{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T12:08:29Z","timestamp":1788005309004,"version":"build-2784847793"},"reference-count":50,"publisher":"The Endocrine Society","issue":"6","license":[{"start":{"date-parts":[[2025,12,18]],"date-time":"2025-12-18T00:00:00Z","timestamp":1766016000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,19]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Context<\/jats:title>\n                    <jats:p>The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) incorporates conventional grayscale ultrasonography (US) as the only imaging technique without considering the clinical and demographic characteristics of patients.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This study assessed whether the addition of demographic information, color Doppler US (CDUS), and strain elastography (SE) could enhance malignancy risk stratification beyond the current ACR TI-RADS criteria.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This prospective study enrolled 556 adult patients with thyroid nodules 10 mm or greater who were referred for fine-needle aspiration (FNA) according to the ACR TI-RADS recommendations. All nodules underwent standardized US evaluations and vascularity assessments using CDUS and SE, with cytological analysis performed according to the Bethesda system. Surgical pathology was the gold standard for malignancy when available.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Applying elastography ratio (ER) thresholds (&amp;gt;1.60, &amp;gt;0.44, and &amp;gt;0.54 for ACR TI-RADS categories 3, 4, and 5, respectively) as an additional criterion for FNA reduced the number of procedures from 501 to 260, without missing any malignant cases. Notably, elastography demonstrated an excellent discriminative performance in ACR TI-RADS 3 nodules (Youden index 0.994, area under the curve 0.994), supporting its value in improving risk stratification in this challenging, predominantly benign category.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Integrating elastography into the ACR TI-RADS framework can optimize FNA utilization in the management of thyroid nodules by reducing the number of unnecessary aspiration biopsies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1210\/clinem\/dgaf670","type":"journal-article","created":{"date-parts":[[2025,12,18]],"date-time":"2025-12-18T09:03:04Z","timestamp":1766048584000},"page":"e1616-e1625","source":"Crossref","is-referenced-by-count":4,"title":["Elastography Enhances Diagnostic Accuracy of ACR TI-RADS in Thyroid Nodule Evaluation"],"prefix":"10.1210","volume":"111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8901-7161","authenticated-orcid":false,"given":"Nikolaos","family":"Angelopoulos","sequence":"first","affiliation":[{"name":"2nd Academic Department of Nuclear Medicine, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences , Thessaloniki 54636 ,","place":["Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dimitrios G","family":"Goulis","sequence":"additional","affiliation":[{"name":"Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki , Thessaloniki 54636 ,","place":["Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioannis","family":"Chrisogonidis","sequence":"additional","affiliation":[{"name":"Department of Radiology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki , Thessaloniki 54636 ,","place":["Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioannis","family":"Iakovou","sequence":"additional","affiliation":[{"name":"2nd Academic Department of Nuclear Medicine, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences , Thessaloniki 54636 ,","place":["Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Franklin N","family":"Tessler","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Alabama at Birmingham , Birmingham, AL 35249 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"80","published-online":{"date-parts":[[2025,12,18]]},"reference":[{"issue":"5","key":"2026051819581889600_dgaf670-B1","doi-asserted-by":"crossref","first-page":"1748","DOI":"10.1210\/jc.2008-1724","article-title":"An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management","volume":"94","author":"Horvath","year":"2009","journal-title":"J Clin Endocrinol Metab"},{"issue":"5","key":"2026051819581889600_dgaf670-B2","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1159\/000478927","article-title":"European Thyroid Association guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: the EU-TIRADS","volume":"6","author":"Russ","year":"2017","journal-title":"Eur Thyroid J"},{"issue":"5","key":"2026051819581889600_dgaf670-B3","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1016\/j.jacr.2017.01.046","article-title":"ACR thyroid imaging, reporting and data system (TI-RADS): white paper of the ACR TI-RADS Committee","volume":"14","author":"Tessler","year":"2017","journal-title":"J Am Coll Radiol"},{"issue":"12","key":"2026051819581889600_dgaf670-B4","doi-asserted-by":"crossref","first-page":"2094","DOI":"10.3348\/kjr.2021.0713","article-title":"2021 Korean thyroid imaging reporting and data system and imaging-based management of thyroid nodules: Korean Society of Thyroid Radiology consensus statement and recommendations","volume":"22","author":"Ha","year":"2021","journal-title":"Korean J Radiol"},{"issue":"3","key":"2026051819581889600_dgaf670-B5","doi-asserted-by":"crossref","first-page":"370","DOI":"10.3348\/kjr.2016.17.3.370","article-title":"Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology consensus statement and recommendations","volume":"17","author":"Shin","year":"2016","journal-title":"Korean J Radiol"},{"issue":"1","key":"2026051819581889600_dgaf670-B6","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1186\/s40644-024-00663-1","article-title":"Ultrasound microflow patterns help in distinguishing malignant from benign thyroid nodules","volume":"24","author":"Li","year":"2024","journal-title":"Cancer Imaging"},{"issue":"4","key":"2026051819581889600_dgaf670-B7","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/S2213-8587(22)00035-3","article-title":"The epidemiological landscape of thyroid cancer worldwide: GLOBOCAN estimates for incidence and mortality rates in 2020","volume":"10","author":"Pizzato","year":"2022","journal-title":"Lancet Diabetes Endocrinol"},{"issue":"5","key":"2026051819581889600_dgaf670-B8","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1093\/jrr\/rrad044","article-title":"Confounding factors and biases involved in regional differences in the detection rate of thyroid cancer in the second-round thyroid ultrasound examination: the Fukushima health management survey","volume":"64","author":"Shimura","year":"2023","journal-title":"J Radiat Res"},{"issue":"10","key":"2026051819581889600_dgaf670-B9","doi-asserted-by":"crossref","first-page":"1145","DOI":"10.1089\/thy.2010.0079","article-title":"Real-time elastography for the differentiation of benign and malignant thyroid nodules: a meta-analysis","volume":"20","author":"Bojunga","year":"2010","journal-title":"Thyroid"},{"issue":"6","key":"2026051819581889600_dgaf670-B10","doi-asserted-by":"crossref","first-page":"2451","DOI":"10.1159\/000452513","article-title":"Comparing the diagnostic accuracy of RTE and SWE in differentiating malignant thyroid nodules from benign ones: a meta-analysis","volume":"39","author":"Tian","year":"2016","journal-title":"Cell Physiol Biochem"},{"issue":"43","key":"2026051819581889600_dgaf670-B11","doi-asserted-by":"crossref","first-page":"e8282","DOI":"10.1097\/MD.0000000000008282","article-title":"Diagnostic potential of real-time elastography (RTE) and shear wave elastography (SWE) to differentiate benign and malignant thyroid nodules","volume":"96","author":"Hu","year":"2017","journal-title":"Medicine (Baltimore)"},{"issue":"4","key":"2026051819581889600_dgaf670-B12","doi-asserted-by":"crossref","first-page":"180","DOI":"10.3390\/diagnostics10040180","article-title":"TI-RADS diagnostic performance: which algorithm is superior and how elastography and 4D vascularity improve the malignancy risk assessment","volume":"10","author":"Borlea","year":"2020","journal-title":"Diagnostics"},{"issue":"10","key":"2026051819581889600_dgaf670-B13","doi-asserted-by":"crossref","first-page":"2329","DOI":"10.1016\/j.ultrasmedbio.2014.03.028","article-title":"Elastography can effectively decrease the number of fine-needle aspiration biopsies in patients with calcified thyroid nodules","volume":"40","author":"Kim","year":"2014","journal-title":"Ultrasound Med Biol"},{"issue":"9","key":"2026051819581889600_dgaf670-B14","doi-asserted-by":"crossref","first-page":"1346","DOI":"10.1089\/thy.2019.0353","article-title":"Standardized map of iodine status in Europe","volume":"30","author":"Ittermann","year":"2020","journal-title":"Thyroid"},{"issue":"9","key":"2026051819581889600_dgaf670-B15","first-page":"1039","article-title":"The 2023 Bethesda system for reporting thyroid cytopathology","volume":"33","author":"Ali","year":"2023","journal-title":"Thyroid"},{"key":"2026051819581889600_dgaf670-B16","doi-asserted-by":"crossref","unstructured":"Angelopoulos N, Goulis DG, Chrisogonidis I, Iakovou I, Tessler FN. 2025. Supplementary material for: Elastography enhances diagnostic accuracy of ACR TI-RADS in thyroid nodule evaluation. JCEM. Figshare. doi: 10.6084\/m9.figshare.30535406","DOI":"10.1210\/clinem\/dgaf670"},{"issue":"1","key":"2026051819581889600_dgaf670-B17","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1016\/j.eprac.2024.10.004","article-title":"Diagnostic performance of European and American College of Radiology thyroid imaging reporting and data system classification systems in thyroid nodules over 20 mm in diameter","volume":"31","author":"Angelopoulos","year":"2025","journal-title":"Endocr Pract"},{"issue":"1","key":"2026051819581889600_dgaf670-B18","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1007\/s12020-025-04248-1","article-title":"The additive value of real-time elastography to thyroid ultrasound in detecting papillary carcinoma in nodules over 20 mm in diameter","volume":"89","author":"Angelopoulos","year":"2025","journal-title":"Endocrine"},{"issue":"1","key":"2026051819581889600_dgaf670-B19","doi-asserted-by":"crossref","first-page":"10632","DOI":"10.1038\/s41598-020-67543-z","article-title":"Diagnostic performances and unnecessary US-FNA rates of various TIRADS after application of equal size thresholds","volume":"10","author":"Huh","year":"2020","journal-title":"Sci Rep"},{"issue":"3","key":"2026051819581889600_dgaf670-B20","first-page":"e23118","article-title":"Reducing the number of unnecessary thyroid nodule biopsies with the American College of Radiology (ACR) thyroid imaging reporting and data system (TI-RADS)","volume":"14","author":"Abou Shaar","year":"2022","journal-title":"Cureus"},{"issue":"5","key":"2026051819581889600_dgaf670-B21","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1002\/jcu.23662","article-title":"Enhancing malignancy prediction in thyroid nodules: a multimodal ultrasound radiomics approach in TI-RADS category 4 lesions","volume":"52","author":"Li","year":"2024","journal-title":"J Clin Ultrasound"},{"issue":"12","key":"2026051819581889600_dgaf670-B22","doi-asserted-by":"crossref","first-page":"4524","DOI":"10.1210\/jc.2012-2951","article-title":"Ultrasound sensitivity for thyroid malignancy is increased by real-time elastography: a prospective multicenter study","volume":"97","author":"Trimboli","year":"2012","journal-title":"J Clin Endocrinol Metab"},{"issue":"6","key":"2026051819581889600_dgaf670-B23","first-page":"735","article-title":"Role of elastography strain ratio and TIRADS score in predicting malignant thyroid nodule","volume":"64","author":"Okasha","year":"2020","journal-title":"Arch Endocrinol Metab"},{"issue":"2","key":"2026051819581889600_dgaf670-B24","doi-asserted-by":"crossref","first-page":"328","DOI":"10.18203\/2320-6012.ijrms20190329","article-title":"Clinical utility of TIRADS and ultrasound elastography in characterization of thyroid nodules","volume":"7","author":"Sachdev","year":"2019","journal-title":"Int J Res Med Sci"},{"issue":"1","key":"2026051819581889600_dgaf670-B25","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/j.ultrasmedbio.2016.06.022","article-title":"WFUMB guidelines and recommendations on the clinical use of ultrasound elastography: part 4. thyroid","volume":"43","author":"Cosgrove","year":"2017","journal-title":"Ultrasound Med Biol"},{"issue":"2","key":"2026051819581889600_dgaf670-B26","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1210\/clinem\/dgac646","article-title":"Current controversies in low-risk differentiated thyroid cancer: reducing overtreatment in an era of overdiagnosis","volume":"108","author":"Ullmann","year":"2023","journal-title":"J Clin Endocrinol Metab"},{"issue":"12","key":"2026051819581889600_dgaf670-B27","doi-asserted-by":"crossref","first-page":"4790","DOI":"10.1210\/jc.2013-2672","article-title":"Comparison of elastographic strain index and thyroid fine-needle aspiration cytology in 631 thyroid nodules","volume":"98","author":"Magri","year":"2013","journal-title":"J Clin Endocrinol Metab"},{"issue":"5","key":"2026051819581889600_dgaf670-B28","doi-asserted-by":"crossref","first-page":"2877","DOI":"10.1007\/s00330-020-07384-6","article-title":"Unnecessary thyroid nodule biopsy rates under four ultrasound risk stratification systems: a systematic review and meta-analysis","volume":"31","author":"Kim","year":"2020","journal-title":"Eur Radiol"},{"issue":"1","key":"2026051819581889600_dgaf670-B29","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1111\/j.1365-2265.2011.04170.x","article-title":"Shear wave elastography in the diagnosis of thyroid nodules: feasibility in the case of coexistent chronic autoimmune Hashimoto's thyroiditis","volume":"76","author":"Magri","year":"2012","journal-title":"Clin Endocrinol (Oxf)"},{"issue":"4","key":"2026051819581889600_dgaf670-B30","doi-asserted-by":"crossref","first-page":"896","DOI":"10.2214\/AJR.11.7009","article-title":"Interobserver agreement and intraobserver reproducibility in thyroid ultrasound elastography","volume":"198","author":"Lim","year":"2012","journal-title":"AJR Am J Roentgenol"},{"key":"2026051819581889600_dgaf670-B31","doi-asserted-by":"crossref","first-page":"692879","DOI":"10.3389\/fendo.2021.692879","article-title":"Association between aggressive clinicopathologic features of papillary thyroid carcinoma and body mass index: a systematic review and meta-analysis","volume":"12","author":"Economides","year":"2021","journal-title":"Front Endocrinol (Lausanne)"},{"issue":"3","key":"2026051819581889600_dgaf670-B32","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1089\/thy.2021.0445","article-title":"Body mass index and thyroid cancer risk: a pooled analysis of half a million men and women in the Asia cohort consortium","volume":"32","author":"Shin","year":"2022","journal-title":"Thyroid"},{"issue":"9","key":"2026051819581889600_dgaf670-B33","doi-asserted-by":"crossref","first-page":"4244","DOI":"10.1210\/jc.2010-0440","article-title":"The relationship between body mass index and thyroid cancer pathology features and outcomes: a clinicopathological cohort study","volume":"95","author":"Paes","year":"2010","journal-title":"J Clin Endocrinol Metab"},{"issue":"7","key":"2026051819581889600_dgaf670-B34","doi-asserted-by":"crossref","first-page":"1429","DOI":"10.3390\/cancers16071429","article-title":"Exploring the link between BMI and aggressive histopathological subtypes in differentiated thyroid carcinoma\u2014insights from a multicentre retrospective study","volume":"16","author":"Di Filippo","year":"2024","journal-title":"Cancers (Basel)"},{"key":"2026051819581889600_dgaf670-B35","doi-asserted-by":"crossref","first-page":"e9675","DOI":"10.7717\/peerj.9675","article-title":"Correlation between obesity and clinicopathological characteristics in patients with papillary thyroid cancer: a study of 1579 cases: a retrospective study","volume":"8","author":"Wang","year":"2020","journal-title":"PeerJ"},{"issue":"3","key":"2026051819581889600_dgaf670-B36","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1158\/1055-9965.EPI-10-1220","article-title":"Obesity and thyroid cancer risk among U.S. men and women: a pooled analysis of five prospective studies","volume":"20","author":"Kitahara","year":"2011","journal-title":"Cancer Epidemiol Biomarkers Prev"},{"issue":"3","key":"2026051819581889600_dgaf670-B37","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1089\/thy.2022.0618","article-title":"Obesity, physical activity, and thyroid cancer risk\u2014disentangling true associations from detection bias","volume":"33","author":"Kitahara","year":"2022","journal-title":"Thyroid"},{"issue":"1","key":"2026051819581889600_dgaf670-B38","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1186\/s13058-019-1122-3","article-title":"Hypothyroidism and the risk of breast cancer recurrence and all-cause mortality\u2014a Danish population-based study","volume":"21","author":"Falstie-Jensen","year":"2019","journal-title":"Breast Cancer Res"},{"key":"2026051819581889600_dgaf670-B39","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/j.jss.2019.07.025","article-title":"Increased incidental thyroid cancer in patients with subclinical chronic lymphocytic thyroiditis","volume":"245","author":"Jackson","year":"2020","journal-title":"J Surg Res"},{"issue":"4","key":"2026051819581889600_dgaf670-B40","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1089\/thy.2019.0347","article-title":"Incidentally discovered papillary thyroid microcarcinomas are more frequently found in patients with chronic lymphocytic thyroiditis than with multinodular Goiter or Graves' disease","volume":"30","author":"Paparodis","year":"2020","journal-title":"Thyroid"},{"issue":"1","key":"2026051819581889600_dgaf670-B41","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1530\/eje.0.1380041","article-title":"Role of conventional ultrasonography and color flow-Doppler sonography in predicting malignancy in \u201ccold\u201d thyroid nodules","volume":"138","author":"Rago","year":"1998","journal-title":"Eur J Endocrinol"},{"issue":"5","key":"2026051819581889600_dgaf670-B42","doi-asserted-by":"crossref","first-page":"1941","DOI":"10.1210\/jcem.87.5.8504","article-title":"Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features","volume":"87","author":"Papini","year":"2002","journal-title":"J Clin Endocrinol Metab"},{"issue":"1","key":"2026051819581889600_dgaf670-B43","first-page":"44","article-title":"Role of color Doppler ultrasonography in the preoperative management of cold thyroid nodules","volume":"6","author":"Varverakis","year":"2007","journal-title":"Hormones (Athens)"},{"issue":"10","key":"2026051819581889600_dgaf670-B44","doi-asserted-by":"crossref","first-page":"1083","DOI":"10.7863\/jum.2003.22.10.1083","article-title":"Common and uncommon sonographic features of papillary thyroid carcinoma","volume":"22","author":"Chan","year":"2003","journal-title":"J Ultrasound Med"},{"issue":"1","key":"2026051819581889600_dgaf670-B45","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1148\/radiol.09091284","article-title":"Can vascularity at power Doppler US help predict thyroid malignancy?","volume":"255","author":"Moon","year":"2010","journal-title":"Radiology"},{"issue":"5","key":"2026051819581889600_dgaf670-B46","doi-asserted-by":"crossref","first-page":"538","DOI":"10.1089\/thy.2014.0353","article-title":"Thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies","volume":"25","author":"Remonti","year":"2015","journal-title":"Thyroid"},{"issue":"1","key":"2026051819581889600_dgaf670-B47","doi-asserted-by":"crossref","first-page":"89","DOI":"10.7863\/ultra.16.03043","article-title":"Most thyroid cancers detected by sonography lack intranodular vascularity on color Doppler imaging: review of the literature and sonographic-pathologic correlations for 698 thyroid neoplasms","volume":"36","author":"Yang","year":"2017","journal-title":"J Ultrasound Med"},{"key":"2026051819581889600_dgaf670-B48","doi-asserted-by":"crossref","first-page":"3991","DOI":"10.2147\/CMAR.S307166","article-title":"The value of sonography in distinguishing follicular thyroid carcinoma from adenoma","volume":"13","author":"Li","year":"2021","journal-title":"Cancer Manag Res"},{"issue":"1","key":"2026051819581889600_dgaf670-B49","doi-asserted-by":"crossref","first-page":"e240705","DOI":"10.1148\/radiol.240705","article-title":"Evaluation of US elastography in thyroid nodule diagnosis: the ElaTION randomized control trial","volume":"313","author":"Mehanna","year":"2024","journal-title":"Radiology"},{"key":"2026051819581889600_dgaf670-B50","doi-asserted-by":"crossref","first-page":"845549","DOI":"10.3389\/fonc.2022.845549","article-title":"US-elastography with different techniques for thyroid nodule characterization: systematic review and meta-analysis","volume":"12","author":"Cantisani","year":"2022","journal-title":"Front Oncol"}],"container-title":["The Journal of Clinical Endocrinology &amp; Metabolism"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jcem\/advance-article-pdf\/doi\/10.1210\/clinem\/dgaf670\/65947256\/dgaf670.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jcem\/article-pdf\/111\/6\/e1616\/65947256\/dgaf670.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jcem\/article-pdf\/111\/6\/e1616\/65947256\/dgaf670.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T23:58:28Z","timestamp":1779148708000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jcem\/article\/111\/6\/e1616\/8383055"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,18]]},"references-count":50,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,12,18]]},"published-print":{"date-parts":[[2026,5,19]]}},"URL":"https:\/\/doi.org\/10.1210\/clinem\/dgaf670","relation":{},"ISSN":["0021-972X","1945-7197"],"issn-type":[{"value":"0021-972X","type":"print"},{"value":"1945-7197","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,6]]},"published":{"date-parts":[[2025,12,18]]}}}