{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T16:17:11Z","timestamp":1787847431915,"version":"build-2784847793"},"reference-count":54,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T00:00:00Z","timestamp":1765843200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Thyroid nodules are common, and distinguishing benign from malignant lesions is essential for clinical decision-making. While EU-TIRADS provides ultrasound-based risk stratification, fine-needle aspiration biopsy (FNAB) and the Bethesda System remain central diagnostic tools. This study aimed to compare the diagnostic performance of EU-TIRADS and Bethesda classifications and to identify ultrasonographic features independently associated with malignancy. Materials and Methods: This retrospective single-center study included 824 patients (1132 nodules) who underwent FNAB between August 2021 and June 2024. All ultrasound examinations and FNAB procedures were performed by the same endocrinologist. Sonographic features, EU-TIRADS categories, Bethesda classes, surgical indications, and histopathology were analyzed. Diagnostic accuracy was assessed using ROC curves, and multivariable logistic regression was applied to determine independent predictors of malignancy. Results: Among all nodules, 51.0% were EU-TIRADS 3, 28.6% were EU-TIRADS 4, and 19.2% were EU-TIRADS 5. Bethesda class II constituted 62.7% of FNAB results. Of the 289 surgically treated nodules, 53.3% were malignant. Malignant nodules were smaller, more often solitary and unilateral, and more frequently located in the upper pole (p &lt; 0.05). Irregular margins (OR = 8.15, p &lt; 0.001) and microcalcifications (OR = 10.01, p = 0.003) were independent predictors of malignancy. Taller-than-wide shape also showed significant association. ROC analyses demonstrated that EU-TIRADS (AUC = 0.808) and Bethesda (AUC = 0.869) were both significant predictors, with Bethesda showing higher specificity. Malignancy rates were 0% in EU-TIRADS II, 4.3% in III, 14.5% in IV, and 37.8% in V. Conclusions: EU-TIRADS is a practical and sensitive non-invasive tool for malignancy risk stratification; however, Bethesda classification remains superior in overall diagnostic accuracy. Microcalcification and irregular margins were the strongest ultrasonographic predictors of malignancy, while macrocalcification, parenchymal heterogeneity, and thyroiditis showed no significant association. These findings support the complementary roles of EU-TIRADS and FNAB and highlight key sonographic markers that enhance malignancy prediction in thyroid nodule evaluation.<\/jats:p>","DOI":"10.3390\/medicina61122217","type":"journal-article","created":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T11:00:26Z","timestamp":1765882826000},"page":"2217","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Microcalcification and Irregular Margins as Key Predictors of Thyroid Cancer: Integrated Analysis of EU-TIRADS, Bethesda, and Histopathology"],"prefix":"10.3390","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8344-3509","authenticated-orcid":false,"given":"\u015eebnem","family":"\u00c7imen","sequence":"first","affiliation":[{"name":"Department of General Surgery, Akyurt State Hospital, Ankara 06750, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5033-834X","authenticated-orcid":false,"given":"Nazif","family":"Zeybek","sequence":"additional","affiliation":[{"name":"Department of General Surgery, G\u00fclhane Training and Reseach Hospital, University of Health Sciences, Ankara 06010, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0777-8934","authenticated-orcid":false,"given":"Adile Beg\u00fcm","family":"Bah\u00e7ecio\u011flu","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, G\u00fclhane Training and Reseach Hospital, University of Health Sciences, Ankara 06010, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5514-4103","authenticated-orcid":false,"given":"Kerim Bora","family":"Y\u0131lmaz","sequence":"additional","affiliation":[{"name":"Department of General Surgery, G\u00fclhane Training and Reseach Hospital, University of Health Sciences, Ankara 06010, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8212-5752","authenticated-orcid":false,"given":"Ne\u015fe Ers\u00f6z","family":"G\u00fcl\u00e7elik","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, G\u00fclhane Training and Reseach Hospital, University of Health Sciences, Ankara 06010, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8967-7303","authenticated-orcid":false,"given":"Mehmet Ali","family":"G\u00fcl\u00e7elik","sequence":"additional","affiliation":[{"name":"Department of Surgical Oncology, G\u00fclhane Training and Reseach Hospital, University of Health Sciences, Ankara 06010, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2411","DOI":"10.1007\/s00330-001-1163-7","article-title":"Ultrasound of thyroid, parathyroid glands and neck lymph nodes","volume":"11","author":"Solbiati","year":"2001","journal-title":"Eur. Radiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"W487","DOI":"10.2214\/AJR.12.9071","article-title":"Correlation of ultrasound findings with the Bethesda cytopathology classification for thyroid nodule fine-needle aspiration: A primer for radiologists","volume":"201","author":"Heller","year":"2013","journal-title":"Am. J. Roentgenol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1089\/thy.2015.0020","article-title":"2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer","volume":"26","author":"Haugen","year":"2016","journal-title":"Thyroid"},{"key":"ref_4","first-page":"1039","article-title":"The 2023 Bethesda System for Reporting Thyroid Cytopathology","volume":"33","author":"Ali","year":"2023","journal-title":"Thyroid"},{"key":"ref_5","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."},{"key":"ref_6","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."},{"key":"ref_7","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."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"160","DOI":"10.4274\/jcrpe.galenos.2024.2023-8-12","article-title":"Evaluating Postoperative Outcomes and Investigating the Usefulness of EU-TIRADS Scoring in Managing Pediatric Thyroid Nodules Bethesda 3 and 4","volume":"16","author":"Bitkay","year":"2024","journal-title":"J. Clin. Res. Pediatr. Endocrinol."},{"key":"ref_9","first-page":"728","article-title":"Ultrasound criteria (EU-TIRADS) to identify thyroid nodule malignancy risk in adolescents. Correlation with cyto-histological findings","volume":"68","author":"Felip","year":"2021","journal-title":"Endocrinol. Diabetes Nutr."},{"key":"ref_10","first-page":"206","article-title":"Diagnostic Performance of Thyroid Nodule Risk Stratification Systems: Comparison of ACR-TIRADS, EU-TIRADS, K-TIRADS, and ATA Guidelines","volume":"39","author":"Yucel","year":"2023","journal-title":"Ultrasound Q."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1029926","DOI":"10.3389\/fonc.2022.1029926","article-title":"Mapping global epidemiology of thyroid nodules among general population: A systematic review and meta-analysis","volume":"12","author":"Mu","year":"2022","journal-title":"Front. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"468","DOI":"10.4158\/EP.16.3.468","article-title":"American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: Executive summary of recommendations","volume":"16","author":"Gharib","year":"2010","journal-title":"Endocr. Pract."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1056\/NEJM199302253280807","article-title":"Management of a solitary thyroid nodule","volume":"328","author":"Mazzaferri","year":"1993","journal-title":"N. Engl. J. Med."},{"key":"ref_14","first-page":"559","article-title":"Thyroid nodules","volume":"67","author":"Welker","year":"2003","journal-title":"Am. Fam. Physician."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Xu, W., Chen, Z., Liu, H., Huo, L., Huang, Y., Jin, X., Deng, J., Zhu, S., Jin, W., and Zhang, S. (2014). The association of thyroid nodule with non-iodized salt among Chinese children. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0102726"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1111\/j.1365-2362.2009.02162.x","article-title":"Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination","volume":"39","author":"Guth","year":"2009","journal-title":"Eur. J. Clin. Investig."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"4434","DOI":"10.1210\/jc.2015-3100","article-title":"The Influence of Patient Age on Thyroid Nodule Formation, Multinodularity, and Thyroid Cancer Risk","volume":"100","author":"Kwong","year":"2015","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"183","DOI":"10.14639\/0392-100X-N2288","article-title":"TSH level as a risk factor of thyroid malignancy for nodules in euthyroid patients","volume":"43","author":"Alaraifi","year":"2023","journal-title":"Acta Otorhinolaryngol. Ital."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"3803647","DOI":"10.1155\/2016\/3803647","article-title":"Does Tumor Size Influence the Diagnostic Accuracy of Ultrasound-Guided Fine-Needle Aspiration Cytology for Thyroid Nodules?","volume":"2016","author":"Koo","year":"2016","journal-title":"Int. J. Endocrinol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1016\/j.surg.2007.08.012","article-title":"The incidence of cancer and rate of false-negative cytology in thyroid nodules greater than or equal to 4 cm in size","volume":"142","author":"McCoy","year":"2007","journal-title":"Surgery"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1305","DOI":"10.1002\/lary.23861","article-title":"False negatives in thyroid cytology: Impact of large nodule size and follicular variant of papillary carcinoma","volume":"123","author":"Mehanna","year":"2013","journal-title":"Laryngoscope"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1210\/jc.2012-2968","article-title":"Thyroid nodule size and prediction of cancer","volume":"98","author":"Kamran","year":"2013","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1089","DOI":"10.1001\/jamaoto.2015.1451","article-title":"Association of Thyroid Nodule Size and Bethesda Class With Rate of Malignant Disease","volume":"141","author":"Magister","year":"2015","journal-title":"JAMA Otolaryngol. Head Neck Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1251","DOI":"10.1089\/thy.2012.0265","article-title":"The impact of thyroid nodule size on the risk of malignancy and accuracy of fine-needle aspiration: A 10-year study from a single institution","volume":"22","author":"Shrestha","year":"2012","journal-title":"Thyroid"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"622","DOI":"10.1002\/dc.23289","article-title":"The diagnostic accuracy of ultrasound-guided fine-needle aspiration biopsy for thyroid nodules three centimeters or larger in size","volume":"43","author":"Ucler","year":"2015","journal-title":"Diagn. Cytopathol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1089\/thy.2016.0336","article-title":"Thyroid Nodule Size at Ultrasound as a Predictor of Malignancy and Final Pathologic Size","volume":"27","author":"Cavallo","year":"2017","journal-title":"Thyroid"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1186\/s13044-022-00140-6","article-title":"Solitary and multiple thyroid nodules as predictors of malignancy: A systematic review and meta-analysis","volume":"15","author":"Rehman","year":"2022","journal-title":"Thyroid Res."},{"key":"ref_28","first-page":"e29421","article-title":"The Importance of the Thyroid Nodule Location in Determining the Risk of Malignancy: A Retrospective Study","volume":"14","author":"Ageeli","year":"2022","journal-title":"Cureus"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"884","DOI":"10.1016\/j.ultrasmedbio.2013.11.021","article-title":"Heterogeneous echogenicity of the thyroid parenchyma does not influence the detection of multi-focality in papillary thyroid carcinoma on preoperative ultrasound staging","volume":"40","author":"Herh","year":"2014","journal-title":"Ultrasound Med. Biol."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Park, M., Park, S.H., Kim, E.-K., Yoon, J.H., Moon, H.J., Lee, H.S., and Kwak, J.Y. (2013). Heterogeneous echogenicity of the underlying thyroid parenchyma: How does this affect the analysis of a thyroid nodule?. BMC Cancer, 13.","DOI":"10.1186\/1471-2407-13-550"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"656","DOI":"10.1016\/j.tem.2014.09.001","article-title":"Hashimoto\u2019s thyroiditis and papillary thyroid cancer: Are they immunologically linked?","volume":"25","author":"Ehlers","year":"2014","journal-title":"Trends Endocrinol. Metab."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3615","DOI":"10.1210\/jc.2011-1740","article-title":"Clinical review: Clinical utility of thyroglobulin antibody (TgAb) measurements for patients with differentiated thyroid cancers (DTC)","volume":"96","author":"Spencer","year":"2011","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_33","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."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1210\/jc.2013-2928","article-title":"The accuracy of thyroid nodule ultrasound to predict thyroid cancer: Systematic review and meta-analysis","volume":"99","author":"Brito","year":"2014","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1653","DOI":"10.1007\/s00330-019-06527-8","article-title":"Ultrasound malignancy risk stratification of thyroid nodules based on the degree of hypoechogenicity and echotexture","volume":"30","author":"Lee","year":"2020","journal-title":"Eur. Radiol."},{"key":"ref_36","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"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1159\/000504219","article-title":"Taller-Than-Wide Shape: A New Definition Improves the Specificity of TIRADS Systems","volume":"9","author":"Grani","year":"2020","journal-title":"Eur. Thyroid J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"595","DOI":"10.1530\/EJE-18-0083","article-title":"Differences between ATA, AACE\/ACE\/AME and ACR TI-RADS ultrasound classifications performance in identifying cytological high-risk thyroid nodules","volume":"178","author":"Maddaloni","year":"2018","journal-title":"Eur. J. Endocrinol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.2214\/AJR.16.17613","article-title":"Multiinstitutional Analysis of Thyroid Nodule Risk Stratification Using the American College of Radiology Thyroid Imaging Reporting and Data System","volume":"208","author":"Middleton","year":"2017","journal-title":"Am. J. Roentgenol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1148\/radiol.2473070944","article-title":"Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study","volume":"247","author":"Moon","year":"2008","journal-title":"Radiology"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1089\/thy.2015.0460","article-title":"Thyroid Imaging Reporting and Data System Risk Stratification of Thyroid Nodules: Categorization Based on Solidity and Echogenicity","volume":"26","author":"Na","year":"2016","journal-title":"Thyroid"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"127","DOI":"10.4103\/jmu.jmu_19_22","article-title":"Performance of European Thyroid Imaging Reporting and Data System in Stratifying Malignancy Risk of Thyroid Nodules: A Prospective Study","volume":"31","author":"Nabahati","year":"2023","journal-title":"J. Med. Ultrasound"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"110","DOI":"10.3348\/kjr.2013.14.1.110","article-title":"Image reporting and characterization system for ultrasound features of thyroid nodules: Multicentric Korean retrospective study","volume":"14","author":"Kwak","year":"2013","journal-title":"Korean J. Radiol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.bjorl.2016.01.013","article-title":"Sonographic scoring of solid thyroid nodules: Effects of nodule size and suspicious cervical lymph node","volume":"83","author":"Unsal","year":"2017","journal-title":"Braz. J. Otorhinolaryngol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"31","DOI":"10.2214\/AJR.09.2822","article-title":"Biopsy of thyroid nodules: Comparison of three sets of guidelines","volume":"194","author":"Ahn","year":"2010","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1948","DOI":"10.1007\/s00268-008-9600-2","article-title":"Predictive value of sonographic features in preoperative evaluation of malignant thyroid nodules in a multinodular goiter","volume":"32","author":"Erbil","year":"2008","journal-title":"World J. Surg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"18442","DOI":"10.1038\/s41598-022-22954-y","article-title":"Ultrasound performance using the EU-TIRADS score in the diagnosis of thyroid cancer in Congolese hospitals","volume":"12","author":"Bayauli","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1530\/EJE-20-0204","article-title":"Performance of EU-TIRADS in malignancy risk stratification of thyroid nodules: A meta-analysis","volume":"183","author":"Castellana","year":"2020","journal-title":"Eur. J. Endocrinol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1227339","DOI":"10.3389\/fendo.2023.1227339","article-title":"Diagnostic efficiency among Eu-\/C-\/ACR-TIRADS and S-Detect for thyroid nodules: A systematic review and network meta-analysis","volume":"14","author":"Yang","year":"2023","journal-title":"Front. Endocrinol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/s13044-023-00155-7","article-title":"Analysis of 665 thyroid nodules using both EU-TIRADS and ACR TI-RADS classification systems","volume":"16","author":"Borges","year":"2023","journal-title":"Thyroid Res."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"437","DOI":"10.4103\/0019-509X.73564","article-title":"Fine needle aspiration cytology of thyroid swellings: How useful and accurate is it?","volume":"47","author":"Bagga","year":"2010","journal-title":"Indian J. Cancer"},{"key":"ref_52","first-page":"12","article-title":"Fine-needle aspiration cytology of thyroid nodules\u2014How well are we doing?","volume":"13","author":"Cheung","year":"2007","journal-title":"Hong Kong Med. J."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"76","DOI":"10.4103\/ijabmr.IJABMR_169_17","article-title":"Evaluation of Thyroid Lesions by Fine-needle Aspiration Cytology According to Bethesda System and its Histopathological Correlation","volume":"8","author":"Nandedkar","year":"2018","journal-title":"Int. J. Appl. Basic Med. Res."},{"key":"ref_54","first-page":"451","article-title":"Diagnostic accuracy of fine-needle aspiration cytology of thyroid gland lesions: A study of 200 cases in Himalayan belt","volume":"13","author":"Sharma","year":"2017","journal-title":"J. Cancer Res. Ther."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/12\/2217\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T11:22:01Z","timestamp":1765884121000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/12\/2217"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,16]]},"references-count":54,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["medicina61122217"],"URL":"https:\/\/doi.org\/10.3390\/medicina61122217","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,16]]}}}