{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T05:11:43Z","timestamp":1783746703448,"version":"3.55.0"},"reference-count":53,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Beijing Natural Science Foundation General Projec","award":["Grant No. 7242152"],"award-info":[{"award-number":["Grant No. 7242152"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objective: The objective of this study is to investigate the clinical value of the triglyceride-glucose (TyG) index combined with alanine aminotransferase (ALT) in identifying prevalent metabolic-associated fatty liver disease (MAFLD) in patients with obstructive sleep apnea (OSA), and to construct and validate a diagnostic risk-stratification model. Methods: Clinical data of OSA patients were retrospectively collected from two centers: the Department of Geriatrics, Peking University People\u2019s Hospital (August 2021 to December 2025) and the Department of Geriatrics, Shijiazhuang People\u2019s Hospital (June 2023 to December 2025). MAFLD was diagnosed by abdominal ultrasonography performed by experienced radiologists blinded to laboratory results. Candidate predictors were selected using univariate logistic regression, LASSO regression, and bootstrap stability testing. Model performance was assessed by discrimination (area under the receiver operating characteristic curve, AUC), calibration (Hosmer\u2013Lemeshow test, calibration curves), and clinical utility (decision curve analysis). Internal validation was performed using 10-fold cross-validation and bootstrap resampling with optimism correction. External validation was conducted in an independent cohort. Sensitivity analyses included subgroup analyses stratified by sex, age, BMI, and OSA severity. Results: A total of 962 patients were included in the development set and 116 in the external validation set. Multivariate analysis identified TyG index (OR = 1.95, 95% CI: 1.51\u20132.53), LDL-C (OR = 1.24, 95% CI: 1.02\u20131.49), BMI (OR = 1.21, 95% CI: 1.16\u20131.26), and ALT (OR = 1.04, 95% CI: 1.02\u20131.05) as variables independently associated with prevalent MAFLD, while platelet-to-lymphocyte ratio (PLR) was protective (OR = 0.996, 95% CI: 0.993\u20130.999). The simplified TyG-ALT model achieved an AUC of 0.714 (95% CI: 0.685\u20130.744) in the development set, with an optimism-corrected AUC of 0.712, and an AUC of 0.783 (95% CI: 0.701\u20130.866) in external validation. The model demonstrated good calibration and favorable clinical net benefit within the threshold range of 0.30\u20130.70. The optimal cutoff was 0.564, with sensitivity of 68.7% and specificity of 79.6%. Conclusions: The TyG-ALT model demonstrates good discriminative ability, calibration, and clinical utility for case-finding and risk stratification of prevalent MAFLD in OSA patients, particularly for identifying high-risk individuals requiring confirmatory imaging.<\/jats:p>","DOI":"10.3390\/jcm15145346","type":"journal-article","created":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T17:27:31Z","timestamp":1783531651000},"page":"5346","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Construction and Validation of a TyG-ALT-Based Diagnostic Risk-Stratification Model for Metabolic-Associated Fatty Liver Disease in Patients with Obstructive Sleep Apnea"],"prefix":"10.3390","volume":"15","author":[{"given":"Xiaohui","family":"Wang","sequence":"first","affiliation":[{"name":"Department of Geriatrics, Peking University People\u2019s Hospital, Beijing 100044, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lihua","family":"Deng","sequence":"additional","affiliation":[{"name":"Department of Geriatrics, Peking University People\u2019s Hospital, Beijing 100044, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2022-6512","authenticated-orcid":false,"given":"Ya\u2019nan","family":"Wei","sequence":"additional","affiliation":[{"name":"Department of Geriatrics, Peking University People\u2019s Hospital, Beijing 100044, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6371-9763","authenticated-orcid":false,"given":"Qian","family":"Xue","sequence":"additional","affiliation":[{"name":"Department of Geriatrics, Peking University People\u2019s Hospital, Beijing 100044, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meiqi","family":"Liu","sequence":"additional","affiliation":[{"name":"Shijiazhuang People\u2019s Hospital, Shijiazhuang 050011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jianping","family":"Zhang","sequence":"additional","affiliation":[{"name":"Shijiazhuang People\u2019s Hospital, Shijiazhuang 050011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0878-2054","authenticated-orcid":false,"given":"Jingtong","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Geriatrics, Peking University People\u2019s Hospital, Beijing 100044, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1097\/CM9.0000000000002089","article-title":"From MAFLD to hepatocellular carcinoma and everything in between","volume":"135","author":"Bae","year":"2022","journal-title":"Chin. Med. J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1194","DOI":"10.1002\/hep.31420","article-title":"From NAFLD to MAFLD: Implications of a Premature Change in Terminology","volume":"73","author":"Younossi","year":"2021","journal-title":"Hepatology"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1038\/s41575-020-00381-6","article-title":"Global epidemiology of NAFLD-related HCC: Trends, predictions, risk factors and prevention","volume":"18","author":"Huang","year":"2021","journal-title":"Nat. Rev. Gastroenterol. Hepatol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1016\/j.tem.2024.02.007","article-title":"Current status and future trends of the global burden of MASLD","volume":"35","author":"Miao","year":"2024","journal-title":"Trends Endocrinol. Metab."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1797","DOI":"10.1097\/HEP.0000000000000323","article-title":"AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease","volume":"77","author":"Rinella","year":"2023","journal-title":"Hepatology"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"436","DOI":"10.3350\/cmh.2024.0109","article-title":"Global prevalence of metabolic dysfunction-associated fatty liver disease-related hepatocellular carcinoma: A systematic review and meta-analysis","volume":"30","author":"Crane","year":"2024","journal-title":"Clin. Mol. Hepatol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1002\/hep.32131","article-title":"Metabolic dysfunction\u2013associated fatty liver disease improves detection of high liver stiffness: The Rotterdam Study","volume":"75","author":"Ayada","year":"2022","journal-title":"Hepatology"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1111\/jvh.13808","article-title":"A novel non-invasive model for the prediction of advanced liver fibrosis in chronic hepatitis B patients with NAFLD","volume":"30","author":"Wang","year":"2023","journal-title":"J. Viral Hepat."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1002\/hep.30857","article-title":"Nonalcoholic Steatohepatitis Is Associated with Liver-Related Outcomes and All-Cause Mortality in Chronic Hepatitis B","volume":"71","author":"Choi","year":"2020","journal-title":"Hepatology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1115","DOI":"10.1111\/hepr.13685","article-title":"MAFLD better predicts the progression of atherosclerotic cardiovascular risk than NAFLD: Generalized estimating equation approach","volume":"51","author":"Tsutsumi","year":"2021","journal-title":"Hepatol. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1111\/hepr.13795","article-title":"Lean\/normal-weight metabolic dysfunction-associated fatty liver disease is a risk factor for reflux esophagitis","volume":"52","author":"Fukunaga","year":"2022","journal-title":"Hepatol. Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1186\/s13098-022-00887-w","article-title":"MAFLD associated with COPD via systemic inflammation independent of aging and smoking in men","volume":"14","author":"Tsutsumi","year":"2022","journal-title":"Diabetol. Metab. Syndr."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1111\/hepr.13973","article-title":"Impact of non-obese metabolic dysfunction-associated fatty liver disease on risk factors for the recurrence of esophageal squamous cell carcinoma treated with endoscopic submucosal dissection: A multicenter study","volume":"54","author":"Fukunaga","year":"2024","journal-title":"Hepatol. Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1840","DOI":"10.1161\/CIRCULATIONAHA.117.029400","article-title":"INCOSACT Initiative (International Collaboration of Sleep Apnea Cardiovascular Trialists) Sleep Apnea and Cardiovascular Disease: Lessons from Recent Trials and Need for Team Science","volume":"136","author":"Drager","year":"2017","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1016\/j.jacc.2016.11.069","article-title":"Sleep Apnea: Types, Mechanisms, and Clinical Cardiovascular Consequences","volume":"69","author":"Javaheri","year":"2017","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"687","DOI":"10.1016\/S2213-2600(19)30198-5","article-title":"Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis","volume":"7","author":"Benjafield","year":"2019","journal-title":"Lancet Respir. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1016\/j.ecl.2023.01.006","article-title":"A Bidirectional Association Between Obstructive Sleep Apnea and Metabolic-Associated Fatty Liver Disease","volume":"52","author":"Preshy","year":"2023","journal-title":"Endocrinol. Metab. Clin. N. Am."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2669","DOI":"10.3748\/wjg.v26.i20.2669","article-title":"Association between non-alcoholic fatty liver disease and obstructive sleep apnea","volume":"26","author":"Umbro","year":"2020","journal-title":"World J. Gastroenterol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"13473","DOI":"10.1038\/s41598-021-92703-0","article-title":"Nonalcoholic fatty liver disease is associated with the development of obstructive sleep apnea","volume":"11","author":"Chung","year":"2021","journal-title":"Sci. Rep."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Kim, N., Roh, J.-H., Lee, H., Kim, D., and Heo, S.J. (2022). The impact of non-alcoholic fatty liver disease on sleep apnea in healthy adults: A nationwide study of Korea. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0271021"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Chen, M., Wang, B., Huang, J., Zhao, J., Chen, J., and Chen, G. (2022). The role of platelet-related parameters for the prediction of NAFLD in OSAHS patients. BMC Pulm. Med., 22.","DOI":"10.1186\/s12890-022-02291-6"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1186\/s12933-024-02352-6","article-title":"Association between the triglyceride glucose-body mass index and future cardiovascular disease risk in a population with Cardiovascular-Kidney-Metabolic syndrome stage 0\u20133: A nationwide prospective cohort study","volume":"23","author":"Li","year":"2024","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1186\/s12933-025-02675-y","article-title":"Cholesterol, high-density lipoprotein, and glucose index versus triglyceride-glucose index in predicting cardiovascular disease risk: A cohort study","volume":"24","author":"Mo","year":"2025","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"3111","DOI":"10.2147\/DMSO.S526411","article-title":"The Triglyceride-Glucose Index Mediates the Association Between Obstructive Sleep Apnea and Non-Alcoholic Fatty Liver Disease: Findings from Two Cross-Sectional Datasets","volume":"18","author":"Wu","year":"2025","journal-title":"Diabetes Metab. Syndr. Obes."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1111\/jdi.14343","article-title":"A novel index for diagnosis of type 2 diabetes mellitus: Cholesterol, High density lipoprotein, and Glucose (CHG) index","volume":"16","author":"Mansoori","year":"2025","journal-title":"J. Diabetes Investig."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1186\/s12933-024-02343-7","article-title":"Association between triglyceride-glucose related indices and mortality among individuals with non-alcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease","volume":"23","author":"Chen","year":"2024","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Cai, Y., Chen, J., Deng, X., Wang, B., Huang, J., and Lian, N. (2024). Triglyceride-glucose index and combined indicators: Effective indicators for screening NAFLD in snoring patients. BMC Pulm. Med., 24.","DOI":"10.1186\/s12890-024-03166-8"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Bogdan, R.G., Boicean, A., Anderco, P., Ichim, C., Iliescu-Glaja, M., Todor, S.B., Leonte, E., Bloanca, V.A., Crainiceanu, Z.P., and Popa, M.L. (2025). From Liver to Kidney: The Overlooked Burden of Nonalcoholic Fatty Liver Disease in Chronic Kidney Disease. J. Clin. Med., 14.","DOI":"10.3390\/jcm14072486"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Ichim, C., Boicean, A., Todor, S.B., Boeras, I., Anderco, P., and Birlutiu, V. (2026). Clinical and MicroRNA Responses to Fecal Microbiota Transplantation in Patients with Alcohol-Related Cirrhosis: A Pilot Study. Diagnostics, 16.","DOI":"10.3390\/diagnostics16060846"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"m441","DOI":"10.1136\/bmj.m441","article-title":"Calculating the sample size required for developing a clinical prediction model","volume":"368","author":"Riley","year":"2020","journal-title":"BMJ"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1016\/j.metabol.2016.05.004","article-title":"Nonalcoholic fatty liver disease and obstructive sleep apnea","volume":"65","author":"Clement","year":"2016","journal-title":"Metabolism"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2423","DOI":"10.1113\/JP273312","article-title":"Adipose tissue inflammation by intermittent hypoxia: Mechanistic link between obstructive sleep apnoea and metabolic dysfunction","volume":"595","author":"Ryan","year":"2017","journal-title":"J. Physiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1427","DOI":"10.1159\/000366348","article-title":"Hypoxia induces dysregulation of lipid metabolism in HepG2 cells via activation of HIF-2\u03b1","volume":"34","author":"Cao","year":"2014","journal-title":"Cell Physiol. Biochem."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1016\/j.bbrc.2021.01.002","article-title":"Hypoxia-inducible factor-2 promotes liver fibrosis in non-alcoholic steatohepatitis liver disease via the NF-\u03baB signalling pathway","volume":"540","author":"Cai","year":"2021","journal-title":"Biochem. Biophys. Res. Commun."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Wang, D., Si, D., Li, G., Ding, Z., Yang, X., and Gao, C. (2022). Dysregulated autophagic activity induced in response to chronic intermittent hypoxia contributes to the pathogenesis of NAFLD. Front. Physiol., 13.","DOI":"10.3389\/fphys.2022.941706"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"5112","DOI":"10.12998\/wjcc.v9.i19.5112","article-title":"Impact of continuous positive airway pressure therapy for nonalcoholic fatty liver disease in patients with obstructive sleep apnea","volume":"9","author":"Hirono","year":"2021","journal-title":"World J. Clin. Cases"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"3419","DOI":"10.1007\/s00018-016-2222-1","article-title":"Hypoxia-regulated mechanisms in the pathogenesis of obesity and non-alcoholic fatty liver disease","volume":"73","author":"Lefere","year":"2016","journal-title":"Cell Mol. Life Sci."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e2405955","DOI":"10.1002\/advs.202405955","article-title":"Obstructive Sleep Apnea Syndrome Exacerbates NASH Progression via Selective Autophagy-Mediated Eepd1 Degradation","volume":"11","author":"Xiong","year":"2024","journal-title":"Adv. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1186\/s12967-021-02854-x","article-title":"The roles and mechanisms of hypoxia in liver fibrosis","volume":"19","author":"Cai","year":"2021","journal-title":"J. Transl. Med."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Tang, H., Lv, F., Zhang, P., Liu, J., and Mao, J. (2023). The impact of obstructive sleep apnea on nonalcoholic fatty liver disease. Front. Endocrinol., 14.","DOI":"10.3389\/fendo.2023.1254459"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1136\/gutjnl-2020-322564","article-title":"Caucasian lean subjects with non-alcoholic fatty liver disease share long-term prognosis of non-lean: Time for reappraisal of BMI-driven approach?","volume":"71","author":"Younes","year":"2022","journal-title":"Gut"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1038\/s41575-021-00433-5","article-title":"What are the clinical settings and outcomes of lean NAFLD?","volume":"18","author":"Ren","year":"2021","journal-title":"Nat. Rev. Gastroenterol. Hepatol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"772","DOI":"10.1136\/gutjnl-2025-336127","article-title":"Long-term prognosis of lean MASLD: Evidence from three population-based prospective cohorts","volume":"75","author":"Huo","year":"2026","journal-title":"Gut"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1007\/s12072-022-10347-2","article-title":"Chronic intermittent hypoxia contributes to non-alcoholic steatohepatitis progression in patients with obesity","volume":"16","author":"Fu","year":"2022","journal-title":"Hepatol. Int."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1515","DOI":"10.1007\/s11325-020-02018-z","article-title":"Obstructive sleep apnea and liver injury in severely obese patients with nonalcoholic fatty liver disease","volume":"24","author":"Zhang","year":"2020","journal-title":"Sleep Breath."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Kim, T., Choi, H., Lee, J., and Kim, J. (2022). Obstructive Sleep Apnea and Nonalcoholic Fatty Liver Disease in the General Population: A Cross-Sectional Study Using Nationally Representative Data. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19148398"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.2147\/NSS.S316674","article-title":"Development and Validation of a Nomogram for Predicting Obstructive Sleep Apnea in Bariatric Surgery Candidates","volume":"13","author":"Chen","year":"2021","journal-title":"Nat. Sci. Sleep"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1016\/j.soard.2020.02.003","article-title":"Prevalence of obstructive sleep apnea in an Asian bariatric population: An underdiagnosed dilemma","volume":"16","author":"Loo","year":"2020","journal-title":"Surg. Obes. Relat. Dis."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1861","DOI":"10.1038\/ajg.2013.349","article-title":"Cohort study of non-alcoholic fatty liver disease, NAFLD fibrosis score, and the risk of incident diabetes in a Korean population","volume":"108","author":"Chang","year":"2013","journal-title":"Am. J. Gastroenterol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1461","DOI":"10.1016\/j.cgh.2017.04.040","article-title":"Histologic Scores for Fat and Fibrosis Associate with Development of Type 2 Diabetes in Patients with Nonalcoholic Fatty Liver Disease","volume":"15","author":"Hultcrantz","year":"2017","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"2537","DOI":"10.1016\/j.cell.2021.04.015","article-title":"Mechanisms and disease consequences of nonalcoholic fatty liver disease","volume":"184","author":"Loomba","year":"2021","journal-title":"Cell"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"372","DOI":"10.2337\/dc17-1902","article-title":"Nonalcoholic Fatty Liver Disease and Risk of Incident Type 2 Diabetes: A Meta-analysis","volume":"41","author":"Mantovani","year":"2018","journal-title":"Diabetes Care"},{"key":"ref_53","unstructured":"European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), and European Association for the Study of Obesity (EASO) (2024). EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J. Hepatol., 81, 492\u2013542."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/14\/5346\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T04:12:29Z","timestamp":1783743149000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/14\/5346"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,8]]},"references-count":53,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["jcm15145346"],"URL":"https:\/\/doi.org\/10.3390\/jcm15145346","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,8]]}}}