{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T16:24:12Z","timestamp":1762273452597,"version":"3.43.0"},"reference-count":43,"publisher":"American Medical Association (AMA)","issue":"8","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>Congenital aortic valve disease predominantly manifests as bicuspid aortic valve (BAV), while quadricuspid aortic valve (QAV) is considerably rarer. Whether outcomes vary between these 2 types of congenital aortic valve disease remains unknown.<\/jats:p><\/jats:sec>Objective<\/jats:title>To compare outcomes between patients with QAV and patients with BAV.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>In this cohort study, patients diagnosed with QAV or BAV were retrospectively identified from echocardiographic examinations performed from January 1, 2011, to December 31, 2023, at 2 tertiary hospitals in China. Patients with QAV were propensity score matched 1:5 by age and sex with patients with BAV.<\/jats:p><\/jats:sec>Exposure<\/jats:title>Presence of QAV or BAV.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Outcomes of interest included aortic valve intervention (surgical or transcatheter), aortic surgery, aortic dissection, infective endocarditis (IE), heart failure hospitalization (HFH), and all-cause death. Morbidity rates were estimated using the cumulative incidence function to account for competing risk of death. Relative survival was calculated as the ratio of observed survival to the expected survival in the general population.<\/jats:p><\/jats:sec>Results<\/jats:title>From 2\u202f945\u202f132 echocardiographic examinations, 139 patients with QAV (median age, 54.8 [IQR, 46.2-63.9] years; 85 [61.2%] male) and 695 with BAV (median age, 55.4 [IQR, 45.5-64.2] years; 425 [61.2%] male) were included. Over a median follow-up of 4.8 years (IQR, 2.4-8.0 years), patients with QAV had a similar incidence of aortic valve intervention (77.4% [95% CI, 64.5%-86.1%] vs 75.7% [95% CI, 71.1%-79.8%]; P<\/jats:italic>\u2009=\u2009.26) but lower incidence of aortic surgery (5.1% [95% CI, 0.9%-15.0%] vs 33.8% [95% CI, 28.4%-39.2%]; P<\/jats:italic>\u2009&amp;lt;\u2009.001) and IE (not observed vs 9.6% [95% CI, 6.4%-13.5%]; P<\/jats:italic>\u2009=\u2009.01) compared with patients with BAV. Aortic dissection was rare in both groups (QAV, 0.9% [95% CI, 0.1%-4.1%]; BAV, 3.6% [95% CI, 1.8%-6.4%]; P<\/jats:italic>\u2009=\u2009.57). Compared with BAV, QAV morphology was associated with an increased risk of HFH after multivariable adjustments (adjusted hazard ratio [AHR], 2.52; 95% CI, 1.51-4.20; P<\/jats:italic>\u2009&amp;lt;\u2009.001). Presence of cardiomyopathies was an independent factor associated with HFH in patients with QAV (AHR, 4.27; 95% CI, 2.26-8.07; P<\/jats:italic>\u2009&amp;lt;\u2009.001). The 5-year relative survival rate compared with the age- and sex-matched general population was 102.9% (95% CI, 97.9%-107.2%) for patients with QAV and 102.4% (95% CI, 99.3%-104.8%) for those with BAV.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this large, retrospective cohort study, both QAV and BAV were associated with a high risk of aortic valve intervention. Individuals with QAV had a greater risk of HFH, while those with BAV had higher incidence of IE and aortic surgery. Despite the substantial morbidity burden, survival in both groups was similar to that in the general population.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.24915","type":"journal-article","created":{"date-parts":[[2025,8,4]],"date-time":"2025-08-04T15:00:26Z","timestamp":1754319626000},"page":"e2524915","source":"Crossref","is-referenced-by-count":1,"title":["Clinical Outcomes in Patients With Quadricuspid vs Bicuspid Aortic Valve"],"prefix":"10.1001","volume":"8","author":[{"given":"Jingnan","family":"Zhang","sequence":"first","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fang","family":"Fang","sequence":"additional","affiliation":[{"name":"Structural Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Disease, Beijing, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhiyuan","family":"Xia","sequence":"additional","affiliation":[{"name":"Structural Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Disease, Beijing, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wenhao","family":"Zhu","sequence":"additional","affiliation":[{"name":"Structural Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Disease, Beijing, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher Tze-Wei","family":"Tsang","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Qingwen","family":"Ren","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jiayi","family":"Huang","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ran","family":"Guo","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wenli","family":"Gu","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Haochen","family":"Xuan","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yap-Hang","family":"Chan","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tai-Leung","family":"Chan","sequence":"additional","affiliation":[{"name":"Cardiothoracic Surgery Unit, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alan C.","family":"Yeung","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Victoria","family":"Delgado","sequence":"additional","affiliation":[{"name":"University Hospital, Germans Trias i Pujol Hospital, Badalona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiangbin","family":"Pan","sequence":"additional","affiliation":[{"name":"Structural Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Disease, Beijing, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gejun","family":"Zhang","sequence":"additional","affiliation":[{"name":"Structural Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Disease, Beijing, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kai-Hang","family":"Yiu","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong\u2013Shenzhen Hospital, Shenzhen, China"},{"name":"Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","published-online":{"date-parts":[[2025,8,4]]},"reference":[{"issue":"7","key":"zoi250705r1","doi-asserted-by":"publisher","first-page":"765","DOI":"10.1093\/ehjci\/jeaa355","article-title":"Prevalence, multimodality imaging characterization, and mid-term prognosis of quadricuspid aortic valves: an analysis of eight cases, based on 160?004 exams performed during 12?years in a tertiary care hospital.","volume":"22","author":"Manuel","year":"2021","journal-title":"Eur Heart J Cardiovasc Imaging"},{"issue":"6","key":"zoi250705r2","doi-asserted-by":"publisher","first-page":"561","DOI":"10.1001\/jama.2020.27205","article-title":"Prevalence of bicuspid aortic valve and associated aortopathy in newborns in Copenhagen, Denmark.","volume":"325","author":"Sillesen","year":"2021","journal-title":"JAMA"},{"key":"zoi250705r3","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehaa554","article-title":"ESC guidelines for the management of adult congenital heart disease.","author":"Baumgartner","year":"2021","journal-title":"Eur Heart J"},{"issue":"3","key":"zoi250705r4","doi-asserted-by":"publisher","first-page":"312","DOI":"10.1161\/CIRCULATIONAHA.115.017743","article-title":"Quadricuspid aortic valve: characteristics, associated structural cardiovascular abnormalities, and clinical outcomes.","volume":"133","author":"Tsang","year":"2016","journal-title":"Circulation"},{"issue":"9","key":"zoi250705r5","doi-asserted-by":"publisher","first-page":"1035","DOI":"10.1111\/j.1540-8175.2011.01477.x","article-title":"Quadricuspid aortic valve: a report of 12 cases and a review of the literature.","volume":"28","author":"Jagannath","year":"2011","journal-title":"Echocardiography"},{"issue":"43","key":"zoi250705r6","doi-asserted-by":"publisher","first-page":"4549","DOI":"10.1093\/eurheartj\/ehad477","article-title":"Bicuspid aortic valve: long-term morbidity and mortality.","volume":"44","author":"Yang","year":"2023","journal-title":"Eur Heart J"},{"issue":"3","key":"zoi250705r7","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1093\/ehjci\/jead312","article-title":"Long-term outcome of bicuspid aortic valve disease.","volume":"25","author":"Aschauer","year":"2024","journal-title":"Eur Heart J Cardiovasc Imaging"},{"issue":"1","key":"zoi250705r8","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.51871","article-title":"An unlucky four-leaf clover stenosis with a single coronary artery.","volume":"16","author":"Machraa","year":"2024","journal-title":"Cureus"},{"issue":"11","key":"zoi250705r9","doi-asserted-by":"publisher","first-page":"682","DOI":"10.1253\/circrep.CR-21-0049","article-title":"Quadricuspid aortic valve and anomalous aortic origin of the right coronary artery.","volume":"3","author":"Oda","year":"2021","journal-title":"Circ Rep"},{"issue":"3","key":"zoi250705r10","doi-asserted-by":"publisher","DOI":"10.14503\/THIJ-23-8109","article-title":"Nonischemic dilated cardiomyopathy with quadricuspid aortic valve.","volume":"50","author":"Khabsa","year":"2023","journal-title":"Tex Heart Inst J"},{"issue":"5","key":"zoi250705r11","doi-asserted-by":"publisher","first-page":"e35","DOI":"10.1161\/CIR.0000000000000932","article-title":"2020 ACC\/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines.","volume":"143","author":"Otto","year":"2021","journal-title":"Circulation"},{"issue":"14","key":"zoi250705r12","doi-asserted-by":"publisher","first-page":"e1126","DOI":"10.4244\/EIJ-E-21-00009","article-title":"2021 ESC\/EACTS guidelines for the management of valvular heart disease.","volume":"17","author":"Vahanian","year":"2022","journal-title":"EuroIntervention"},{"issue":"1","key":"zoi250705r13","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.echo.2014.10.003","article-title":"Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.","volume":"28","author":"Lang","year":"2015","journal-title":"J Am Soc Echocardiogr"},{"issue":"6","key":"zoi250705r15","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1016\/j.jcct.2015.09.003","article-title":"Cardiac computed tomography in current cardiology guidelines.","volume":"9","author":"Al-Mallah","year":"2015","journal-title":"J Cardiovasc Comput Tomogr"},{"issue":"9","key":"zoi250705r16","doi-asserted-by":"publisher","first-page":"1835","DOI":"10.1016\/j.jcmg.2019.01.045","article-title":"Why and how to measure aortic valve calcification in patients with aortic stenosis.","volume":"12","author":"Pawade","year":"2019","journal-title":"JACC Cardiovasc Imaging"},{"issue":"12","key":"zoi250705r17","doi-asserted-by":"publisher","first-page":"983","DOI":"10.1161\/CIRCULATIONAHA.121.055347","article-title":"Coronary artery anomalies.","volume":"144","author":"Gentile","year":"2021","journal-title":"Circulation"},{"issue":"37","key":"zoi250705r18","doi-asserted-by":"publisher","first-page":"3503","DOI":"10.1093\/eurheartj\/ehad194","article-title":"2023 ESC guidelines for the management of cardiomyopathies.","volume":"44","author":"Arbelo","year":"2023","journal-title":"Eur Heart J"},{"issue":"4","key":"zoi250705r19","doi-asserted-by":"publisher","first-page":"518","DOI":"10.1093\/cid\/ciad271","article-title":"The 2023 Duke-International Society for Cardiovascular Infectious Diseases criteria for infective endocarditis: updating the modified Duke criteria.","volume":"77","author":"Fowler","year":"2023","journal-title":"Clin Infect Dis"},{"issue":"11","key":"zoi250705r21","doi-asserted-by":"publisher","first-page":"1317","DOI":"10.1001\/jama.300.11.1317","article-title":"Outcomes in adults with bicuspid aortic valves.","volume":"300","author":"Tzemos","year":"2008","journal-title":"JAMA"},{"issue":"7","key":"zoi250705r22","doi-asserted-by":"publisher","first-page":"1158","DOI":"10.1016\/j.mayocp.2018.11.034","article-title":"Contemporary etiologies, mechanisms, and surgical approaches in pure native aortic regurgitation.","volume":"94","author":"Yang","year":"2019","journal-title":"Mayo Clin Proc"},{"issue":"8","key":"zoi250705r23","doi-asserted-by":"publisher","first-page":"543","DOI":"10.1136\/heartjnl-2023-323499","article-title":"Towards a gender-specific and morphology-specific assessment of aortic valve stenosis severity.","volume":"110","author":"Jander","year":"2024","journal-title":"Heart"},{"issue":"1","key":"zoi250705r24","first-page":"122","article-title":"In-vitro study of a porcine quadricuspid aortic valve.","volume":"23","author":"Vismara","year":"2014","journal-title":"J Heart Valve Dis"},{"issue":"2","key":"zoi250705r25","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1016\/j.jcct.2024.01.008","article-title":"Hemodynamics, anatomy, and outcomes of quadricuspid aortic valves: multimodality imaging assessment.","volume":"18","author":"Zhang","year":"2024","journal-title":"J Cardiovasc Comput Tomogr"},{"key":"zoi250705r26","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1016\/j.carpath.2018.03.005","article-title":"New morphological classification of congenital quadricuspid aortic valve and its histopathologic features.","volume":"35","author":"Cheng","year":"2018","journal-title":"Cardiovasc Pathol"},{"issue":"2","key":"zoi250705r27","first-page":"134","article-title":"Congenital quadricuspid aortic valve: report of nine surgical cases.","volume":"9","author":"Yotsumoto","year":"2003","journal-title":"Ann Thorac Cardiovasc Surg"},{"issue":"6","key":"zoi250705r28","doi-asserted-by":"publisher","first-page":"1342","DOI":"10.1002\/jmri.24498","article-title":"From unicuspid to quadricuspid: influence of aortic valve morphology on aortic three-dimensional hemodynamics.","volume":"40","author":"Entezari","year":"2014","journal-title":"J Magn Reson Imaging"},{"issue":"5","key":"zoi250705r29","doi-asserted-by":"publisher","first-page":"448","DOI":"10.1016\/j.jacc.2022.10.042","article-title":"Mechanisms of aortic dilation in patients with bicuspid aortic valve: JACC state-of-the-art review.","volume":"82","author":"Rodr\u00edguez-Palomares","year":"2023","journal-title":"J Am Coll Cardiol"},{"issue":"9","key":"zoi250705r30","doi-asserted-by":"publisher","first-page":"1235","DOI":"10.1093\/ehjci\/jeae103","article-title":"Aortic aneurysms in a general population cohort: prevalence and risk factors in men and women.","volume":"25","author":"Pham","year":"2024","journal-title":"Eur Heart J Cardiovasc Imaging"},{"issue":"2","key":"zoi250705r31","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1016\/j.jtcvs.2017.10.161","article-title":"The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: executive summary.","volume":"156","author":"Borger","year":"2018","journal-title":"J Thorac Cardiovasc Surg"},{"issue":"7","key":"zoi250705r32","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.64419","article-title":"Quadricuspid aortic valve: a rare case of endocarditis suspicion and management.","volume":"16","author":"Olaniyi","year":"2024","journal-title":"Cureus"},{"issue":"2","key":"zoi250705r33","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1002\/jcu.22495","article-title":"Quadricuspid aortic valve infective endocarditis.","volume":"46","author":"Jackson","year":"2018","journal-title":"J Clin Ultrasound"},{"issue":"24","key":"zoi250705r34","doi-asserted-by":"publisher","first-page":"2731","DOI":"10.1016\/j.jacc.2018.03.534","article-title":"Infective endocarditis in patients with bicuspid aortic valve or mitral valve prolapse.","volume":"71","author":"Zegri-Reiriz","year":"2018","journal-title":"J Am Coll Cardiol"},{"key":"zoi250705r35","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1161\/01.CIR.27.1.18","article-title":"Blood velocity and endocarditis.","volume":"27","author":"Rodbard","year":"1963","journal-title":"Circulation"},{"issue":"1","key":"zoi250705r36","doi-asserted-by":"publisher","first-page":"83","DOI":"10.1136\/hrt.78.1.83","article-title":"Congenital quadricuspid aortic valve anomaly associated with hypertrophic non-obstructive cardiomyopathy: a case report and review of the literature.","volume":"78","author":"Janssens","year":"1997","journal-title":"Heart"},{"issue":"5","key":"zoi250705r37","doi-asserted-by":"publisher","first-page":"459","DOI":"10.5543\/tkda.2013.29498","article-title":"Quadricuspid aortic valve associated with persistent left superior vena cava and right ventricular noncompaction cardiomyopathy.","volume":"41","author":"Dogan","year":"2013","journal-title":"Turk Kardiyol Dern Ars"},{"issue":"4","key":"zoi250705r38","first-page":"E7","article-title":"An uncommon coincidence of congenital quadricuspid aortic valve accompanied by hypertrophic obstructive cardiomyopathy.","volume":"7","author":"Bilge","year":"2007","journal-title":"Anadolu Kardiyol Derg"},{"issue":"17","key":"zoi250705r39","doi-asserted-by":"publisher","first-page":"1643","DOI":"10.1056\/NEJMra0902923","article-title":"Inherited cardiomyopathies.","volume":"364","author":"Watkins","year":"2011","journal-title":"N Engl J Med"},{"issue":"1","key":"zoi250705r40","doi-asserted-by":"publisher","first-page":"47","DOI":"10.1161\/CIRCULATIONAHA.121.058767","article-title":"A human hereditary cardiomyopathy shares a genetic substrate with bicuspid aortic valve.","volume":"147","author":"Siguero-\u00c1lvarez","year":"2023","journal-title":"Circulation"},{"issue":"17","key":"zoi250705r41","doi-asserted-by":"publisher","first-page":"1310","DOI":"10.1161\/CIRCULATIONAHA.122.060125","article-title":"Patients with bicuspid aortic stenosis demonstrate adverse left ventricular remodeling and impaired cardiac function before surgery with increased risk of postoperative heart failure.","volume":"146","author":"Wedin","year":"2022","journal-title":"Circulation"},{"issue":"4","key":"zoi250705r42","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCHEARTFAILURE.120.007871","article-title":"Prognostic role of prior heart failure hospitalization among patients hospitalized for worsening chronic heart failure.","volume":"14","author":"Blumer","year":"2021","journal-title":"Circ Heart Fail"},{"issue":"10","key":"zoi250705r43","doi-asserted-by":"publisher","first-page":"1104","DOI":"10.1001\/jama.2011.1286","article-title":"Incidence of aortic complications in patients with bicuspid aortic valves.","volume":"306","author":"Michelena","year":"2011","journal-title":"JAMA"},{"year":"2017","author":"von Knobelsdorff-Brenkenhoff","key":"zoi250705r14"},{"unstructured":"National Bureau of Statistics of China. Accessed December 20, 2024. http:\/\/www.stats.gov.cn","key":"zoi250705r20"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2837212\/zhang_2025_oi_250705_1753721758.63597.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,4]],"date-time":"2025-08-04T15:00:28Z","timestamp":1754319628000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2837212"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,4]]},"references-count":43,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2025,8,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.24915","relation":{},"ISSN":["2574-3805"],"issn-type":[{"type":"electronic","value":"2574-3805"}],"subject":[],"published":{"date-parts":[[2025,8,4]]}}}