelengths were compared. Figure 5(a) shows the relationship between the SNR and the noise level σnoise2. σnoise2 was defined as σnoise2=(σnoise2(R)+σnoise2(T))/2. The mwANN method showed a higher SNR and better estimation accuracy when compared with the IMC, owANN and GF methods, except in the case where σnoise2 was near zero. The SNR, which tended to decrease with increasing noise levels, was improved by using the multi-wavelength model, and the high SNR was retained. The IMC and owANN methods both showed a significant reduction in their SNR characteristics, indicating reduced noise robustness. The mwANN method was more robust to the measurement noise than the other methods. Even at high noise levels, the mwANN method was able to reduce the noise and determine the optical properties accurately. Figure 5(b) shows the coefficient of determination (R2) characteristics with the varying noise levels. The mwANN method kept the R2 at the same level (more than 0.99) as the estimated results from noise-free data (σnoise2=0) with the IMC method, even at high noise levels. The difference between the true and estimated values was maintained at the same level as the noiseless case, indicating that the mwANN method reduces noise without smoothing out the information of the actual μa and μs.

    Fig. 5.

    Fig. 5. (a) SNR characteristics of estimated (i) μa(λ) and (ii) μs(λ) for various noise levels σnoise2. (b) R2 characteristics of estimated (i) μa(λ) and (ii) μs(λ) values relative to the true values.

    3.4. Experimental verification

    The μa(λ) and μs(λ) spectra of the chicken breast tissue were estimated from experimental R(λ) and T(λ) characteristics measured using the DIS system for experimental verification. Figure 6(a) shows the R(λ) and T(λ) spectra of the chicken breast tissues when measured with the number of scans to be averaged of 1 or 100. The acquisition time for the R(λ) and T(λ) spectra for one scan can be shortened to 1/100 of that for 100 scans. Figure 6(b) shows the μa(λ) and μs(λ) spectra obtained via the IMC method when using measured data that were averaged over 100 scans. A strong absorption peak was observed at approximately 412nm and smaller peaks were observed at approximately 548nm and 575nm. These peaks were considered to be derived from hemoglobin. Some blood vessels might be included in the chicken breast tissue sample. The μs(λ) spectrum decreased monotonically with increasing wavelength, which was attributed to a reduction in the Rayleigh scattering contribution and an increase in Mie scattering. Figures 6(c) and 6(d) show the μa(λ) and μs(λ) spectra determined from R(λ) and T(λ) when measured with one scan by the IMC and mwANN methods, respectively. The mwANN method reduced the effects of noise propagation on the measurement of both R(λ) and T(λ). The resulting μa(λ) and μs(λ) spectra showed values that were closer to the spectra shown in Fig. 6(b). The small absorption peaks produced by hemoglobin at approximately 548nm and 575nm were identified more clearly by the mwANN method than by the IMC method. These results indicate that the mwANN model can reduce the number of scans required for the DIS measurements, and thus contributes to reduction of the measurement time required to perform spectroscopy.

    Fig. 6.

    Fig. 6. Optical properties of chicken breast tissue for different numbers of scans in the DIS measurements. (a) Measured spectra of (i) R and (ii) T with numbers of scans to be averaged of 1 and 100. (b) Estimated spectra of (i) μa and (ii) μs from the measured R and T spectra when averaged over 100 scans by the IMC method. (c), (d) Estimated spectra of (i) μa and (ii) μs from the measured R and T spectra with one scan by the IMC and mwANN methods, respectively.

    3.5. Adaptability evaluation

    To evaluate the adaptability of the trained mwANN, the μa(λ) and μs(λ) spectra of human subcutaneous fat were estimated based on previously reported R(λ) and T(λ) results.24 In the previous work,24 the μa(λ) spectrum has a peak for bilirubin at 475nm, i.e., a spectrum with a shape that differs from that for hemoglobin absorption. Figure 7 shows the μa(λ) and μs(λ) spectra obtained by the IMC and mwANN methods. In the μa spectrum that was analyzed using the IMC method, the absorption peaks of hemoglobin were observed at wavelengths of approximately 415nm, 450nm and 574nm, while the peak for bilirubin was observed at 475nm. Although spectra with bilirubin absorption bands were not included among the training datasets, the mwANN method was still able to estimate the absorption peak. The μs(λ) spectrum also showed agreement between the IMC and mwANN methods. The peaks of other absorbers could be estimated because the spectral shape changes in R and T were trained appropriately.

    Fig. 7.

    Fig. 7. Spectra of (a) μa and (b) μs for human subcutaneous fat. The calculations of the spectra were executed by the IMC and mwANN methods using the same R and T spectra.

    4. Discussion

    An ANN model that used R and T values at multiple wavelengths as inputs was constructed for noise-reduced measurement of the μa(λ) and μs(λ) spectra. The numerical and experimental results demonstrated that the mwANN was robust to measurement noise and that it improved the estimation accuracy of μa(λ) and μs(λ) from the noised R(λ) and T(λ) characteristics. The use of multiple wavelengths as inputs is an effective approach for noise reduction and can be applied regardless of the actual noise level. In addition, accurate μa(λ) and μs(λ) spectra can be calculated from R(λ) and T(λ) when measured using a small number of scans in the DIS system, which contributes to reduced DIS measurement times. There are few restrictions with regard to the biological tissues to which the mwANN can be applied because absorption peaks that are not considered in the optical properties model for the dataset can be estimated.

    In the mwANN method, noise reduction was achieved by focusing on the nature of the continuity of the absorption and scattering spectra of the biological tissues. The proposed mwANN method was applied over the visible to near-infrared wavelength range in this study. The same algorithm can be used to estimate μa(λ) and μs(λ) over other wavelength ranges, as long as an appropriate training dataset is prepared. In the construction of the training dataset, the main optical absorbers in biological tissues (i.e., hemoglobin, oxyhemoglobin, water and melanin) were considered. Because the optical properties were estimated from spectral changes in R(λ) and T(λ), absorption bands that were not considered as part of the training data were also detected, as shown in Fig. 7. Other absorption peaks may be detected, along with that of bilirubin.

    The results from the owANN and mwANN methods were compared as shown in Fig. 5. When using the owANN method, the R2 values of the estimated μa(λ) and μs(λ) were 0.9684 and 0.9905, respectively, for the simulated R(λ) and T(λ) when assuming DIS measurements with 100 scans. The mwANN method estimated the μa(λ) and μs(λ) spectra more accurately, with R2 values of 0.9944 and 0.9932, respectively. The mwANN method determined μa(λ) and μs(λ) with higher R2 values than the owANN method, even in measurements performed with measurement noise variance that was 60 times larger. The mwANN model was more robust to noise signals when compared with the owANN model. The mwANN can shorten the acquisition time by using measured data that have been averaged over smaller numbers of scans in the DIS system. At least three measurements are required for R(λ) or T(λ) in conventional DIS measurements, making the measurement time relatively long.26 Prolonged measurements might lead to changes in the optical properties of the biological sample. Zhu et al. reported that the absorption coefficient of porcine liver tissue increased over time because of the weight loss and water loss caused by drying.27 By using the mwANN method, it is expected that the reduced DIS measurement time requirement will enable measurements that minimize any changes in the optical properties caused by the sample conditions.

    Although the input to the mwANN will need to be modified, an ANN-based approach with multiple wavelength inputs could be implemented for in vivo measurements when using broadband wavelengths. In diffuse reflection spectroscopy (DRS), the absorption and scattering coefficient spectra were estimated by the IMC28 and ANN29 methods from spatially resolved diffuse reflectance. Generally, the SNR in DRS decreases with increasing source-detector separation, or with increasing distance between the optical fibers that deliver and collect the light.30 The potential for noise reduction when using an ANN-based approach may provide a higher SNR for in vivo optical properties. Furthermore, the time required to perform in vivo spectroscopy can be reduced, thus contributing to real-time measurement of the optical properties.

    5. Conclusions

    This study has presented an ANN-based method for noise-resistant determination of the optical properties of biological tissues. The ANN was trained to output μa and μs values at a target wavelength based on the inputs of R and T at the surrounding wavelengths. The ANN-based method demonstrated better noise reduction performance than the conventional methods in this field. Furthermore, in vitro experiments showed that the ANN can contribute to the performance of short-time DIS measurements and can be applied to samples with absorption peaks that are not included in the dataset. This method will improve the accuracy of optical properties determination and will enable DIS measurements with minimized effects from changes in the optical properties over time.

    Acknowledgments

    This work was supported by the Japan Society for the Promotion of Science KAKENHI (Grant numbers: 20H04549 and 19K12822) and the Japan Science and Technology Agency ACT–X (Grant Number: JPMJAX21K7).

    Conflicts of Interest

    The authors have no conflicts of interest relevant to this article.

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