{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,2]],"date-time":"2026-11-02T18:26:23Z","timestamp":1793643983256,"version":"4.5.1"},"reference-count":44,"publisher":"Springer Science and Business Media LLC","issue":"14","license":[{"start":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T00:00:00Z","timestamp":1769731200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T00:00:00Z","timestamp":1769731200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"publisher","award":["RD24\/0003\/0019"],"award-info":[{"award-number":["RD24\/0003\/0019"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"publisher","award":["RD21\/0009\/0004"],"award-info":[{"award-number":["RD21\/0009\/0004"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Universitat Aut\u00f2noma de Barcelona","id":[{"id":"https:\/\/ror.org\/052g8jq94","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J GEN INTERN MED"],"published-print":{"date-parts":[[2026,11]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Alcohol use disorder (AUD) is associated with many health consequences, including cardiomyopathy with impaired systolic function, liver disease, and metabolic disturbances.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>We aimed to study the main echocardiographic abnormalities in otherwise asymptomatic individuals with AUD admitted for inpatient treatment, and to assess their associations with advanced liver fibrosis and insulin resistance, including their interaction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A cross-sectional study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Individuals with AUD admitted for inpatient treatment between 2019 and 2024 in a university hospital in Spain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main measures<\/jats:title>\n                    <jats:p>We ascertained demographic information, alcohol use characteristics, anthropometric measurements, blood test parameters, and echocardiography findings upon admission. We estimated liver fibrosis with the FIB-4 index and insulin resistance with the triglyceride (TG)\/HDL ratio. We performed multivariate logistic regression analyses to assess the main associations between cardiac abnormalities, advanced liver fibrosis, and insulin resistance.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We included 145 individuals (28% women), with a median age of 53\u00a0years [Interquartile range (IQR) 48\u201358\u00a0years], daily alcohol consumption of 10.3 standard drink units (SDU) [IQR 6.8\u201316.30 SDU], and body mass index of 25.8\u00a0kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      [IQR 22.9\u201330.0\u00a0kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      ]. Among them, 33% had hypertension and 14% had diabetes. The most common echocardiographic abnormality was diastolic dysfunction, which was present in 96 patients (66%), while systolic impairment was detected only in 7 cases (5%). Advanced liver fibrosis (FIB-4\u2009&gt;\u20093.25) was more prevalent in those with diastolic dysfunction (\n                      <jats:italic>p<\/jats:italic>\n                      -value\u2009=\u20090.010). In the multivariate logistic regression analysis, advanced liver fibrosis and TG\/HDL ratio\u2009\u2265\u20093 were independently associated with diastolic dysfunction, with an OR of 3.53 (95% confidence interval (CI)1.20\u201310.41) and 4.55 (95% CI 1.57\u201313.22), respectively. However, no interaction between them was found (\n                      <jats:italic>p<\/jats:italic>\n                      -value for interaction\u2009=\u20090.92).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Diastolic dysfunction is a common finding in apparently asymptomatic individuals with AUD admitted for inpatient treatment, and it is independently associated with advanced liver fibrosis and insulin resistance.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11606-025-10106-7","type":"journal-article","created":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T14:27:17Z","timestamp":1769783237000},"page":"4112-4120","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Diastolic Dysfunction is Associated with Liver Fibrosis and Insulin Resistance in Alcohol Use Disorder"],"prefix":"10.1007","volume":"41","author":[{"given":"Anna","family":"Hern\u00e1ndez-Rubio","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Ceballos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xavier","family":"Garc\u00eda-Calvo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paola","family":"Zuluaga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javier","family":"L\u00f3pez-Ayerbe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Faconti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Muga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1262-5860","authenticated-orcid":false,"given":"Daniel","family":"Fuster","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,30]]},"reference":[{"key":"10106_CR1","unstructured":"World Health Organization. Global Status Report on Alcohol and Health and Treatment of Substance Use Disorders.; 2024."},{"key":"10106_CR2","doi-asserted-by":"publisher","unstructured":"Bryazka D, Reitsma MB, Griswold MG, et al. Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020. Lancet. 2022;400(10347):185-235. https:\/\/doi.org\/10.1016\/S0140-6736(22)00847-9.","DOI":"10.1016\/S0140-6736(22)00847-9"},{"key":"10106_CR3","doi-asserted-by":"publisher","unstructured":"Haber PS. Identification and Treatment of Alcohol Use Disorder. N Engl J Med. 2025;392(3):258-266. https:\/\/doi.org\/10.1056\/NEJMra2306511.","DOI":"10.1056\/NEJMra2306511"},{"key":"10106_CR4","doi-asserted-by":"publisher","unstructured":"Fuster D, Samet JH. Alcohol Use in Patients with Chronic Liver Disease. N Engl J Med. Published online 2018. https:\/\/doi.org\/10.1056\/nejmra1715733.","DOI":"10.1056\/nejmra1715733"},{"key":"10106_CR5","doi-asserted-by":"publisher","unstructured":"Kim SJ, Kim DJ. Alcoholism and diabetes mellitus. Diabetes Metab J. 2012;36(2):108-115. https:\/\/doi.org\/10.4093\/DMJ.2012.36.2.108.","DOI":"10.4093\/DMJ.2012.36.2.108"},{"key":"10106_CR6","doi-asserted-by":"publisher","unstructured":"Hern\u00e1ndez-Rubio A, Sanvisens A, Bolao F, et al. Prevalence and associations of metabolic syndrome in patients with alcohol use disorder. Sci Rep. 2022;12(1):2625. https:\/\/doi.org\/10.1038\/s41598-022-06010-3.","DOI":"10.1038\/s41598-022-06010-3"},{"key":"10106_CR7","doi-asserted-by":"publisher","unstructured":"Ju A, Cheon Y-H, Lee K-S, et al. The change of plasma ghrelin and leptin levels by the development of type 2 diabetes mellitus in patients with alcohol dependence. Alcohol Clin Exp Res. 2011;35(5):905-911. https:\/\/doi.org\/10.1111\/j.1530-0277.2010.01420.x.","DOI":"10.1111\/j.1530-0277.2010.01420.x"},{"key":"10106_CR8","doi-asserted-by":"publisher","unstructured":"Biddinger KJ, Emdin CA, Haas ME, et al. Association of Habitual Alcohol Intake with Risk of Cardiovascular Disease. JAMA Netw Open. 2022;5(3):E223849. https:\/\/doi.org\/10.1001\/JAMANETWORKOPEN.2022.3849.","DOI":"10.1001\/JAMANETWORKOPEN.2022.3849"},{"key":"10106_CR9","doi-asserted-by":"publisher","unstructured":"Holmes M V, Dale CE, Zuccolo L, et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014;349:g4164.https:\/\/doi.org\/10.1136\/bmj.g4164.","DOI":"10.1136\/bmj.g4164"},{"key":"10106_CR10","doi-asserted-by":"publisher","unstructured":"Guzzo-Merello G, Segovia J, Dominguez F, et al. Natural history and prognostic factors in alcoholic cardiomyopathy. JACC Heart Fail. 2015;3(1):78-86. https:\/\/doi.org\/10.1016\/j.jchf.2014.07.014.","DOI":"10.1016\/j.jchf.2014.07.014"},{"key":"10106_CR11","doi-asserted-by":"publisher","unstructured":"Rehm J, Hasan OSM, Imtiaz S, Neufeld M. Quantifying the contribution of alcohol to cardiomyopathy: A systematic review. Alcohol. 2017;61:9-15. https:\/\/doi.org\/10.1016\/j.alcohol.2017.01.011.","DOI":"10.1016\/j.alcohol.2017.01.011"},{"key":"10106_CR12","doi-asserted-by":"publisher","unstructured":"Fern\u00e1ndez-Sol\u00e0 J. The Effects of Ethanol on the Heart: Alcoholic Cardiomyopathy. Nutrients. 2020;12(2). https:\/\/doi.org\/10.3390\/nu12020572.","DOI":"10.3390\/nu12020572"},{"key":"10106_CR13","doi-asserted-by":"publisher","unstructured":"Luo Y, Yin S, Chen Q, Liu J, Chong Y, Zhong J. Comparison of the 2005 Montreal Criteria and the 2019 Cirrhotic Cardiomyopathy Consortium Criteria for the Diagnosis of Cirrhotic Cardiomyopathy. Am J Cardiol. 2023;208:180-189. https:\/\/doi.org\/10.1016\/j.amjcard.2023.09.069.","DOI":"10.1016\/j.amjcard.2023.09.069"},{"key":"10106_CR14","doi-asserted-by":"crossref","unstructured":"American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V). 5th ed.; 2013.","DOI":"10.1176\/appi.books.9780890425596"},{"key":"10106_CR15","doi-asserted-by":"publisher","unstructured":"Fuster D, Garcia-Calvo X, Zuluaga P, et al. Ultrasound findings of liver damage in a series of patients consecutively admitted for treatment of alcohol use disorder. Drug Alcohol Depend. 2018;190:195-199. https:\/\/doi.org\/10.1016\/j.drugalcdep.2018.06.012.","DOI":"10.1016\/j.drugalcdep.2018.06.012"},{"key":"10106_CR16","doi-asserted-by":"publisher","unstructured":"Miller WR, Heather N, Hall W. Calculating standard drink units: international comparisons. Br J Addict. 1991;86(1):43-47. https:\/\/doi.org\/10.1111\/j.1360-0443.1991.tb02627.x.","DOI":"10.1111\/j.1360-0443.1991.tb02627.x"},{"key":"10106_CR17","doi-asserted-by":"publisher","unstructured":"Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV\/HCV coinfection. Hepatology. 2006;43(6):1317-1325. https:\/\/doi.org\/10.1002\/hep.21178.","DOI":"10.1002\/hep.21178"},{"key":"10106_CR18","doi-asserted-by":"publisher","unstructured":"EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol. 2024;81(3):492\u2013542. https:\/\/doi.org\/10.1016\/j.jhep.2024.04.031.","DOI":"10.1016\/j.jhep.2024.04.031"},{"key":"10106_CR19","doi-asserted-by":"publisher","unstructured":"McLaughlin T, Abbasi F, Cheal K, Chu J, Lamendola C, Reaven G. Use of metabolic markers to identify overweight individuals who are insulin resistant. Ann Intern Med. 2003;139(10):802-809. https:\/\/doi.org\/10.7326\/0003-4819-139-10-200311180-00007.","DOI":"10.7326\/0003-4819-139-10-200311180-00007"},{"key":"10106_CR20","doi-asserted-by":"publisher","unstructured":"Kosmas CE, Rodriguez Polanco S, Bousvarou MD, et al. The Triglyceride\/High-Density Lipoprotein Cholesterol (TG\/HDL-C) Ratio as a Risk Marker for Metabolic Syndrome and Cardiovascular Disease. Diagnostics (Basel, Switzerland). 2023;13(5). https:\/\/doi.org\/10.3390\/diagnostics13050929.","DOI":"10.3390\/diagnostics13050929"},{"key":"10106_CR21","doi-asserted-by":"publisher","unstructured":"Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Hear journal Cardiovasc Imaging. 2015;16(3):233-270. https:\/\/doi.org\/10.1093\/ehjci\/jev014.","DOI":"10.1093\/ehjci\/jev014"},{"key":"10106_CR22","doi-asserted-by":"publisher","unstructured":"Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Hear journal Cardiovasc Imaging. 2016;17(12):1321-1360. https:\/\/doi.org\/10.1093\/ehjci\/jew082.","DOI":"10.1093\/ehjci\/jew082"},{"key":"10106_CR23","doi-asserted-by":"publisher","unstructured":"McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45(38):3912-4018.https:\/\/doi.org\/10.1093\/eurheartj\/ehae178.","DOI":"10.1093\/eurheartj\/ehae178"},{"key":"10106_CR24","doi-asserted-by":"publisher","unstructured":"Kuznetsova T, Herbots L, L\u00f3pez B, et al. Prevalence of left ventricular diastolic dysfunction in a general population. Circ Heart Fail. 2009;2(2):105-112. https:\/\/doi.org\/10.1161\/CIRCHEARTFAILURE.108.822627.","DOI":"10.1161\/CIRCHEARTFAILURE.108.822627"},{"key":"10106_CR25","doi-asserted-by":"publisher","unstructured":"Lazarevi\u0107 AM, Nakatani S, Neskovi\u0107 AN, et al. Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking. J Am Coll Cardiol. 2000;35(6):1599-1606. https:\/\/doi.org\/10.1016\/s0735-1097(00)00565-9.","DOI":"10.1016\/s0735-1097(00)00565-9"},{"key":"10106_CR26","unstructured":"Av\u015faroglu D, Inal TC, Demir M, et al. Biochemical indicators and cardiac function tests in chronic alcohol abusers. Croat Med J. 2005;46(2):233-237."},{"key":"10106_CR27","doi-asserted-by":"publisher","unstructured":"Ho CY, Solomon SD. A clinician\u2019s guide to tissue Doppler imaging. Circulation. 2006;113(10):e396-8. https:\/\/doi.org\/10.1161\/CIRCULATIONAHA.105.579268.","DOI":"10.1161\/CIRCULATIONAHA.105.579268"},{"key":"10106_CR28","doi-asserted-by":"publisher","unstructured":"Park SK, Moon K, Ryoo J-H, et al. The association between alcohol consumption and left ventricular diastolic function and geometry change in general Korean population. Eur Hear journal Cardiovasc Imaging. 2018;19(3):271-278. https:\/\/doi.org\/10.1093\/ehjci\/jex091.","DOI":"10.1093\/ehjci\/jex091"},{"key":"10106_CR29","doi-asserted-by":"publisher","unstructured":"Rodrigues P, Santos-Ribeiro S, Teodoro T, et al. Association Between Alcohol Intake and Cardiac Remodeling. J Am Coll Cardiol. 2018;72(13):1452-1462. https:\/\/doi.org\/10.1016\/j.jacc.2018.07.050.","DOI":"10.1016\/j.jacc.2018.07.050"},{"key":"10106_CR30","doi-asserted-by":"publisher","unstructured":"Kasper EK, Agema WR, Hutchins GM, Deckers JW, Hare JM, Baughman KL. The causes of dilated cardiomyopathy: a clinicopathologic review of 673 consecutive patients. J Am Coll Cardiol. 1994;23(3):586-590. https:\/\/doi.org\/10.1016\/0735-1097(94)90740-4.","DOI":"10.1016\/0735-1097(94)90740-4"},{"key":"10106_CR31","doi-asserted-by":"publisher","unstructured":"Dom\u00ednguez F, Adler E, Garc\u00eda-Pav\u00eda P. Alcoholic cardiomyopathy: an update. Eur Heart J. 2024;45(26):2294-2305. https:\/\/doi.org\/10.1093\/eurheartj\/ehae362.","DOI":"10.1093\/eurheartj\/ehae362"},{"key":"10106_CR32","doi-asserted-by":"publisher","unstructured":"Urbano-M\u00e1rquez A, Fern\u00e1ndez-Sol\u00e0 J. Effects of alcohol on skeletal and cardiac muscle. Muscle Nerve. 2004;30(6):689-707. https:\/\/doi.org\/10.1002\/mus.20168.","DOI":"10.1002\/mus.20168"},{"key":"10106_CR33","doi-asserted-by":"publisher","unstructured":"Li X, Nie Y, Lian H, Hu S. Histopathologic features of alcoholic cardiomyopathy compared with idiopathic dilated cardiomyopathy. Medicine (Baltimore). 2018;97(39):e12259.https:\/\/doi.org\/10.1097\/MD.0000000000012259.","DOI":"10.1097\/MD.0000000000012259"},{"key":"10106_CR34","doi-asserted-by":"publisher","unstructured":"Ndakotsu A, Nduka TC, Agrawal S, Asuka E. Cirrhotic cardiomyopathy: comprehensive insights into pathophysiology, diagnosis, and management. Heart Fail Rev. Published online March 2025. https:\/\/doi.org\/10.1007\/s10741-025-10500-7.","DOI":"10.1007\/s10741-025-10500-7"},{"key":"10106_CR35","doi-asserted-by":"publisher","unstructured":"So-Armah KA, Lim JK, Lo Re V III, et al. FIB-4 stage of liver fibrosis is associated with incident heart failure with preserved, but not reduced, ejection fraction among people with and without HIV or hepatitis C. Prog Cardiovasc Dis. 2020;63(2):184\u2013191. https:\/\/doi.org\/10.1016\/j.pcad.2020.02.010.","DOI":"10.1016\/j.pcad.2020.02.010"},{"key":"10106_CR36","doi-asserted-by":"crossref","unstructured":"Kim G, Yu TY, Jee JH, Bae JC, Kang M, Kim JH. Association between nonalcoholic fatty liver disease and left ventricular diastolic dysfunction: A 7-year retrospective cohort study of 3,380 adults using serial echocardiography. Diabetes Metab. 2024;50(3):101534. https:\/\/doi.org\/10.1016\/j.diabet.2024.101534.","DOI":"10.1016\/j.diabet.2024.101534"},{"key":"10106_CR37","doi-asserted-by":"publisher","unstructured":"Mili\u0107 S, Luli\u0107 D, \u0160timac D, Ru\u017ei\u0107 A, Zaputovi\u0107 L. Cardiac manifestations in alcoholic liver disease. Postgrad Med J. 2016;92(1086):235-239. https:\/\/doi.org\/10.1136\/postgradmedj-2015-133755.","DOI":"10.1136\/postgradmedj-2015-133755"},{"key":"10106_CR38","doi-asserted-by":"publisher","unstructured":"Dhand R, Okumura K, Wolfe K, et al. Alcoholic Cardiomyopathy in Patients With Advanced Alcoholic Liver Disease: Single-Center Experience and Review of Literature. Cardiol Rev. Published online February 2025. https:\/\/doi.org\/10.1097\/CRD.0000000000000880.","DOI":"10.1097\/CRD.0000000000000880"},{"key":"10106_CR39","doi-asserted-by":"publisher","unstructured":"Sultani R, Tong DC, Peverelle M, Lee YS, Baradi A, Wilson AM. Elevated Triglycerides to High-Density Lipoprotein Cholesterol (TG\/HDL-C) Ratio Predicts Long-Term Mortality in High-Risk Patients. Heart Lung Circ. 2020;29(3):414-421. https:\/\/doi.org\/10.1016\/j.hlc.2019.03.019.","DOI":"10.1016\/j.hlc.2019.03.019"},{"key":"10106_CR40","doi-asserted-by":"crossref","unstructured":"Gratac\u00f3s-Gin\u00e8s J, Ari\u00f1o S, Sancho-Bru P, Bataller R, Pose E. MetALD: Clinical aspects, pathophysiology and treatment. JHEP reports Innov Hepatol. 2025;7(2):101250. https:\/\/doi.org\/10.1016\/j.jhepr.2024.101250.","DOI":"10.1016\/j.jhepr.2024.101250"},{"key":"10106_CR41","doi-asserted-by":"publisher","unstructured":"Fontes-Carvalho R, Ladeiras-Lopes R, Bettencourt P, Leite-Moreira A, Azevedo A. Diastolic dysfunction in the diabetic continuum: association with insulin resistance, metabolic syndrome and type 2 diabetes. Cardiovasc Diabetol. 2015;14:4. https:\/\/doi.org\/10.1186\/s12933-014-0168-x.","DOI":"10.1186\/s12933-014-0168-x"},{"key":"10106_CR42","doi-asserted-by":"publisher","unstructured":"Zhao D, Wang Y, Wong ND, Wang J. Impact of Aging on Cardiovascular Diseases: From Chronological Observation to Biological Insights: JACC Family Series. JACC Asia. 2024;4(5):345-358. https:\/\/doi.org\/10.1016\/j.jacasi.2024.02.002.","DOI":"10.1016\/j.jacasi.2024.02.002"},{"key":"10106_CR43","doi-asserted-by":"publisher","unstructured":"Kane GC, Karon BL, Mahoney DW, et al. Progression of left ventricular diastolic dysfunction and risk of heart failure. JAMA. 2011;306(8):856-863. https:\/\/doi.org\/10.1001\/jama.2011.1201.","DOI":"10.1001\/jama.2011.1201"},{"key":"10106_CR44","doi-asserted-by":"publisher","unstructured":"World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. https:\/\/doi.org\/10.1001\/jama.2013.281053.","DOI":"10.1001\/jama.2013.281053"}],"container-title":["Journal of General Internal Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-025-10106-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11606-025-10106-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-025-10106-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,11,2]],"date-time":"2026-11-02T17:29:53Z","timestamp":1793640593000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11606-025-10106-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,30]]},"references-count":44,"journal-issue":{"issue":"14","published-print":{"date-parts":[[2026,11]]}},"alternative-id":["10106"],"URL":"https:\/\/doi.org\/10.1007\/s11606-025-10106-7","relation":{},"ISSN":["0884-8734","1525-1497"],"issn-type":[{"value":"0884-8734","type":"print"},{"value":"1525-1497","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,30]]},"assertion":[{"value":"11 August 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"9 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 January 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The Ethics Committee-Institutional Review Board of the center approved the study (approval number CEXT042013). The methods used in this study complied with the ethical standards for medical research and the principles of good clinical practice established in the Declaration of Helsinki.\n                      44","order":1,"name":"Ethics","label":"Human ethics and consent to participate declarations","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}