{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T02:32:19Z","timestamp":1788402739401,"version":"build-2803163510"},"reference-count":52,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2020,11,14]],"date-time":"2020-11-14T00:00:00Z","timestamp":1605312000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004663","name":"Ministry of Science and Technology, Taiwan","doi-asserted-by":"publisher","award":["MOST109-2314-B-038-024"],"award-info":[{"award-number":["MOST109-2314-B-038-024"]}],"id":[{"id":"10.13039\/501100004663","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Shuang Ho Hospital, Taipei Medical University","award":["109IIT-02"],"award-info":[{"award-number":["109IIT-02"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Patients with dementia are predisposed to multiple physiological abnormalities. It is uncertain if dementia associates with higher rates of perioperative mortality and morbidity. We used reimbursement claims data of Taiwan\u2019s National Health Insurance and conducted propensity score matching analyses to evaluate the risk of mortality and major complications in patients with or without dementia undergoing major surgery between 2004 and 2013. We applied multivariable logistic regressions to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for the outcome of interest. After matching to demographic and clinical covariates, 7863 matched pairs were selected for analysis. Dementia was significantly associated with greater risks of 30-day in-hospital mortality (aOR: 1.71, 95% CI: 1.09\u20132.70), pneumonia (aOR: 1.48, 95% CI: 1.16\u20131.88), urinary tract infection (aOR: 1.59, 95% CI: 1.30\u20131.96), and sepsis (OR: 1.77, 95% CI: 1.34\u20132.34) compared to non-dementia controls. The mortality risk in dementia patients was attenuated but persisted over time, 180 days (aOR: 1.49, 95% CI: 1.23\u20131.81) and 365 days (aOR: 1.52, 95% CI: 1.30\u20131.78) after surgery. Additionally, patients with dementia were more likely to receive blood transfusion (aOR: 1.32, 95% CI: 1.11\u20131.58) and to need intensive care (aOR: 1.40, 95% CI: 1.12\u20131.76) compared to non-dementia controls. Senile dementia and Alzheimer\u2019s disease were independently associated with higher rates of perioperative mortality and complications, but vascular dementia was not affected. We found that preexisting dementia was associated with mortality and morbidity after major surgery.<\/jats:p>","DOI":"10.3390\/ijerph17228431","type":"journal-article","created":{"date-parts":[[2020,11,16]],"date-time":"2020-11-16T11:04:20Z","timestamp":1605524660000},"page":"8431","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study"],"prefix":"10.3390","volume":"17","author":[{"given":"Yu-Ming","family":"Wu","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hsien-Cheng","family":"Kuo","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chun-Cheng","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hsiang-Ling","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Taipei Veterans General Hospital, Taipei 11217, Taiwan"},{"name":"School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jui-Tai","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yih-Giun","family":"Cherng","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8350-0232","authenticated-orcid":false,"given":"Tzeng-Ji","family":"Chen","sequence":"additional","affiliation":[{"name":"School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan"},{"name":"Department of Family Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3279-4509","authenticated-orcid":false,"given":"Ying-Xiu","family":"Dai","sequence":"additional","affiliation":[{"name":"School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan"},{"name":"Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hsin-Yi","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5210-6873","authenticated-orcid":false,"given":"Ying-Hsuan","family":"Tai","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan"},{"name":"Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,11,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"217","DOI":"10.2147\/CLEP.S186590","article-title":"Epidemiology of dementia: Prevalence and incidence estimates using validated electronic health records from primary care","volume":"11","author":"Ponjoan","year":"2019","journal-title":"Clin. Epidemiol."},{"key":"ref_2","unstructured":"Martin Prince, A., Wimo, A., and Guerchet, M. (2015). World Alzheimer Report 2015: The Global Impact of Dementia an Analysis of Prevalence, Incidence, Cost and Trends, Alzheimer\u2019s Disease International."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1111\/anae.14530","article-title":"Guidelines for the peri-operative care of people with dementia: Guidelines from the Association of Anaesthetists","volume":"74","author":"White","year":"2019","journal-title":"Anaesthesia"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1529","DOI":"10.1056\/NEJMoa0902234","article-title":"The clinical course of advanced dementia","volume":"361","author":"Mitchell","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1002\/jcsm.12380","article-title":"Cachexia and advanced dementia","volume":"10","author":"Minaglia","year":"2019","journal-title":"J. Cachexia Sarcopenia Muscle"},{"key":"ref_6","first-page":"682","article-title":"Adverse surgical outcomes among patients with cognitive impairments","volume":"57","author":"Bernstein","year":"1991","journal-title":"Am. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2119","DOI":"10.1007\/s00264-013-2068-1","article-title":"Predictors of early mortality after hip fracture surgery","volume":"37","author":"Khan","year":"2013","journal-title":"Int. Orthop."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1016\/j.avsg.2016.05.136","article-title":"Dementia in patients suffering from critical limb ischemia","volume":"38","author":"Steunenberg","year":"2017","journal-title":"Ann. Vasc. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Kassahun, W.T. (2018). The effects of pre-existing dementia on surgical outcomes in emergent and nonemergent general surgical procedures: Assessing differences in surgical risk with dementia. BMC. Geriatr., 18.","DOI":"10.1186\/s12877-018-0844-x"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1016\/j.jamda.2013.12.011","article-title":"Effects of dementia on postoperative outcomes of older adults with hip fractures: A population-based study","volume":"15","author":"Seitz","year":"2014","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1511","DOI":"10.1007\/s00402-015-2321-8","article-title":"Association between dementia and postoperative complications after hip fracture surgery in the elderly: Analysis of 87,654 patients using a national administrative database","volume":"135","author":"Tsuda","year":"2015","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1131","DOI":"10.1016\/j.jaad.2019.11.064","article-title":"Bidirectional association between alopecia areata and major depressive disorder among probands and unaffected siblings: A nationwide population-based study","volume":"82","author":"Dai","year":"2020","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1510","DOI":"10.1111\/jdv.16225","article-title":"Increased risk of major depressive disorder among probands with psoriasis and unaffected siblings: A nationwide population-based study","volume":"34","author":"Dai","year":"2020","journal-title":"J. Eur. Acad. Dermatol. Venereol."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Dai, Y.X., Yeh, F.Y., Shen, Y.J., Tai, Y.H., Chou, Y.J., Chang, Y.T., Chen, T.J., Li, C.P., and Wu, C.Y. (2020). Cigarette smoking, alcohol consumption, and risk of alopecia areata: A population-based cohort study in Taiwan. Am. J. Clin. Dermatol, (Epub ahead of print).","DOI":"10.1007\/s40257-020-00547-7"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Tai, Y.H., Chen, T.L., Cherng, Y.G., Yeh, C.C., Chang, C.C., and Liao, C.C. (2019). Previous use of mammography as a proxy for general health checks in association with better outcomes after major surgeries. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16224432"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1235","DOI":"10.2147\/CLEP.S261179","article-title":"Long-term risk of stroke and poststroke outcomes in patients with heart failure: Two nationwide studies","volume":"12","author":"Tai","year":"2020","journal-title":"Clin. Epidemiol."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Zhang, B., Wang, H.E., Bai, Y.M., Tsai, S.J., Su, T.P., Chen, T.J., Wang, Y.P., and Chen, M.H. (2020). Inflammatory bowel disease is associated with higher dementia risk: A nationwide longitudinal study. Gut, (Epub ahead of print).","DOI":"10.1136\/gutjnl-2020-320789"},{"key":"ref_18","unstructured":"National Health Insurance Research Database (2020, November 11). Data Subsets. Available online: https:\/\/nhird.nhri.org.tw\/en\/Data_Subsets.html."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1589","DOI":"10.1001\/jama.2019.4782","article-title":"Diagnosis and management of dementia: Review","volume":"322","author":"Arvanitakis","year":"2019","journal-title":"JAMA"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1097\/00000658-199810000-00006","article-title":"The Department of Veterans Affairs\u2019 NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program","volume":"228","author":"Khuri","year":"1998","journal-title":"Ann. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1503\/cmaj.131547","article-title":"Sleep apnea and risk of pneumonia: A nationwide population-based study","volume":"186","author":"Su","year":"2014","journal-title":"CMAJ"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"500","DOI":"10.2188\/jea.JE20140076","article-title":"Validation of acute myocardial infarction cases in the national health insurance research database in Taiwan","volume":"24","author":"Cheng","year":"2014","journal-title":"J. Epidemiol."},{"key":"ref_23","first-page":"254","article-title":"Validating the diagnosis of acute ischemic stroke in a National Health Insurance claims database","volume":"114","author":"Hsieh","year":"2015","journal-title":"J. Med. Assoc."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.ejca.2020.09.004","article-title":"The association of non-small-cell lung cancer recurrence with allogenic blood transfusion following surgical resection: A propensity score analysis of 1,803 patients","volume":"140","author":"Tai","year":"2020","journal-title":"Eur. J. Cancer"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1111\/anae.14862","article-title":"The association of allogeneic blood transfusion and the recurrence of hepatic cancer after surgical resection","volume":"75","author":"Tai","year":"2020","journal-title":"Anaesthesia"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"13345","DOI":"10.1038\/s41598-018-31662-5","article-title":"The impact of blood transfusion on recurrence and mortality following colorectal cancer resection: A propensity score analysis of 4030 patients","volume":"8","author":"Wu","year":"2018","journal-title":"Sci. Rep."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1080\/00273171.2011.568786","article-title":"An introduction to propensity score methods for reducing the effects of confounding in observational studies","volume":"46","author":"Austin","year":"2011","journal-title":"Multivar. Behav. Res."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"3083","DOI":"10.1002\/sim.3697","article-title":"Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples","volume":"28","author":"Austin","year":"2009","journal-title":"Stat. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e143","DOI":"10.1111\/anae.14786","article-title":"More than just morbidity and mortality-quality of recovery and long-term functional recovery after surgery","volume":"75","author":"Myles","year":"2020","journal-title":"Anaesthesia"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1093\/bja\/aex130","article-title":"Postoperative delirium in elderly patients is associated with subsequent cognitive impairment","volume":"119","author":"Sprung","year":"2017","journal-title":"Br. J. Anaesth."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1016\/j.bja.2020.04.072","article-title":"Preoperative cognitive dysfunction in older elective noncardiac surgical patients in South Africa","volume":"125","author":"Amado","year":"2020","journal-title":"Br. J. Anaesth."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1224","DOI":"10.1097\/ALN.0000000000000671","article-title":"Preexisting cognitive impairment is associated with postoperative cognitive dysfunction after hip joint replacement surgery","volume":"122","author":"Silbert","year":"2015","journal-title":"Anesthesiology"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1097\/ALN.0000000000002849","article-title":"Postoperative delirium is associated with long-term decline in activities of daily living","volume":"131","author":"Shi","year":"2019","journal-title":"Anesthesiology"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"341.e15","DOI":"10.1016\/j.urolonc.2018.04.012","article-title":"A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries","volume":"36","author":"Ha","year":"2018","journal-title":"Urol. Oncol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1663","DOI":"10.1016\/j.athoracsur.2015.12.074","article-title":"The impact of delirium after cardiac surgical procedures on postoperative resource use","volume":"101","author":"Brown","year":"2016","journal-title":"Ann. Thorac. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1016\/j.bja.2017.12.046","article-title":"Postoperative delirium in total knee and hip arthroplasty patients: A study of perioperative modifiable risk factors","volume":"120","author":"Weinstein","year":"2018","journal-title":"Br. J. Anaesth."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"18","DOI":"10.4065\/mcp.2009.0469","article-title":"Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair","volume":"85","author":"Sieber","year":"2010","journal-title":"Mayo Clin. Proc."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1001\/jama.2018.22005","article-title":"Effect of electroencephalography-guided anesthetic administration on postoperative delirium among older adults undergoing major surgery: The ENGAGES randomized clinical trial","volume":"321","author":"Wildes","year":"2019","journal-title":"JAMA"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e020757","DOI":"10.1136\/bmjopen-2017-020757","article-title":"Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: A systematic review","volume":"8","author":"Patel","year":"2018","journal-title":"BMJ. Open"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1097\/ALN.0000000000000951","article-title":"Dexmedetomidine versus propofol sedation reduces delirium after cardiac surgery: A randomized controlled trial","volume":"124","author":"Djaiani","year":"2016","journal-title":"Anesthesiology"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1038\/ni.3102","article-title":"Innate immunity in Alzheimer\u2019s disease","volume":"16","author":"Heneka","year":"2015","journal-title":"Nat. Immunol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"385","DOI":"10.3233\/JAD-170602","article-title":"Cerebrospinal fluid and plasma levels of inflammation differentially relate to CNS markers of Alzheimer\u2019s disease pathology and neuronal damage","volume":"62","author":"Bettcher","year":"2018","journal-title":"J. Alzheimer\u2019s Dis"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Degersk\u00e4r, A.N.W., and Englund, E.M. (2020). Cause of death in autopsy-confirmed dementia disorders. Eur. J. Neurol., (Epub ahead of print).","DOI":"10.1111\/ene.14450"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1227","DOI":"10.1038\/mp.2013.178","article-title":"An anemia of Alzheimer\u2019s disease","volume":"19","author":"Faux","year":"2014","journal-title":"Mol. Psychiatry"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e917","DOI":"10.1212\/WNL.0000000000008003","article-title":"Hemoglobin and anemia in relation to dementia risk and accompanying changes on brain MRI","volume":"93","author":"Wolters","year":"2019","journal-title":"Neurology"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1385","DOI":"10.1164\/rccm.201807-1220OC","article-title":"Impaired Lung Function, Lung Disease, and Risk of Incident Dementia","volume":"199","author":"Lutsey","year":"2019","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"S63","DOI":"10.1016\/j.jalz.2012.10.010","article-title":"Differences in rate of functional decline across three dementia types","volume":"9","author":"Gill","year":"2013","journal-title":"Alzheimer\u2019s Dement"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"907","DOI":"10.2169\/internalmedicine.56.7879","article-title":"Factors associated with pneumonia-caused death in older adults with autopsy-confirmed dementia","volume":"56","author":"Manabe","year":"2017","journal-title":"Intern. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"908","DOI":"10.1002\/alz.12091","article-title":"Age-stratified longitudinal study of Alzheimer\u2019s and vascular dementia patients","volume":"16","author":"Lademann","year":"2020","journal-title":"Alzheimer\u2019s Dement"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"7","DOI":"10.31887\/DCNS.2003.5.1\/rravonaspringer","article-title":"Is the distinction between Alzheimer\u2019s disease and vascular dementia possible and relevant?","volume":"5","author":"Davidson","year":"2003","journal-title":"Dialogues Clin. Neurosci."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1136\/bmj.39433.616678.25","article-title":"Survival times in people with dementia: Analysis from population based cohort study with 14 year follow-up","volume":"336","author":"Xie","year":"2008","journal-title":"BMJ"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1097\/WAD.0000000000000274","article-title":"Nutritional status is associated with severe dementia and mortality: The Cache County Dementia Progression Study","volume":"32","author":"Sanders","year":"2018","journal-title":"Alzheimer\u2019s Dis. Assoc. Disord"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/22\/8431\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:33:21Z","timestamp":1760178801000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/22\/8431"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,11,14]]},"references-count":52,"journal-issue":{"issue":"22","published-online":{"date-parts":[[2020,11]]}},"alternative-id":["ijerph17228431"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17228431","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,11,14]]}}}