{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,11]],"date-time":"2025-09-11T20:29:02Z","timestamp":1757622542565,"version":"3.44.0"},"reference-count":41,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T00:00:00Z","timestamp":1754438400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T00:00:00Z","timestamp":1754438400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"This study was supported by Hebei Province 2024 Medical Research Project Plan.","award":["No.20241295","No.20241295","No.20241295","No.20241295","No.20241295","No.20241295"],"award-info":[{"award-number":["No.20241295","No.20241295","No.20241295","No.20241295","No.20241295","No.20241295"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Microbiol"],"abstract":"<jats:title>Abstract<\/jats:title>\n          <jats:p>Cervical incompetence (CI) is recognized as a critical factor contributing to mid-pregnancy miscarriage and preterm delivery, significantly affecting pregnancy outcomes. Despite this, the specific role of the microbiome in this pathological process remains inadequately understood. This study seeks to elucidate the core microbiome associated with CI in pregnant women and explore its potential biological mechanisms. Utilizing 16\u00a0S rRNA metagenomic sequencing, we examined the cervical mucus microbiota of women with CI both pre-operatively (PreOp) and post-operatively (PostOp). Subsequently, the immunomodulatory effects of these microbial communities on the immune system were systematically assessed using quantitative real-time PCR, Western blotting, and enzyme-linked immunosorbent assay. The findings revealed a significant reduction in microbial diversity and richness in PostOp cervical mucus, alongside notable alterations in microbiota composition. The genera <jats:italic>Lactobacillus<\/jats:italic>, <jats:italic>Bifidobacterium<\/jats:italic>, <jats:italic>Gardnerella<\/jats:italic>, <jats:italic>Streptococcus<\/jats:italic>, and <jats:italic>Anaerococcus<\/jats:italic> were identified as predominant. Further analysis demonstrated that treatment with 25% <jats:italic>Lactobacillus crispatus<\/jats:italic> (<jats:italic>L. crispatus<\/jats:italic>) supernatants, in comparison to 25% Group B Streptococcus (GBS) supernatants, resulted in high cell viability and normal morphology in HcerEpic cells. Importantly, the combination of 25% <jats:italic>L. crispatus<\/jats:italic> and 25% GBS supernatants significantly reduced the mRNA and protein expression levels of Toll-like receptor 4 (TLR4), Toll-like receptor 2 (TLR2), and nuclear factor kappa B (NF-\u03baB) in vitro. These results indicate that <jats:italic>L. crispatus<\/jats:italic> may play a role in modulating cervical inflammation in CI by suppressing the TLR\/NF-\u03baB signaling pathway, potentially contributing to a more stable cervical microenvironment during pregnancy.<\/jats:p>","DOI":"10.1186\/s12866-025-04203-0","type":"journal-article","created":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T02:34:08Z","timestamp":1754447648000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The role of cervical microbiome in cervical incompetence: insights from 16\u00a0S rRNA metagenomic sequencing"],"prefix":"10.1186","volume":"25","author":[{"given":"Jiang","family":"Jingwen","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fu","family":"Jingran","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Miao","family":"Liye","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Han","family":"Yu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Meng","family":"Yancen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhang","family":"Jingya","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,8,6]]},"reference":[{"issue":"4","key":"4203_CR1","doi-asserted-by":"publisher","first-page":"54","DOI":"10.21037\/atm.2019.12.148","volume":"8","author":"W Li","year":"2020","unstructured":"Li W, Li Y, Zhao X, et al. Diagnosis and treatment of cervical incompetence combined with intrauterine adhesions[J]. Ann Transl Med. 2020;8(4):54.","journal-title":"Ann Transl Med"},{"key":"4203_CR2","doi-asserted-by":"crossref","unstructured":"G\u00f3mez-Castellano M, Sabonet-Morente L, Gonz\u00e1lez-Mesa E et al. A Three-Step procedure for emergency cerclage: gestational and neonatal Outcomes[J]. Int J Environ Res Public Health 2022;19(5).","DOI":"10.3390\/ijerph19052636"},{"issue":"5","key":"4203_CR3","doi-asserted-by":"publisher","first-page":"1381","DOI":"10.12669\/pjms.41.5.11966","volume":"41","author":"X Zhang","year":"2025","unstructured":"Zhang X, Chen Y, Zhu K, et al. Characteristics of vaginal microbiota in pregnant women with cervical insufficiency and its association with adverse pregnancy outcomes[J]. Pak J Med Sci. 2025;41(5):1381\u20137.","journal-title":"Pak J Med Sci"},{"key":"4203_CR4","doi-asserted-by":"crossref","unstructured":"Vaduva CC, Petrescu AM, Dira LM et al. Probiotics in the prophylaxis of premature rupture of membranes and cervical Incompetence[J]. Nutrients 2024;16(23).","DOI":"10.3390\/nu16234230"},{"key":"4203_CR5","doi-asserted-by":"publisher","first-page":"986326","DOI":"10.3389\/fmicb.2022.986326","volume":"13","author":"M Sun","year":"2022","unstructured":"Sun M, Geng H, Bai J, et al. Characterization of cervical Canal and vaginal bacteria in pregnant women with cervical incompetence[J]. Front Microbiol. 2022;13:986326.","journal-title":"Front Microbiol"},{"key":"4203_CR6","first-page":"e934771","volume":"28","author":"Y Wang","year":"2022","unstructured":"Wang Y, Ning X, Yu Y, et al. Comparison of outcomes following general anesthesia and spinal anesthesia during emergency cervical cerclage in singleton pregnant women in the second trimester at a single Center[J]. Med Sci Monit. 2022;28:e934771.","journal-title":"Med Sci Monit"},{"issue":"5","key":"4203_CR7","doi-asserted-by":"publisher","first-page":"1215","DOI":"10.1007\/s43032-019-00111-7","volume":"27","author":"B Koullali","year":"2020","unstructured":"Koullali B, Zhang Y, Peterson A, et al. Cervical augmentation with an injectable Silk-Based gel: biocompatibility in a rat model of Pregnancy[J]. Reprod Sci. 2020;27(5):1215\u201321.","journal-title":"Reprod Sci"},{"issue":"3","key":"4203_CR8","first-page":"2465","volume":"20","author":"D Nemescu","year":"2020","unstructured":"Nemescu D, Tanasa IA, Bohiltea RE, et al. Anatomical and functional changes in arteries of uterine circulation after modified laparoscopic transabdominal cerclage in pregnancy: A case report and review of the literature[J]. Exp Ther Med. 2020;20(3):2465\u20139.","journal-title":"Exp Ther Med"},{"issue":"9","key":"4203_CR9","doi-asserted-by":"publisher","first-page":"571","DOI":"10.21037\/atm-2020-78","volume":"8","author":"S Ishioka","year":"2020","unstructured":"Ishioka S, Mariya T, Someya M, et al. Transabdominal cerclage (TAC) as a new tool for the treatment of cervical incompetence (CI)[J]. Ann Transl Med. 2020;8(9):571.","journal-title":"Ann Transl Med"},{"issue":"1","key":"4203_CR10","doi-asserted-by":"publisher","first-page":"773","DOI":"10.1186\/s12884-022-05108-w","volume":"22","author":"G Huang","year":"2022","unstructured":"Huang G, Deng C, Liao H, et al. Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre[J]. BMC Pregnancy Childbirth. 2022;22(1):773.","journal-title":"BMC Pregnancy Childbirth"},{"issue":"350","key":"4203_CR11","doi-asserted-by":"publisher","first-page":"350ra102","DOI":"10.1126\/scitranslmed.aag1026","volume":"8","author":"LM Kindinger","year":"2016","unstructured":"Kindinger LM, Macintyre DA, Lee YS, et al. Relationship between vaginal microbial dysbiosis, inflammation, and pregnancy outcomes in cervical cerclage[J]. Sci Transl Med. 2016;8(350):350ra102.","journal-title":"Sci Transl Med"},{"issue":"12","key":"4203_CR12","doi-asserted-by":"publisher","first-page":"1403","DOI":"10.1111\/aogs.14460","volume":"101","author":"M Vargas","year":"2022","unstructured":"Vargas M, Ya\u00f1ez F, Elias A, et al. Cervical Pessary and cerclage placement for preterm birth prevention and cervicovaginal Microbiome changes[J]. Acta Obstet Gynecol Scand. 2022;101(12):1403\u201313.","journal-title":"Acta Obstet Gynecol Scand"},{"key":"4203_CR13","doi-asserted-by":"crossref","unstructured":"Nicol\u00f2 S, Tanturli M, Mattiuz G et al. Vaginal lactobacilli and vaginal dysbiosis-associated bacteria differently affect cervical epithelial and immune homeostasis and anti-viral defenses[J]. Int J Mol Sci 2021;22(12).","DOI":"10.3390\/ijms22126487"},{"issue":"1","key":"4203_CR14","doi-asserted-by":"publisher","first-page":"92","DOI":"10.1186\/s12916-023-02805-x","volume":"21","author":"LG Dos Anjos Borges","year":"2023","unstructured":"Dos Anjos Borges LG, Pastuschek J, Heimann Y, et al. Vaginal and neonatal microbiota in pregnant women with preterm premature rupture of membranes and consecutive early onset neonatal sepsis[J]. BMC Med. 2023;21(1):92.","journal-title":"BMC Med"},{"issue":"1","key":"4203_CR15","doi-asserted-by":"publisher","first-page":"e1008236","DOI":"10.1371\/journal.ppat.1008236","volume":"16","author":"T Hoang","year":"2020","unstructured":"Hoang T, Toler E, Delong K, et al. The cervicovaginal mucus barrier to HIV-1 is diminished in bacterial vaginosis[J]. PLoS Pathog. 2020;16(1):e1008236.","journal-title":"PLoS Pathog"},{"issue":"1","key":"4203_CR16","doi-asserted-by":"publisher","first-page":"e0045222","DOI":"10.1128\/msphere.00452-22","volume":"8","author":"NR Jimenez","year":"2023","unstructured":"Jimenez NR, Maarsingh JD, \u0141aniewski P, et al. Commensal lactobacilli metabolically contribute to cervical epithelial homeostasis in a Species-Specific Manner[J]. mSphere. 2023;8(1):e0045222.","journal-title":"mSphere"},{"issue":"1","key":"4203_CR17","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1007\/s00404-021-06119-2","volume":"305","author":"X Zhou","year":"2022","unstructured":"Zhou X, Li XX, Ge YM, et al. Effects of vaginal microbiota and cervical cerclage on obstetric outcomes of twin pregnancies with cervical incompetence: a retrospective study[J]. Arch Gynecol Obstet. 2022;305(1):77\u201386.","journal-title":"Arch Gynecol Obstet"},{"issue":"10","key":"4203_CR18","doi-asserted-by":"publisher","first-page":"2092","DOI":"10.1093\/humrep\/deu195","volume":"29","author":"F Martyn","year":"2014","unstructured":"Martyn F, Mcauliffe FM, Wingfield M. The role of the cervix in fertility: is it time for a reappraisal?[J]. Hum Reprod. 2014;29(10):2092\u20138.","journal-title":"Hum Reprod"},{"issue":"9","key":"4203_CR19","doi-asserted-by":"publisher","first-page":"1511","DOI":"10.1016\/j.jbiomech.2015.02.065","volume":"48","author":"KM Myers","year":"2015","unstructured":"Myers KM, Feltovich H, Mazza E, et al. The mechanical role of the cervix in pregnancy[J]. J Biomech. 2015;48(9):1511\u201323.","journal-title":"J Biomech"},{"key":"4203_CR20","doi-asserted-by":"crossref","unstructured":"Fasoulakis Z, Koutras A, Ntounis T et al. Inflammatory molecules responsible for length shortening and preterm Birth[J]. Cells 2023;12(2).","DOI":"10.3390\/cells12020209"},{"issue":"1","key":"4203_CR21","doi-asserted-by":"publisher","first-page":"10879","DOI":"10.1038\/s41467-024-55233-7","volume":"15","author":"A Decout","year":"2024","unstructured":"Decout A, Krasias I, Roberts L, et al. Lactobacillus crispatus S-layer proteins modulate innate immune response and inflammation in the lower female reproductive tract[J]. Nat Commun. 2024;15(1):10879.","journal-title":"Nat Commun"},{"key":"4203_CR22","doi-asserted-by":"publisher","first-page":"1072960","DOI":"10.3389\/fcimb.2023.1072960","volume":"13","author":"Y Xiao","year":"2023","unstructured":"Xiao Y, Huang S, Yu W, et al. Effects of emergency\/nonemergency cervical cerclage on the vaginal Microbiome of pregnant women with cervical incompetence[J]. Front Cell Infect Microbiol. 2023;13:1072960.","journal-title":"Front Cell Infect Microbiol"},{"key":"4203_CR23","doi-asserted-by":"publisher","first-page":"8340009","DOI":"10.1155\/2022\/8340009","volume":"2022","author":"D He","year":"2022","unstructured":"He D, Zhao D. Analysis of the timing of cervical cerclage treatment in pregnant women with cervical insufficiency and the effect on pregnancy outcome. Emerg Med Int. 2022;2022:8340009.","journal-title":"Emerg Med Int"},{"key":"4203_CR24","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1016\/j.bpobgyn.2018.03.006","volume":"52","author":"DM Chu","year":"2018","unstructured":"Chu DM, Seferovic M, Pace RM, et al. The Microbiome in preterm birth[J]. Best Pract Res Clin Obstet Gynaecol. 2018;52:103\u201313.","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"issue":"6","key":"4203_CR25","doi-asserted-by":"publisher","first-page":"e0133923","DOI":"10.1128\/msystems.01339-23","volume":"9","author":"HL Berman","year":"2024","unstructured":"Berman HL, Goltsman DSA, Anderson M, et al. Gardnerella diversity and ecology in pregnancy and preterm birth[J]. mSystems. 2024;9(6):e0133923.","journal-title":"mSystems"},{"issue":"5","key":"4203_CR26","first-page":"888","volume":"50","author":"F Abbasalizadeh","year":"2021","unstructured":"Abbasalizadeh F, Pourasghary S, Shirizadeh M, et al. Prevalence of group B Streptococcus in vagina and rectum of pregnant women of Islamic & Non-Islamic countries: A systematic review and Meta-Analysis[J]. Iran J Public Health. 2021;50(5):888\u201399.","journal-title":"Iran J Public Health"},{"key":"4203_CR27","doi-asserted-by":"crossref","unstructured":"Menichini D, Chiossi G, Monari F et al. Supplementation of probiotics in pregnant women targeting group B Streptococcus colonization: a systematic review and meta-analysis[J]. Nutrients 2022;14(21).","DOI":"10.3390\/nu14214520"},{"issue":"1","key":"4203_CR28","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1186\/s40168-018-0502-8","volume":"6","author":"AC Freitas","year":"2018","unstructured":"Freitas AC, Bocking A, Hill JE, et al. Increased richness and diversity of the vaginal microbiota and spontaneous preterm birth[J]. Microbiome. 2018;6(1):117.","journal-title":"Microbiome"},{"key":"4203_CR29","doi-asserted-by":"publisher","first-page":"1123026","DOI":"10.3389\/fcimb.2023.1123026","volume":"13","author":"Z Sun","year":"2023","unstructured":"Sun Z, Ge X, Qiu B, et al. Vulvovaginal candidiasis and vaginal microflora interaction: microflora changes and probiotic therapy[J]. Front Cell Infect Microbiol. 2023;13:1123026.","journal-title":"Front Cell Infect Microbiol"},{"issue":"1","key":"4203_CR30","doi-asserted-by":"publisher","first-page":"1592","DOI":"10.1038\/s41467-017-01687-x","volume":"8","author":"SI Saitoh","year":"2017","unstructured":"Saitoh SI, Abe F, Kanno A, et al. TLR7 mediated viral recognition results in focal type I interferon secretion by dendritic cells[J]. Nat Commun. 2017;8(1):1592.","journal-title":"Nat Commun"},{"issue":"12","key":"4203_CR31","doi-asserted-by":"publisher","first-page":"8305","DOI":"10.1111\/jcmm.14707","volume":"23","author":"D Shi","year":"2019","unstructured":"Shi D, Liu W, Zhao S, et al. TLR5 is a new reporter for triple-negative breast cancer indicated by radioimmunoimaging and fluorescent staining[J]. J Cell Mol Med. 2019;23(12):8305\u201313.","journal-title":"J Cell Mol Med"},{"issue":"4","key":"4203_CR32","doi-asserted-by":"publisher","first-page":"649","DOI":"10.1016\/j.immuni.2024.03.004","volume":"57","author":"T Kawai","year":"2024","unstructured":"Kawai T, Ikegawa M, Ori D, et al. Decoding Toll-like receptors: recent insights and perspectives in innate immunity[J]. Immunity. 2024;57(4):649\u201373.","journal-title":"Immunity"},{"issue":"1","key":"4203_CR33","doi-asserted-by":"publisher","first-page":"86","DOI":"10.1186\/s12916-016-0632-4","volume":"14","author":"R Migale","year":"2016","unstructured":"Migale R, Macintyre DA, Cacciatore S, et al. Modeling hormonal and inflammatory contributions to preterm and term labor using uterine Temporal transcriptomics[J]. BMC Med. 2016;14(1):86.","journal-title":"BMC Med"},{"issue":"5","key":"4203_CR34","doi-asserted-by":"publisher","first-page":"569","DOI":"10.1530\/rep.1.00197","volume":"130","author":"TM Lindstr\u00f6m","year":"2005","unstructured":"Lindstr\u00f6m TM, Bennett PR. The role of nuclear factor kappa B in human labour[J]. Reproduction. 2005;130(5):569\u201381.","journal-title":"Reproduction"},{"key":"4203_CR35","doi-asserted-by":"publisher","first-page":"102616","DOI":"10.1016\/j.jri.2019.102616","volume":"136","author":"AL Areia","year":"2019","unstructured":"Areia AL, Moura P, Mota-Pinto A. The role of innate immunity in spontaneous preterm labor: A systematic review[J]. J Reprod Immunol. 2019;136:102616.","journal-title":"J Reprod Immunol"},{"issue":"5","key":"4203_CR36","doi-asserted-by":"publisher","first-page":"834","DOI":"10.1111\/j.1439-0531.2008.01096.x","volume":"44","author":"E Van Engelen","year":"2009","unstructured":"Van Engelen E, De Groot MW, Breeveld-Dwarkasing VN, et al. Cervical ripening and parturition in cows are driven by a cascade of pro-inflammatory cytokines[J]. Reprod Domest Anim. 2009;44(5):834\u201341.","journal-title":"Reprod Domest Anim"},{"issue":"4","key":"4203_CR37","doi-asserted-by":"publisher","first-page":"429","DOI":"10.1530\/REP-11-0466","volume":"143","author":"M Mahendroo","year":"2012","unstructured":"Mahendroo M. Cervical remodeling in term and preterm birth: insights from an animal model[J]. Reproduction. 2012;143(4):429\u201338.","journal-title":"Reproduction"},{"issue":"6","key":"4203_CR38","doi-asserted-by":"publisher","first-page":"534","DOI":"10.1111\/j.1600-0897.2011.01064.x","volume":"66","author":"T Agrawal","year":"2011","unstructured":"Agrawal T, Bhengraj AR, Vats V, et al. Expression of TLR 2, TLR 4 and iNOS in cervical monocytes of Chlamydia trachomatis-infected women and their role in host immune response[J]. Am J Reprod Immunol. 2011;66(6):534\u201343.","journal-title":"Am J Reprod Immunol"},{"key":"4203_CR39","doi-asserted-by":"publisher","first-page":"831115","DOI":"10.3389\/fmed.2022.831115","volume":"9","author":"F Lu","year":"2022","unstructured":"Lu F, Wei J, Zhong Y, et al. Antibiotic therapy and vaginal microbiota transplantation reduce endometriosis disease progression in female mice via NF-\u03baB signaling Pathway[J]. Front Med (Lausanne). 2022;9:831115.","journal-title":"Front Med (Lausanne)"},{"key":"4203_CR40","doi-asserted-by":"crossref","unstructured":"Flis W, Socha MW. The role of the NLRP3 inflammasome in the molecular and biochemical mechanisms of cervical ripening: A comprehensive Review[J]. Cells 2024;13(7).","DOI":"10.3390\/cells13070600"},{"issue":"1","key":"4203_CR41","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1186\/s40168-022-01317-9","volume":"10","author":"L Anton","year":"2022","unstructured":"Anton L, Ferguson B, Friedman ES, et al. Gardnerella vaginalis alters cervicovaginal epithelial cell function through microbe-specific immune responses[J]. Microbiome. 2022;10(1):119.","journal-title":"Microbiome"}],"container-title":["BMC Microbiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12866-025-04203-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12866-025-04203-0\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12866-025-04203-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,8]],"date-time":"2025-09-08T20:49:31Z","timestamp":1757364571000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcmicrobiol.biomedcentral.com\/articles\/10.1186\/s12866-025-04203-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,6]]},"references-count":41,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["4203"],"URL":"https:\/\/doi.org\/10.1186\/s12866-025-04203-0","relation":{},"ISSN":["1471-2180"],"issn-type":[{"type":"electronic","value":"1471-2180"}],"subject":[],"published":{"date-parts":[[2025,8,6]]},"assertion":[{"value":"24 April 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"9 July 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"6 August 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The experimental protocol was formulated in accordance with the ethical guidelines of the Declaration of Helsinki and approved by the Human Ethics Committee of Shijiazhuang fourth Hospital. The written informed consent of the individual or guardian of the participant is obtained.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"486"}}