Relationship between Polycystic Ovarian Syndrome and Subsequent Gestational Diabetes Mellitus: A Nationwide Population-Based Study
This nationwide population-based study aims to explore the relationship between polycystic ovarian syndrome (PCOS) and subsequent gestational diabetes mellitus (GDM). Data from 1998-2012 Taiwan National Health Insurance Research Database were used for this study. ICD9-CM codes 256.4X and 648.X were...
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| description | This nationwide population-based study aims to explore the relationship between polycystic ovarian syndrome (PCOS) and subsequent gestational diabetes mellitus (GDM).
Data from 1998-2012 Taiwan National Health Insurance Research Database were used for this study. ICD9-CM codes 256.4X and 648.X were used separately for the diagnoses of PCOS and GDM, which were further confirmed by records of blood tests or ultrasonography to ensure the accuracy of the diagnoses. Women diagnosed at < 15 or > 45 years of age, and those diagnosed with overt diabetes mellitus or GDM prior to PCOS were excluded. During pregnancy, each woman with a previous diagnosis of PCOS was age-matched to 10 women without PCOS. Odds ratios (ORs) for risk of GDM were calculated by logistic regression analysis with adjustment for economic status and co-morbidities.
Among 7,629 eligible women with a valid PCOS diagnosis, 3,109 (42.87%) had subsequent pregnancies. GDM occurred frequently among women with a history of PCOS as compared to those without PCOS (20.46% vs. 10.54%, p0.05). If not used after conception, OHAs did not reduce the risk of GDM (adjusted OR = 1.20; 95% CI:0.88-1.62).
A history of PCOS is a significant and independent risk factor for development of GDM. Medication for PCOS or pre-pregnancy use of OHAs does not reduce the risk of GDM. When at-risk women become pregnant, they require closer surveillance for maternal and fetal well-being, and should follow a strict diet and adhere to weight gain control to avoid obstetric complications due to GDM. |
| doi_str_mv | 10.1371/journal.pone.0140544 |
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Data from 1998-2012 Taiwan National Health Insurance Research Database were used for this study. ICD9-CM codes 256.4X and 648.X were used separately for the diagnoses of PCOS and GDM, which were further confirmed by records of blood tests or ultrasonography to ensure the accuracy of the diagnoses. Women diagnosed at < 15 or > 45 years of age, and those diagnosed with overt diabetes mellitus or GDM prior to PCOS were excluded. During pregnancy, each woman with a previous diagnosis of PCOS was age-matched to 10 women without PCOS. Odds ratios (ORs) for risk of GDM were calculated by logistic regression analysis with adjustment for economic status and co-morbidities.
Among 7,629 eligible women with a valid PCOS diagnosis, 3,109 (42.87%) had subsequent pregnancies. GDM occurred frequently among women with a history of PCOS as compared to those without PCOS (20.46% vs. 10.54%, p<0.0001). Logistic regression analysis revealed that PCOS was associated with GDM (adjusted OR = 2.15; 95% CI:1.96-2.37). Among 3,109 affected patients, 1,160 (37.31%) had used medications for PCOS and 261 (8.39%) were treated with an oral hypoglycemic agent (OHA). There was no significant difference in development of GDM between the medication and no medication sub-groups (p>0.05). If not used after conception, OHAs did not reduce the risk of GDM (adjusted OR = 1.20; 95% CI:0.88-1.62).
A history of PCOS is a significant and independent risk factor for development of GDM. Medication for PCOS or pre-pregnancy use of OHAs does not reduce the risk of GDM. When at-risk women become pregnant, they require closer surveillance for maternal and fetal well-being, and should follow a strict diet and adhere to weight gain control to avoid obstetric complications due to GDM.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0140544</identifier><identifier>PMID: 26488176</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adolescent ; Adult ; Analysis ; Body weight gain ; Care and treatment ; Comorbidity ; Complications ; Diabetes mellitus ; Diabetes, Gestational - epidemiology ; Diagnosis ; Drugs ; Economic analysis ; Female ; Fetuses ; Gestational diabetes ; Glucose ; Health aspects ; Humans ; Hypoglycemic Agents - therapeutic use ; Metformin - therapeutic use ; Middle Aged ; Polycystic ovary syndrome ; Polycystic Ovary Syndrome - drug therapy ; Polycystic Ovary Syndrome - epidemiology ; Population studies ; Population-based studies ; Pregnancy ; Pregnancy complications ; Pregnant women ; Regression analysis ; Risk Factors ; Risk reduction ; Studies ; Taiwan ; Ultrasound ; Ultrasound imaging ; Well being ; Womens health ; Young Adult</subject><ispartof>PloS one, 2015-10, Vol.10 (10), p.e0140544-e0140544</ispartof><rights>COPYRIGHT 2015 Public Library of Science</rights><rights>2015 Pan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2015 Pan et al 2015 Pan et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c692t-40a5b26ef1fc7169bc254b59e9f7538885d747b8e9edb082c27143100f59b8b63</citedby><cites>FETCH-LOGICAL-c692t-40a5b26ef1fc7169bc254b59e9f7538885d747b8e9edb082c27143100f59b8b63</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4619482/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4619482/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,2102,2928,23866,27924,27925,53791,53793,79600,79601</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/26488176$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Wolfe, Andrew</contributor><creatorcontrib>Pan, Mei-Lien</creatorcontrib><creatorcontrib>Chen, Li-Ru</creatorcontrib><creatorcontrib>Tsao, Hsiao-Mei</creatorcontrib><creatorcontrib>Chen, Kuo-Hu</creatorcontrib><title>Relationship between Polycystic Ovarian Syndrome and Subsequent Gestational Diabetes Mellitus: A Nationwide Population-Based Study</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>This nationwide population-based study aims to explore the relationship between polycystic ovarian syndrome (PCOS) and subsequent gestational diabetes mellitus (GDM).
Data from 1998-2012 Taiwan National Health Insurance Research Database were used for this study. ICD9-CM codes 256.4X and 648.X were used separately for the diagnoses of PCOS and GDM, which were further confirmed by records of blood tests or ultrasonography to ensure the accuracy of the diagnoses. Women diagnosed at < 15 or > 45 years of age, and those diagnosed with overt diabetes mellitus or GDM prior to PCOS were excluded. During pregnancy, each woman with a previous diagnosis of PCOS was age-matched to 10 women without PCOS. Odds ratios (ORs) for risk of GDM were calculated by logistic regression analysis with adjustment for economic status and co-morbidities.
Among 7,629 eligible women with a valid PCOS diagnosis, 3,109 (42.87%) had subsequent pregnancies. GDM occurred frequently among women with a history of PCOS as compared to those without PCOS (20.46% vs. 10.54%, p<0.0001). Logistic regression analysis revealed that PCOS was associated with GDM (adjusted OR = 2.15; 95% CI:1.96-2.37). Among 3,109 affected patients, 1,160 (37.31%) had used medications for PCOS and 261 (8.39%) were treated with an oral hypoglycemic agent (OHA). There was no significant difference in development of GDM between the medication and no medication sub-groups (p>0.05). If not used after conception, OHAs did not reduce the risk of GDM (adjusted OR = 1.20; 95% CI:0.88-1.62).
A history of PCOS is a significant and independent risk factor for development of GDM. Medication for PCOS or pre-pregnancy use of OHAs does not reduce the risk of GDM. When at-risk women become pregnant, they require closer surveillance for maternal and fetal well-being, and should follow a strict diet and adhere to weight gain control to avoid obstetric complications due to GDM.</description><subject>Adolescent</subject><subject>Adult</subject><subject>Analysis</subject><subject>Body weight gain</subject><subject>Care and treatment</subject><subject>Comorbidity</subject><subject>Complications</subject><subject>Diabetes mellitus</subject><subject>Diabetes, Gestational - epidemiology</subject><subject>Diagnosis</subject><subject>Drugs</subject><subject>Economic analysis</subject><subject>Female</subject><subject>Fetuses</subject><subject>Gestational diabetes</subject><subject>Glucose</subject><subject>Health aspects</subject><subject>Humans</subject><subject>Hypoglycemic Agents - therapeutic use</subject><subject>Metformin - therapeutic use</subject><subject>Middle Aged</subject><subject>Polycystic ovary syndrome</subject><subject>Polycystic Ovary Syndrome - drug therapy</subject><subject>Polycystic Ovary Syndrome - epidemiology</subject><subject>Population studies</subject><subject>Population-based studies</subject><subject>Pregnancy</subject><subject>Pregnancy complications</subject><subject>Pregnant women</subject><subject>Regression analysis</subject><subject>Risk Factors</subject><subject>Risk reduction</subject><subject>Studies</subject><subject>Taiwan</subject><subject>Ultrasound</subject><subject>Ultrasound imaging</subject><subject>Well being</subject><subject>Womens health</subject><subject>Young Adult</subject><issn>1932-6203</issn><issn>1932-6203</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2015</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><sourceid>DOA</sourceid><recordid>eNqNk01vEzEQhlcIREvgHyBYCQnBIcGf-8EBKRQokQpBDXC1bO9s4shZh7W3JVd-OU6yrRLUA9qDV_Yz73hezyTJU4xGmOb4zdJ1bSPtaO0aGCHMEGfsXnKKS0qGGUH0_sH_SfLI-yVCnBZZ9jA5IRkrCpxnp8mfS7AyGNf4hVmnCsI1QJN-c3ajNz4YnU6vZGtkk842TdW6FaSyqdJZpzz86qAJ6Tn4sBOQNv1gZFQAn34Ba03o_Nt0nH7dnV6bCqLsuttnG76XHqJO6KrN4-RBLa2HJ_06SH58-vj97PPwYno-ORtfDHVWkjBkSHJFMqhxrXOclUoTzhQvoazzWFdR8CpnuSqghEqhgmiSY0YxQjUvVaEyOkie73XX1nnR2-cFzglHuGCYRmKyJyonl2LdmpVsN8JJI3Ybrp0L2UZTLAiZSU1VrbQqGUPAY34qawmUE1aWvI5a7_psnVpBpaNXrbRHoscnjVmIubsSLMMlK0gUeNULtC5a7YNYGa-jsbIB1-3unTMaS0cRffEPend1PTWXsQDT1C7m1VtRMWaUEMJxbJBBMrqDil8FK6Njr9Um7h8FvD4KiEyA32EuO-_FZHb5_-z05zH78oBdgLRh4Z3tds16DLI9qFvnfQv1rckYie2o3LghtqMi-lGJYc8OH-g26GY26F_UPQ_B</recordid><startdate>20151021</startdate><enddate>20151021</enddate><creator>Pan, Mei-Lien</creator><creator>Chen, Li-Ru</creator><creator>Tsao, Hsiao-Mei</creator><creator>Chen, Kuo-Hu</creator><general>Public Library of Science</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>IOV</scope><scope>ISR</scope><scope>3V.</scope><scope>7QG</scope><scope>7QL</scope><scope>7QO</scope><scope>7RV</scope><scope>7SN</scope><scope>7SS</scope><scope>7T5</scope><scope>7TG</scope><scope>7TM</scope><scope>7U9</scope><scope>7X2</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FD</scope><scope>8FE</scope><scope>8FG</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABJCF</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>ATCPS</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BHPHI</scope><scope>C1K</scope><scope>CCPQU</scope><scope>D1I</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>H94</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>KB.</scope><scope>KB0</scope><scope>KL.</scope><scope>L6V</scope><scope>LK8</scope><scope>M0K</scope><scope>M0S</scope><scope>M1P</scope><scope>M7N</scope><scope>M7P</scope><scope>M7S</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>P64</scope><scope>PATMY</scope><scope>PDBOC</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PTHSS</scope><scope>PYCSY</scope><scope>RC3</scope><scope>7X8</scope><scope>5PM</scope><scope>DOA</scope></search><sort><creationdate>20151021</creationdate><title>Relationship between Polycystic Ovarian Syndrome and Subsequent Gestational Diabetes Mellitus: A Nationwide Population-Based Study</title><author>Pan, Mei-Lien ; Chen, Li-Ru ; Tsao, Hsiao-Mei ; Chen, Kuo-Hu</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c692t-40a5b26ef1fc7169bc254b59e9f7538885d747b8e9edb082c27143100f59b8b63</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2015</creationdate><topic>Adolescent</topic><topic>Adult</topic><topic>Analysis</topic><topic>Body weight gain</topic><topic>Care and treatment</topic><topic>Comorbidity</topic><topic>Complications</topic><topic>Diabetes mellitus</topic><topic>Diabetes, Gestational - epidemiology</topic><topic>Diagnosis</topic><topic>Drugs</topic><topic>Economic analysis</topic><topic>Female</topic><topic>Fetuses</topic><topic>Gestational diabetes</topic><topic>Glucose</topic><topic>Health aspects</topic><topic>Humans</topic><topic>Hypoglycemic Agents - therapeutic use</topic><topic>Metformin - therapeutic use</topic><topic>Middle Aged</topic><topic>Polycystic ovary syndrome</topic><topic>Polycystic Ovary Syndrome - drug therapy</topic><topic>Polycystic Ovary Syndrome - epidemiology</topic><topic>Population studies</topic><topic>Population-based studies</topic><topic>Pregnancy</topic><topic>Pregnancy complications</topic><topic>Pregnant women</topic><topic>Regression analysis</topic><topic>Risk Factors</topic><topic>Risk reduction</topic><topic>Studies</topic><topic>Taiwan</topic><topic>Ultrasound</topic><topic>Ultrasound imaging</topic><topic>Well being</topic><topic>Womens health</topic><topic>Young Adult</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Pan, Mei-Lien</creatorcontrib><creatorcontrib>Chen, Li-Ru</creatorcontrib><creatorcontrib>Tsao, Hsiao-Mei</creatorcontrib><creatorcontrib>Chen, Kuo-Hu</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Gale In Context: Opposing Viewpoints</collection><collection>Gale In Context: Science</collection><collection>ProQuest Central (Corporate)</collection><collection>Animal Behavior Abstracts</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Biotechnology Research Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Ecology Abstracts</collection><collection>Entomology Abstracts (Full archive)</collection><collection>Immunology Abstracts</collection><collection>Meteorological & Geoastrophysical Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Agricultural Science Collection</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Technology Research Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Technology Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Materials Science & Engineering Collection</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>Agricultural & Environmental Science Collection</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Technology Collection</collection><collection>Natural Science Collection</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Materials Science Collection</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Materials Science Database</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Meteorological & Geoastrophysical Abstracts - 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Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Pan, Mei-Lien</au><au>Chen, Li-Ru</au><au>Tsao, Hsiao-Mei</au><au>Chen, Kuo-Hu</au><au>Wolfe, Andrew</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Relationship between Polycystic Ovarian Syndrome and Subsequent Gestational Diabetes Mellitus: A Nationwide Population-Based Study</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2015-10-21</date><risdate>2015</risdate><volume>10</volume><issue>10</issue><spage>e0140544</spage><epage>e0140544</epage><pages>e0140544-e0140544</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>This nationwide population-based study aims to explore the relationship between polycystic ovarian syndrome (PCOS) and subsequent gestational diabetes mellitus (GDM).
Data from 1998-2012 Taiwan National Health Insurance Research Database were used for this study. ICD9-CM codes 256.4X and 648.X were used separately for the diagnoses of PCOS and GDM, which were further confirmed by records of blood tests or ultrasonography to ensure the accuracy of the diagnoses. Women diagnosed at < 15 or > 45 years of age, and those diagnosed with overt diabetes mellitus or GDM prior to PCOS were excluded. During pregnancy, each woman with a previous diagnosis of PCOS was age-matched to 10 women without PCOS. Odds ratios (ORs) for risk of GDM were calculated by logistic regression analysis with adjustment for economic status and co-morbidities.
Among 7,629 eligible women with a valid PCOS diagnosis, 3,109 (42.87%) had subsequent pregnancies. GDM occurred frequently among women with a history of PCOS as compared to those without PCOS (20.46% vs. 10.54%, p<0.0001). Logistic regression analysis revealed that PCOS was associated with GDM (adjusted OR = 2.15; 95% CI:1.96-2.37). Among 3,109 affected patients, 1,160 (37.31%) had used medications for PCOS and 261 (8.39%) were treated with an oral hypoglycemic agent (OHA). There was no significant difference in development of GDM between the medication and no medication sub-groups (p>0.05). If not used after conception, OHAs did not reduce the risk of GDM (adjusted OR = 1.20; 95% CI:0.88-1.62).
A history of PCOS is a significant and independent risk factor for development of GDM. Medication for PCOS or pre-pregnancy use of OHAs does not reduce the risk of GDM. When at-risk women become pregnant, they require closer surveillance for maternal and fetal well-being, and should follow a strict diet and adhere to weight gain control to avoid obstetric complications due to GDM.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>26488176</pmid><doi>10.1371/journal.pone.0140544</doi><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; DOAJ Directory of Open Access Journals; Public Library of Science (PLoS); EZB-FREE-00999 freely available EZB journals; PubMed Central; Free Full-Text Journals in Chemistry |
| subjects | Adolescent Adult Analysis Body weight gain Care and treatment Comorbidity Complications Diabetes mellitus Diabetes, Gestational - epidemiology Diagnosis Drugs Economic analysis Female Fetuses Gestational diabetes Glucose Health aspects Humans Hypoglycemic Agents - therapeutic use Metformin - therapeutic use Middle Aged Polycystic ovary syndrome Polycystic Ovary Syndrome - drug therapy Polycystic Ovary Syndrome - epidemiology Population studies Population-based studies Pregnancy Pregnancy complications Pregnant women Regression analysis Risk Factors Risk reduction Studies Taiwan Ultrasound Ultrasound imaging Well being Womens health Young Adult |
| title | Relationship between Polycystic Ovarian Syndrome and Subsequent Gestational Diabetes Mellitus: A Nationwide Population-Based Study |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-05T19%3A30%3A00IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_plos_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Relationship%20between%20Polycystic%20Ovarian%20Syndrome%20and%20Subsequent%20Gestational%20Diabetes%20Mellitus:%20A%20Nationwide%20Population-Based%20Study&rft.jtitle=PloS%20one&rft.au=Pan,%20Mei-Lien&rft.date=2015-10-21&rft.volume=10&rft.issue=10&rft.spage=e0140544&rft.epage=e0140544&rft.pages=e0140544-e0140544&rft.issn=1932-6203&rft.eissn=1932-6203&rft_id=info:doi/10.1371/journal.pone.0140544&rft_dat=%3Cgale_plos_%3EA432225105%3C/gale_plos_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1725018413&rft_id=info:pmid/26488176&rft_galeid=A432225105&rft_doaj_id=oai_doaj_org_article_a6ac3bfbcb9440e58883afae3524995f&rfr_iscdi=true |