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This study was reviewed and approved by the independent ethics committee of Zhongshan Hospital, Fudan University (approval no. B2023-154R for initial review; extension approval no. B2023-154).","order":5,"name":"Ethics","label":"Ethical approval","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Clarification of participant overlap and study relationship. Both studies originate from a large-scale, ongoing prospective research program at Zhongshan Hospital aimed at validating quantitative ultrasound techniques against liver biopsy in patients with MASLD. The study by Ji et al (\n                      n\n                      \u2009=\u2009264, recruitment period: August 2022\u2013November 2023) represents an earlier, single-center investigation focusing on the Samsung R10 Prestige ultrasound system and comparing three quantitative parameters (TAI, TSI, and USFF). Our current study is a distinct, subsequent phase of this research program with the following key differences: (1) different ultrasound platform: we employed the ACUSON Sequoia system (Siemens Healthineers) with its vendor-specific UDFF implementation, whereas Ji et al used the Samsung R10 Prestige system. These are two completely different ultrasound platforms with distinct physical principles, calibration methods, and proprietary algorithms for fat fraction calculation. (2) Different research objectives: Ji et al focused on comparing TAI, TSI, and USFF; our study is dedicated exclusively to validating UDFF using a dual-threshold diagnostic strategy with internal and external validation. (3) Expanded cohort and external validation: our study includes 376 patients from Center 1 (recruitment extended to September 2024) and, critically, an independent external validation cohort of 42 patients from Center 2 (Shanghai Oriental Hepatobiliary Hospital)-a distinct institutional cohort not included in Ji et al Regarding participant overlap: We confirm that approximately one-quarter (\n                      n\n                      \u2009=\u200966) of the Center 1 cohort in our study also participated in the Ji et al study. These patients provided voluntary informed consent to undergo both Samsung and Siemens ultrasound examinations on separate occasions within a 24-h window to ensure consistency of liver fat status and avoid mutual interference between the two acquisitions. Both ultrasound examinations were non-invasive, non-ionizing, and performed in accordance with the ALARA principle (as low as reasonably achievable) to ensure participant safety. The two scans were conducted independently under the approval of the institutional review board, and all procedures were performed in full compliance with the Declaration of Helsinki and institutional ethical guidelines for clinical research. These two studies are methodologically independent, technically non-interchangeable, and scientifically complementary.","order":6,"name":"Ethics","label":"Study subjects or cohorts overlap","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"order":7,"name":"Ethics","label":"Methodology","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}}]}}