{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T07:58:19Z","timestamp":1780732699860,"version":"3.54.1"},"reference-count":38,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2023,9,26]],"date-time":"2023-09-26T00:00:00Z","timestamp":1695686400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,9,26]],"date-time":"2023-09-26T00:00:00Z","timestamp":1695686400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Endocr Disord"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>This multi-center, cross-sectional study intended to explore the prevalence and risk factors of nonalcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) in patients with polycystic ovary syndrome (PCOS).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Patients who met the PCOS Rotterdam diagnostic criteria were enrolled in 6 centers in China, and age-matched healthy volunteers were also recruited. Data were collected including medical history, physical characteristics, and blood tests (liver function, blood lipids, blood glucose and insulin, sex hormones, etc.). Transvaginal or transrectal ultrasound was employed to identify polycystic ovarian morphology (PCOM). The serological score Liver Fat Score (LFS) &gt;-0.640 was used for the diagnosis of NAFLD, and the diagnosis of MAFLD was made according to the 2020 new definition.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>A total of 217 PCOS patients and 72 healthy controls were included. PCOS patients had impaired glucose and lipid metabolism, higher liver enzymes and LFS. Both NAFLD (33.6%) and MAFLD (42.8%) was more prevalent in PCOS patients than in controls (4.2%, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.001). Logistic regression results showed that HOMA-IR\u2009\u2265\u20093.54 and ALT\u2009\u2265\u200918.2 were independently associated with NAFLD (<jats:italic>P<\/jats:italic>\u2009&lt;\u20090.001) and MAFLD (<jats:italic>P<\/jats:italic>\u2009\u2264\u20090.001). The prevalence of NAFLD was significantly higher in PCOS patients with free androgen index (FAI)\u2009&gt;\u20098 (53.8% versus 17.4%, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.001) and BMI\u2009\u2265\u200924\u00a0kg\/m<jats:sup>2<\/jats:sup> (57.3%, 11.3%, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.001).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>The prevalence of NAFLD\/MAFLD in PCOS patients was significantly higher than that in healthy controls and was independently associated with HOMA-IR and ALT. PCOS patients with overweight and elevated FAI have a higher prevalence of fatty liver.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12902-023-01456-6","type":"journal-article","created":{"date-parts":[[2023,9,26]],"date-time":"2023-09-26T10:02:43Z","timestamp":1695722563000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Hepatic steatosis in women with polycystic ovary syndrome"],"prefix":"10.1186","volume":"23","author":[{"given":"Xinyu","family":"Hong","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zaixin","family":"Guo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qi","family":"Yu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,9,26]]},"reference":[{"issue":"12","key":"1456_CR1","doi-asserted-by":"publisher","first-page":"2841","DOI":"10.1093\/humrep\/dew218","volume":"31","author":"G Bozdag","year":"2016","unstructured":"Bozdag G, Mumusoglu S, Zengin D, Karabulut E, Yildiz BO. The prevalence and phenotypic features of polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2016;31(12):2841\u201355.","journal-title":"Hum Reprod"},{"issue":"3","key":"1456_CR2","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1016\/j.fertnstert.2018.05.004","volume":"110","author":"HJ Teede","year":"2018","unstructured":"Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2018;110(3):364\u201379.","journal-title":"Fertil Steril"},{"key":"1456_CR3","doi-asserted-by":"publisher","first-page":"774079","DOI":"10.3389\/fmed.2021.774079","volume":"8","author":"NLA Segura-Azuara","year":"2021","unstructured":"Segura-Azuara NLA, Varela-Chinchilla CD, Trinidad-Calderon PA. MAFLD\/NAFLD biopsy-free Scoring Systems for hepatic steatosis, NASH, and fibrosis diagnosis. Front Med (Lausanne). 2021;8:774079.","journal-title":"Front Med (Lausanne)"},{"issue":"1","key":"1456_CR4","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s12020-019-02085-7","volume":"67","author":"SA Paschou","year":"2020","unstructured":"Paschou SA, Polyzos SA, Anagnostis P, et al. Nonalcoholic fatty liver disease in women with polycystic ovary syndrome. Endocrine. 2020;67(1):1\u20138.","journal-title":"Endocrine"},{"issue":"5","key":"1456_CR5","doi-asserted-by":"publisher","first-page":"897","DOI":"10.1016\/j.fertnstert.2022.03.020","volume":"117","author":"I Doycheva","year":"2022","unstructured":"Doycheva I, Ehrmann DA. Nonalcoholic fatty liver disease and obstructive sleep apnea in women with polycystic ovary syndrome. Fertil Steril. 2022;117(5):897\u2013911.","journal-title":"Fertil Steril"},{"issue":"39","key":"1456_CR6","doi-asserted-by":"publisher","first-page":"14172","DOI":"10.3748\/wjg.v20.i39.14172","volume":"20","author":"CE Kelley","year":"2014","unstructured":"Kelley CE, Brown AJ, Diehl AM, Setji TL. Review of nonalcoholic fatty liver disease in women with polycystic ovary syndrome. World J Gastroenterol. 2014;20(39):14172\u201384.","journal-title":"World J Gastroenterol"},{"issue":"1","key":"1456_CR7","doi-asserted-by":"publisher","first-page":"3","DOI":"10.20945\/2359-3997000000442","volume":"66","author":"P Kabakchieva","year":"2022","unstructured":"Kabakchieva P, Gateva A, Velikova T, et al. Elevated levels of interleukin-18 are associated with several indices of general and visceral adiposity and insulin resistance in women with polycystic ovary syndrome. Arch Endocrinol Metab. 2022;66(1):3\u201311.","journal-title":"Arch Endocrinol Metab"},{"issue":"2","key":"1456_CR8","doi-asserted-by":"publisher","first-page":"150","DOI":"10.23736\/S2724-6507.21.03336-4","volume":"48","author":"P Kabakchieva","year":"2023","unstructured":"Kabakchieva P, Gateva A, Velikova T, Georgiev T, Kamenov Z. Anandamide is associated with waist-to-hip ratio but not with body Mass Index in women with polycystic ovary syndrome. Minerva Endocrinol. 2023;48(2):150\u20139.","journal-title":"Minerva Endocrinol"},{"issue":"10","key":"1456_CR9","doi-asserted-by":"publisher","first-page":"3709","DOI":"10.1210\/jc.2012-1382","volume":"97","author":"H Jones","year":"2012","unstructured":"Jones H, Sprung VS, Pugh CJ, et al. Polycystic ovary syndrome with hyperandrogenism is characterized by an increased risk of hepatic steatosis compared to nonhyperandrogenic PCOS phenotypes and healthy controls, independent of obesity and insulin resistance. J Clin Endocrinol Metab. 2012;97(10):3709\u201316.","journal-title":"J Clin Endocrinol Metab"},{"issue":"6","key":"1456_CR10","doi-asserted-by":"publisher","first-page":"1717","DOI":"10.1053\/j.gastro.2019.01.042","volume":"156","author":"PJ Eddowes","year":"2019","unstructured":"Eddowes PJ, Sasso M, Allison M, et al. Accuracy of FibroScan Controlled Attenuation parameter and liver stiffness measurement in assessing steatosis and fibrosis in patients with nonalcoholic fatty liver disease. Gastroenterology. 2019;156(6):1717\u201330.","journal-title":"Gastroenterology"},{"issue":"11","key":"1456_CR11","doi-asserted-by":"publisher","first-page":"1403","DOI":"10.1111\/apt.14058","volume":"45","author":"JJ Kim","year":"2017","unstructured":"Kim JJ, Kim D, Yim JY, et al. Polycystic ovary syndrome with hyperandrogenism as a risk factor for non-obese non-alcoholic fatty liver disease. Aliment Pharmacol Ther. 2017;45(11):1403\u201312.","journal-title":"Aliment Pharmacol Ther"},{"issue":"45","key":"1456_CR12","doi-asserted-by":"publisher","first-page":"9880","DOI":"10.3748\/wjg.v22.i45.9880","volume":"22","author":"RN Karanjia","year":"2016","unstructured":"Karanjia RN, Crossey MM, Cox IJ, et al. Hepatic steatosis and fibrosis: non-invasive assessment. World J Gastroenterol. 2016;22(45):9880\u201397.","journal-title":"World J Gastroenterol"},{"issue":"1","key":"1456_CR13","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1038\/s41574-021-00584-0","volume":"18","author":"N Tamaki","year":"2022","unstructured":"Tamaki N, Ajmera V, Loomba R. Non-invasive methods for imaging hepatic steatosis and their clinical importance in NAFLD. Nat Rev Endocrinol. 2022;18(1):55\u201366.","journal-title":"Nat Rev Endocrinol"},{"issue":"4","key":"1456_CR14","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1016\/j.cgh.2006.10.010","volume":"5","author":"M Gambarin-Gelwan","year":"2007","unstructured":"Gambarin-Gelwan M, Kinkhabwala SV, Schiano TD, Bodian C, Yeh HC, Futterweit W. Prevalence of nonalcoholic fatty liver disease in women with polycystic ovary syndrome. Clin Gastroenterol Hepatol. 2007;5(4):496\u2013501.","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"9","key":"1456_CR15","first-page":"725","volume":"11","author":"ZY Qu","year":"2013","unstructured":"Qu ZY, Zhu YH, Jiang JJ, Shi YH, Chen ZJ. The clinical characteristics and etiological study of nonalcoholic fatty liver disease in chinese women with PCOS. Iran J Reproductive Med. 2013;11(9):725\u201332.","journal-title":"Iran J Reproductive Med"},{"issue":"9","key":"1456_CR16","doi-asserted-by":"publisher","first-page":"1341","DOI":"10.1038\/ijo.2017.116","volume":"41","author":"J Cai","year":"2017","unstructured":"Cai J, Wu CH, Zhang Y, et al. High-free androgen index is associated with increased risk of non-alcoholic fatty liver disease in women with polycystic ovary syndrome, independent of obesity and insulin resistance. Int J Obes (Lond). 2017;41(9):1341\u20137.","journal-title":"Int J Obes (Lond)"},{"key":"1456_CR17","doi-asserted-by":"publisher","first-page":"79","DOI":"10.4103\/ijpvm.IJPVM_305_16","volume":"8","author":"F Mehrabian","year":"2017","unstructured":"Mehrabian F, Jahanmardi R. Nonalcoholic fatty liver disease in a sample of iranian women with polycystic ovary syndrome. Int J Prev Med. 2017;8:79.","journal-title":"Int J Prev Med"},{"issue":"26","key":"1456_CR18","doi-asserted-by":"publisher","first-page":"18180","DOI":"10.18632\/oncotarget.24477","volume":"9","author":"Y Zhang","year":"2018","unstructured":"Zhang Y, Meng F, Sun X, et al. Hyperandrogenism and insulin resistance contribute to hepatic steatosis and inflammation in female rat liver. Oncotarget. 2018;9(26):18180\u201397.","journal-title":"Oncotarget"},{"issue":"6","key":"1456_CR19","doi-asserted-by":"publisher","first-page":"1347","DOI":"10.1093\/humrep\/dew076","volume":"31","author":"D Macut","year":"2016","unstructured":"Macut D, Tziomalos K, Bozic-Antic I, et al. Non-alcoholic fatty liver disease is associated with insulin resistance and lipid accumulation product in women with polycystic ovary syndrome. Hum Reprod. 2016;31(6):1347\u201353.","journal-title":"Hum Reprod"},{"issue":"11","key":"1456_CR20","doi-asserted-by":"publisher","first-page":"e0186136","DOI":"10.1371\/journal.pone.0186136","volume":"12","author":"S Petta","year":"2017","unstructured":"Petta S, Ciresi A, Bianco J, et al. Insulin resistance and hyperandrogenism drive steatosis and fibrosis risk in young females with PCOS. PLoS ONE. 2017;12(11):e0186136.","journal-title":"PLoS ONE"},{"issue":"1","key":"1456_CR21","doi-asserted-by":"publisher","first-page":"202","DOI":"10.1016\/j.jhep.2020.03.039","volume":"73","author":"M Eslam","year":"2020","unstructured":"Eslam M, Newsome PN, Sarin SK, et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement. J Hepatol. 2020;73(1):202\u20139.","journal-title":"J Hepatol"},{"issue":"1","key":"1456_CR22","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1093\/humrep\/deh098","volume":"19","author":"ESHRE Rotterdam","year":"2004","unstructured":"Rotterdam ESHRE, ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41\u20137.","journal-title":"Hum Reprod"},{"issue":"11","key":"1456_CR23","doi-asserted-by":"publisher","first-page":"1440","DOI":"10.1210\/jcem-21-11-1440","volume":"21","author":"D Ferriman","year":"1961","unstructured":"Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab. 1961;21(11):1440\u20137.","journal-title":"J Clin Endocrinol Metab"},{"issue":"3","key":"1456_CR24","doi-asserted-by":"publisher","first-page":"792","DOI":"10.1016\/j.fertnstert.2011.06.040","volume":"96","author":"X Zhao","year":"2011","unstructured":"Zhao X, Ni R, Li L, et al. Defining hirsutism in chinese women: a cross-sectional study. Fertil Steril. 2011;96(3):792\u20136.","journal-title":"Fertil Steril"},{"key":"1456_CR25","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1186\/1471-2261-5-26","volume":"5","author":"HS Kahn","year":"2005","unstructured":"Kahn HS. The lipid accumulation product performs better than the body mass index for recognizing cardiovascular risk: a population-based comparison. BMC Cardiovasc Disord. 2005;5:26.","journal-title":"BMC Cardiovasc Disord"},{"issue":"1","key":"1456_CR26","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1016\/S0015-0282(16)45254-4","volume":"35","author":"RS Mathur","year":"1981","unstructured":"Mathur RS, Moody LO, Landgrebe S, Williamson HO. Plasma androgens and sex hormone-binding globulin in the evaluation of hirsute females. Fertil Steril. 1981;35(1):29\u201335.","journal-title":"Fertil Steril"},{"issue":"7","key":"1456_CR27","doi-asserted-by":"publisher","first-page":"412","DOI":"10.1007\/BF00280883","volume":"28","author":"DR Matthews","year":"1985","unstructured":"Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;28(7):412\u20139.","journal-title":"Diabetologia"},{"issue":"2","key":"1456_CR28","doi-asserted-by":"publisher","first-page":"949","DOI":"10.1210\/jcem.87.2.8223","volume":"87","author":"MJ Quon","year":"2002","unstructured":"Quon MJ. QUICKI is a useful and accurate index of insulin sensitivity. J Clin Endocrinol Metab. 2002;87(2):949\u201351.","journal-title":"J Clin Endocrinol Metab"},{"issue":"3","key":"1456_CR29","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1016\/S0168-8227(99)00116-3","volume":"47","author":"M Gutt","year":"2000","unstructured":"Gutt M, Davis CL, Spitzer SB, et al. Validation of the insulin sensitivity index (ISI(0,120)): comparison with other measures. Diabetes Res Clin Pract. 2000;47(3):177\u201384.","journal-title":"Diabetes Res Clin Pract"},{"issue":"3","key":"1456_CR30","doi-asserted-by":"publisher","first-page":"865","DOI":"10.1053\/j.gastro.2009.06.005","volume":"137","author":"A Kotronen","year":"2009","unstructured":"Kotronen A, Peltonen M, Hakkarainen A, et al. Prediction of non-alcoholic fatty liver disease and liver fat using metabolic and genetic factors. Gastroenterology. 2009;137(3):865\u201372.","journal-title":"Gastroenterology"},{"issue":"7","key":"1456_CR31","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1016\/j.dld.2009.08.002","volume":"42","author":"JH Lee","year":"2010","unstructured":"Lee JH, Kim D, Kim HJ, et al. Hepatic steatosis index: a simple screening tool reflecting nonalcoholic fatty liver disease. Dig Liver Dis. 2010;42(7):503\u20138.","journal-title":"Dig Liver Dis"},{"key":"1456_CR32","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1186\/1471-230X-6-33","volume":"6","author":"G Bedogni","year":"2006","unstructured":"Bedogni G, Bellentani S, Miglioli L, et al. The fatty liver index: a simple and accurate predictor of hepatic steatosis in the general population. BMC Gastroenterol. 2006;6:33.","journal-title":"BMC Gastroenterol"},{"issue":"6","key":"1456_CR33","doi-asserted-by":"publisher","first-page":"788","DOI":"10.1111\/j.1440-1746.2007.05042.x","volume":"22","author":"DN Amarapurkar","year":"2007","unstructured":"Amarapurkar DN, Hashimoto E, Lesmana LA, et al. How common is non-alcoholic fatty liver disease in the Asia-Pacific region and are there local differences? J Gastroenterol Hepatol. 2007;22(6):788\u201393.","journal-title":"J Gastroenterol Hepatol"},{"issue":"7","key":"1456_CR34","doi-asserted-by":"publisher","first-page":"3564","DOI":"10.1007\/s00330-019-06072-4","volume":"29","author":"J Gu","year":"2019","unstructured":"Gu J, Liu S, Du S, et al. Diagnostic value of MRI-PDFF for hepatic steatosis in patients with non-alcoholic fatty liver disease: a meta-analysis. Eur Radiol. 2019;29(7):3564\u201373.","journal-title":"Eur Radiol"},{"issue":"4","key":"1456_CR35","doi-asserted-by":"publisher","first-page":"447","DOI":"10.1111\/apt.14172","volume":"46","author":"TC Yip","year":"2017","unstructured":"Yip TC, Ma AJ, Wong VW, et al. Laboratory parameter-based machine learning model for excluding non-alcoholic fatty liver disease (NAFLD) in the general population. Aliment Pharmacol Ther. 2017;46(4):447\u201356.","journal-title":"Aliment Pharmacol Ther"},{"issue":"7","key":"1456_CR36","doi-asserted-by":"publisher","first-page":"588","DOI":"10.1016\/S0002-9343(00)00602-1","volume":"109","author":"JR Erbey","year":"2000","unstructured":"Erbey JR, Silberman C, Lydick E. Prevalence of abnormal serum alanine aminotransferase levels in obese patients and patients with type 2 diabetes. Am J Med. 2000;109(7):588\u201390.","journal-title":"Am J Med"},{"issue":"1","key":"1456_CR37","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1186\/s12876-020-1165-z","volume":"20","author":"X Ma","year":"2020","unstructured":"Ma X, Liu S, Zhang J, et al. Proportion of NAFLD patients with normal ALT value in overall NAFLD patients: a systematic review and meta-analysis. BMC Gastroenterol. 2020;20(1):10.","journal-title":"BMC Gastroenterol"},{"issue":"1","key":"1456_CR38","doi-asserted-by":"publisher","first-page":"212","DOI":"10.1093\/humrep\/dep380","volume":"25","author":"E Vassilatou","year":"2010","unstructured":"Vassilatou E, Lafoyianni S, Vryonidou A, et al. Increased androgen bioavailability is associated with non-alcoholic fatty liver disease in women with polycystic ovary syndrome. Hum Reprod. 2010;25(1):212\u201320.","journal-title":"Hum Reprod"}],"container-title":["BMC Endocrine Disorders"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12902-023-01456-6.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12902-023-01456-6\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12902-023-01456-6.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,19]],"date-time":"2023-11-19T14:10:02Z","timestamp":1700403002000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcendocrdisord.biomedcentral.com\/articles\/10.1186\/s12902-023-01456-6"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,26]]},"references-count":38,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,12]]}},"alternative-id":["1456"],"URL":"https:\/\/doi.org\/10.1186\/s12902-023-01456-6","relation":{},"ISSN":["1472-6823"],"issn-type":[{"value":"1472-6823","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,26]]},"assertion":[{"value":"20 February 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 September 2023","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 September 2023","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Ethical Review Board of Peking Union Medical College Hospital (ID: JS-3213). Informed consent was obtained from all participants in both groups.","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":"207"}}