{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T10:10:11Z","timestamp":1779185411594,"version":"3.51.4"},"reference-count":31,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["NIHR128137"],"award-info":[{"award-number":["NIHR128137"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"\n Background<\/jats:title>\n Ovarian hyperstimulation syndrome is a potentially serious complication of fertility treatments. Standard care often involves monitoring, then hospitalisation for severe cases. Some evidence suggests early outpatient paracentesis may prevent hospitalisation, but adequately powered randomised trials are lacking.<\/jats:p>\n <\/jats:sec>\n \n Objectives<\/jats:title>\n To establish the clinical and cost-effectiveness, safety and acceptability of early active outpatient management for moderate or severe ovarian hyperstimulation syndrome.<\/jats:p>\n <\/jats:sec>\n \n Design and methods<\/jats:title>\n A pragmatic, parallel, open-label, multicentre, superiority, adaptive, group sequential randomised controlled trial with an internal pilot was planned. The study included preliminary qualitative work and a post-trial survey. The main trial recruited participants with moderate or severe, early or late ovarian hyperstimulation syndrome from UK fertility clinics. Participants were randomised 1\u2005:\u20051 to receive either outpatient paracentesis or usual care (conservative management). The primary outcome was ovarian hyperstimulation syndrome-related hospital admission within 28 days.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The trial was terminated early due to poor recruitment. Only 8 participants were randomised (5 to conservative management, 3 to outpatient paracentesis) across 3 of 9 opened sites, compared to the planned 224 participants. All eight had moderate ovarian hyperstimulation syndrome at baseline. Two participants were hospitalised for ovarian hyperstimulation syndrome-related reasons (one from each group). Six participants\u2019 symptoms resolved during follow-up, while two had unknown outcomes. There were no reported serious adverse events caused by the intervention. The post-trial survey of 16 fertility centres found increased use of preventive measures like freeze-all cycles, antagonist protocols and gonadotropin-releasing hormone trigger, during and after the SARS-CoV-2 (COVID-19) pandemic.<\/jats:p>\n <\/jats:sec>\n \n Limitations<\/jats:title>\n The small sample size precludes drawing any definitive conclusions about effectiveness, safety or cost-effectiveness. The study was severely impacted by the COVID-19 pandemic, affecting site set-up and recruitment, and changes in clinical practice during the pandemic may have reduced ovarian hyperstimulation syndrome cases.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n No definitive clinical conclusions can be drawn from this study about the effectiveness of outpatient management compared to conservative management. The pandemic prompted lasting modifications in ovarian hyperstimulation syndrome prevention strategies at many fertility clinics.<\/jats:p>\n <\/jats:sec>\n \n Future work<\/jats:title>\n Given the observed low incidence rates of ovarian hyperstimulation syndrome and challenges in recruitment, future research may need to consider alternative study designs in observational settings rather than randomised trials that reflect the changing reality of clinical management and prevention of ovarian hyperstimulation syndrome, particularly following the recent COVID pandemic. Additionally, the research community should reflect on strategies to improve trial resilience and adaptability in the face of major disruptions like pandemics.<\/jats:p>\n <\/jats:sec>\n \n Funding<\/jats:title>\n This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128137.<\/jats:p>\n <\/jats:sec>","DOI":"10.3310\/gjmm1724","type":"journal-article","created":{"date-parts":[[2025,7,24]],"date-time":"2025-07-24T08:00:55Z","timestamp":1753344055000},"page":"1-34","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Outpatient paracentesis for Ovarian Hyperstimulation Syndrome: STOP-OHSS feasibility study and RCT Synopsis"],"prefix":"10.3310","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4022-1740","authenticated-orcid":true,"given":"Mostafa","family":"Metwally","sequence":"first","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5036-9610","authenticated-orcid":true,"given":"Katie","family":"Ridsdale","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4929-7215","authenticated-orcid":true,"given":"Clare","family":"Pye","sequence":"additional","affiliation":[{"name":"Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9311-6920","authenticated-orcid":true,"given":"Munya","family":"Dimairo","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7990-7451","authenticated-orcid":true,"given":"Amy","family":"Barr","sequence":"additional","affiliation":[{"name":"National Institute of Health and Care Excellence, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7687-4597","authenticated-orcid":true,"given":"Ying","family":"Cheong","sequence":"additional","affiliation":[{"name":"School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6151-836X","authenticated-orcid":true,"given":"Lauren","family":"Desoysa","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7183-6321","authenticated-orcid":true,"given":"Sarah","family":"Drabble","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8802-4706","authenticated-orcid":true,"given":"Andrew","family":"Drakeley","sequence":"additional","affiliation":[{"name":"Hewitt Fertility Centre, Liverpool Women\u2019s NHS Foundation Trust, Liverpool, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3194-8614","authenticated-orcid":true,"given":"Isaac","family":"Evbuomwan","sequence":"additional","affiliation":[{"name":"Gateshead Health NHS Foundation Trust, Gateshead, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9569-8290","authenticated-orcid":true,"given":"Laura","family":"Flight","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4875-8645","authenticated-orcid":true,"given":"Jennifer","family":"Hannington","sequence":"additional","affiliation":[{"name":"Patient and Public Involvement"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1389-3402","authenticated-orcid":true,"given":"Jane","family":"Hughes","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8889-6806","authenticated-orcid":true,"given":"Anju","family":"Keetharuth","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7089-1580","authenticated-orcid":true,"given":"Amanda","family":"Loban","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8962-7568","authenticated-orcid":true,"given":"Elizabeth","family":"Lumley","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7550-1817","authenticated-orcid":true,"given":"Raj","family":"Mathur","sequence":"additional","affiliation":[{"name":"Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0497-3582","authenticated-orcid":true,"given":"Kirsty","family":"McKendrick","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3086-7348","authenticated-orcid":true,"given":"Cara","family":"Mooney","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4033-506X","authenticated-orcid":true,"given":"Alicia","family":"O\u2019Cathain","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eloise","family":"Pyper","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5024-8272","authenticated-orcid":true,"given":"Rich","family":"Simmonds","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4769-3970","authenticated-orcid":true,"given":"Liz","family":"Taylor","sequence":"additional","affiliation":[{"name":"Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1814-3697","authenticated-orcid":true,"given":"Jessica","family":"Wright","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-2206-9578","authenticated-orcid":true,"given":"Siqi","family":"Wu","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8467-0471","authenticated-orcid":true,"given":"Tracey","family":"Young","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2871-7946","authenticated-orcid":true,"given":"David","family":"White","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"6221","published-online":{"date-parts":[[2026,5]]},"reference":[{"key":"key2026051913093400_ref1-bib1","volume-title":"RCOG Green-top Guideline No. 5: The Management of Ovarian Hyperstimulation Syndrome","author":"Royal College of Obstetricians and Gynaecologists","year":"2016"},{"key":"key2026051913093400_ref2-bib2","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1111\/ajo.12406","article-title":"Consensus statement on prevention and detection of ovarian hyperstimulation syndrome","volume":"55","author":"Boothroyd","year":"2015 [cited 9 December 2019]","journal-title":"Aust N Z J Obstet Gynaecol"},{"key":"key2026051913093400_ref3-bib3","volume-title":"Hospital Episode Statistics, Admitted Patient Care - England, 2010\u201311","author":"NHS Digital","year":"2011"},{"key":"key2026051913093400_ref4-bib4","doi-asserted-by":"crossref","first-page":"1953","DOI":"10.1016\/j.fertnstert.2008.09.011","article-title":"Patients with severe ovarian hyperstimulation syndrome can be managed safely with aggressive outpatient transvaginal paracentesis","volume":"92","author":"Smith","year":"2009","journal-title":"Fertil Steril"},{"key":"key2026051913093400_ref5-bib5","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1023\/A:1014828027282","article-title":"Aggressive outpatient treatment of Ovarian Hyperstimulation Syndrome with ascites using transvaginal culdocentesis and intravenous albumin minimizes hospitalization","volume":"19","author":"Lincoln","year":"2002","journal-title":"J Assist Reprod Genet"},{"key":"key2026051913093400_ref6-bib6","doi-asserted-by":"crossref","first-page":"S95","DOI":"10.1016\/j.fertnstert.2005.07.229","article-title":"Aggressive outpatient management of severe ovarian hyperstimulation syndrome avoids complications and prolonged disease course","volume":"84","author":"Gustofson","year":"2005","journal-title":"Fertil Steril"},{"key":"key2026051913093400_ref7-bib7","doi-asserted-by":"crossref","first-page":"821","DOI":"10.1016\/S0015-0282(99)00606-8","article-title":"An ounce of prevention: outpatient management of the ovarian hyperstimulation syndrome","volume":"73","author":"Fluker","year":"2000","journal-title":"Fertil Steril"},{"key":"key2026051913093400_ref8-bib8","doi-asserted-by":"crossref","first-page":"812","DOI":"10.1093\/oxfordjournals.humrep.a138601","article-title":"Day care management of severe ovarian hyperstimulation syndrome avoids hospitalization and morbidity","volume":"9","author":"Shrivastav","year":"1994 [cited 9 December 2019]","journal-title":"Hum Reprod"},{"key":"key2026051913093400_ref9-bib9","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1093\/humrep\/deg074","article-title":"Pigtail catheter for the treatment of ascites associated with ovarian hyperstimulation syndrome","volume":"18","author":"Abuzeid","year":"2003 [cited 15 January 2021]","journal-title":"Hum Reprod"},{"key":"key2026051913093400_ref10-bib10","first-page":"31","article-title":"Outpatient management of severe ovarian hyperstimulation syndrome (OHSS) with placement of pigtail catheter","volume":"6","author":"Abuzeid","year":"2014","journal-title":"Facts Views Vis ObGyn"},{"key":"key2026051913093400_ref11-bib11","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1186\/1477-7827-10-69","article-title":"Outpatient management of severe early OHSS by administration of GnRH antagonist in the luteal phase: an observational cohort study","volume":"10","author":"Lainas","year":"2012 [cited 9 December 2019]","journal-title":"Reprod Biol Endocrinol"},{"key":"key2026051913093400_ref12-bib12","doi-asserted-by":"crossref","first-page":"57","DOI":"10.5653\/cerm.2017.44.2.57","article-title":"The use of gonadotropin-releasing hormone antagonist post-ovulation trigger in ovarian hyperstimulation syndrome","volume":"44","author":"Chappell","year":"2017","journal-title":"Clin Exp Reprod Med"},{"key":"key2026051913093400_ref13-bib13","first-page":"78","article-title":"High doses of GnRH antagonists are efficient in the management of severe ovarian hyperstimulation syndrome","volume":"36","author":"Bonilla-Musoles","year":"2009 [cited 14 January 2020]","journal-title":"Clin Exp Obstet Gynecol"},{"key":"key2026051913093400_ref14-bib14","doi-asserted-by":"crossref","first-page":"848","DOI":"10.1111\/1471-0528.12572","article-title":"Serum vascular endothelial growth factor levels following luteal gonadotrophin-releasing hormone antagonist administration in women with severe early ovarian hyperstimulation syndrome","volume":"121","author":"Lainas","year":"2014 [cited 9 December 2019]","journal-title":"BJOG"},{"key":"key2026051913093400_ref15-bib15","doi-asserted-by":"crossref","first-page":"1929","DOI":"10.1093\/humrep\/det114","article-title":"Pregnancy and neonatal outcomes following luteal GnRH antagonist administration in patients with severe early OHSS","volume":"28","author":"Lainas","year":"2013 [cited 9 December 2019]","journal-title":"Hum Reprod"},{"key":"key2026051913093400_ref16-bib16","doi-asserted-by":"crossref","first-page":"853","DOI":"10.3109\/09513590.2012.683076","article-title":"Treatment of ovarian hyperstimulation syndrome using gonadotropin releasing hormone antagonist: a pilot study","volume":"28","author":"Hosseini","year":"2012","journal-title":"Gynecol Endocrinol"},{"key":"key2026051913093400_ref17-bib17","doi-asserted-by":"crossref","first-page":"6599","DOI":"10.1111\/jocn.16701","article-title":"Managing ovarian hyperstimulation syndrome: a qualitative interview study with women and healthcare professionals","volume":"32","author":"Lumley","year":"2023","journal-title":"J Clin Nurs"},{"key":"key2026051913093400_ref18-bib18","doi-asserted-by":"crossref","DOI":"10.3310\/GJMM2923","article-title":"Views on outpatient paracentesis and GnRH antagonists for ovarian hyperstimulation syndrome: a qualitative study of patients and healthcare professionals","author":"Lumley","year":"2026","journal-title":"Health Technol Assess"},{"key":"key2026051913093400_ref19-bib19","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1097\/ACM.0000000000001092","article-title":"Is there a consensus on consensus methodology? Descriptions and recommendations for future consensus research","volume":"91","author":"Waggoner","year":"2016","journal-title":"Acad Med"},{"key":"key2026051913093400_ref20-bib20","doi-asserted-by":"crossref","first-page":"e076434","DOI":"10.1136\/bmjopen-2023-076434","article-title":"Outpatient paracentesis for the management of ovarian hyperstimulation syndrome: study protocol for the STOP-OHSS randomised controlled trial","volume":"14","author":"White","year":"2024","journal-title":"BMJ Open"},{"key":"key2026051913093400_ref21-bib21","article-title":"Ovarian Hyperstimulation Syndrome: the STOP-OHSS RCT of outpatient paracentesis and survey on preventive practices","author":"Metwally","year":"2025","journal-title":"MedRxiv"},{"key":"key2026051913093400_ref22-bib22","article-title":"A trial evaluating active outpatient management to prevent hospital admission in women having fertility treatment who develop ovarian hyperstimulation syndrome","author":"Metwally","year":"2022","journal-title":"ISRCTN"},{"key":"key2026051913093400_ref23-bib23","article-title":"STOP-OHSS Trial Simulation Report: summary report on sample size calculation and operating characteristics of the group sequential trial","author":"Dimairo","year":"2024","journal-title":"BMJ Open"},{"key":"key2026051913093400_ref24-bib24","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research electronic data capture (REDCap) \u2013 a metadata-driven methodology and workflow process for providing translational research informatics support","volume":"42","author":"Harris","year":"2009","journal-title":"J Biomed Inform"},{"key":"key2026051913093400_ref25-bib25","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1016\/0149-7189(79)90094-6","article-title":"Assessment of client\/patient satisfaction: development of a general scale","volume":"2","author":"Larsen","year":"1979","journal-title":"Eval Program Plann"},{"key":"key2026051913093400_ref26-bib26","author":"State of the fertility sector 2022\/23 | HFEA"},{"key":"key2026051913093400_ref27-bib27","author":"HFEA. Ethnic diversity in fertility treatment 2018"},{"key":"key2026051913093400_ref28-bib28","doi-asserted-by":"crossref","first-page":"1399","DOI":"10.1016\/j.fertnstert.2009.05.092","article-title":"Factors associated with ovarian hyperstimulation syndrome (OHSS) and its effect on assisted reproductive technology (ART) treatment and outcome","volume":"94","author":"Luke","year":"2010","journal-title":"Fertil Steril"},{"key":"key2026051913093400_ref29-bib29","doi-asserted-by":"crossref","first-page":"1060173","DOI":"10.3389\/fendo.2022.1060173","article-title":"Ovarian Hyperstimulation Syndrome (OHSS) requiring Intensive Care Unit (ICU) admission between 1996\u20132020 in England, Wales, and Northern Ireland","volume":"13","author":"Abbara","year":"2022","journal-title":"Front Endocrinol (Lausanne)"},{"key":"key2026051913093400_ref30-bib30","volume-title":"Unit Costs of Health and Social Care 2023 Manual. Technical Report","author":"Jones","year":"2024"},{"key":"key2026051913093400_ref31-bib31","volume-title":"National Cost Collection 2021\/22"}],"container-title":["Health Technology Assessment"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2051103","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/sites\/journalslibrary\/files\/journal_data\/GJMM1724\/GJMM1724.xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2051103","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T09:43:00Z","timestamp":1779183780000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/hta\/published-articles\/GJMM1724"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5]]},"references-count":31,"alternative-id":["10.3310\/GJMM1724"],"URL":"https:\/\/doi.org\/10.3310\/gjmm1724","relation":{},"ISSN":["2046-4924"],"issn-type":[{"value":"2046-4924","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5]]},"assertion":[{"value":"This content has been made freely available to all.","name":"free","label":"Free to read"},{"value":"12-2019","name":"contractual_start_date","label":"contractual_start_date","group":{"name":"article_history","label":"Article History"}},{"value":"02-2025","name":"editorial_review_begun","label":"editorial review begun","group":{"name":"article_history","label":"Article History"}},{"value":"08-2025","name":"accepted_for_publication","label":"Accepted for publication","group":{"name":"article_history","label":"Article History"}}]}}