{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T00:45:16Z","timestamp":1774485916241,"version":"3.50.1"},"reference-count":42,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2021,11,28]],"date-time":"2021-11-28T00:00:00Z","timestamp":1638057600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>(1) Objective: To investigate changes in mortality rates and predictors of all-cause mortality as well as specific causes of death over time among HIV-positive individuals in the combination antiretroviral therapy (cART) era. (2) Methods: We analyzed all-cause as well as cause-specific mortality among the Austrian HIV Cohort Study between 1997 and 2014. Observation time was divided into five periods: Period 1: 1997\u20132000; period 2: 2001\u20132004; period 3: 2005\u20132008; period 4: 2009\u20132011; and period 5: 2012\u20132014. Mortality rates are presented as deaths per 100 person-years (d\/100py). Potential risk factors associated with all-cause mortality and specific causes of death were identified by using multivariable Cox proportional hazard models. Models were adjusted for time-updated CD4, age and cART, HIV transmission category, population size of residence area and country of birth. To assess potential nonlinear associations, we fitted all CD4 counts per patient using restricted cubic splines with truncation at 1000 cells\/mm3. Vital status of patients was cross-checked with death registry data. (3) Results: Of 6848 patients (59,704 person-years of observation), 1192 died: 380 (31.9%) from AIDS-related diseases. All-cause mortality rates decreased continuously from 3.49 d\/100py in period 1 to 1.40 d\/100py in period 5. Death due to AIDS-related diseases, liver-related diseases and non-AIDS infections declined, whereas cardiovascular diseases as cause of death remained stable (0.27 d\/100py in period 1, 0.10 d\/100py in period 2, 0.16 d\/100py in period 3, 0.09 d\/100py in period 4 and 0.14 d\/100py in period 5) and deaths due to non-AIDS-defining malignancies increased. Compared to latest CD4 counts of 500 cells\/mm3, lower CD4 counts conferred a higher risk of deaths due to AIDS-related diseases, liver-related diseases, non-AIDS infections and non-AIDS-defining malignancies, whereas no significant association was observed for cardiovascular mortality. Results were similar in sensitivity analyses where observation time was divided into two periods: 1997\u20132004 and 2005\u20132014. (4) Conclusions: Since the introduction of cART, risk of death decreased and causes of death changed. We do not find evidence that HIV-positive individuals with a low CD4 count are more likely to die from cardiovascular diseases.<\/jats:p>","DOI":"10.3390\/ijerph182312532","type":"journal-article","created":{"date-parts":[[2021,11,30]],"date-time":"2021-11-30T04:48:37Z","timestamp":1638247717000},"page":"12532","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["A Lower CD4 Count Predicts Most Causes of Death except Cardiovascular Deaths. The Austrian HIV Cohort Study"],"prefix":"10.3390","volume":"18","author":[{"given":"Gisela","family":"Leierer","sequence":"first","affiliation":[{"name":"Department of Dermatology and Venereology, Medical University of Innsbruck, 6020 Innsbruck, Austria"},{"name":"Austrian HIV Cohort Study, 6020 Innsbruck, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Armin","family":"Rieger","sequence":"additional","affiliation":[{"name":"Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brigitte","family":"Schmied","sequence":"additional","affiliation":[{"name":"Otto-Wagner Hospital, 1140 Vienna, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mario","family":"Sarcletti","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, Medical University of Innsbruck, 6020 Innsbruck, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Angela","family":"\u00d6llinger","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Med. Campus III, Kepler University Hospital Linz, Johannes Kepler University Linz, 4040 Linz, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elmar","family":"Wallner","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, General Hospital Graz South-West, 8020 Graz, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"Egle","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University, 5020 Salzburg, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manfred","family":"Kanatschnig","sequence":"additional","affiliation":[{"name":"1st Medical Department, General Hospital Klagenfurt, 9020 Klagenfurt, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"Zoufaly","sequence":"additional","affiliation":[{"name":"Kaiser-Franz-Josef Hospital Vienna, 1100 Vienna, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michele","family":"Atzl","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Oncology, Haematology, Infectious Diseases, State Hospital Feldkirch, 6800 Feldkirch, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michaela","family":"Rappold","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, Medical University of Innsbruck, 6020 Innsbruck, Austria"},{"name":"Austrian HIV Cohort Study, 6020 Innsbruck, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ziad","family":"El-Khatib","sequence":"additional","affiliation":[{"name":"Department of Surveillance and Infectious Disease Epidemiology, Austrian Agency for Health and Food Safety (AGES), Austrian Ministry for Health, Ministry of Sustainability and Tourism, 1220 Vienna, Austria"},{"name":"Department of Social and Preventive Medicine, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6881-4401","authenticated-orcid":false,"given":"Bruno","family":"Ledergerber","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5375-7299","authenticated-orcid":false,"given":"Robert","family":"Zangerle","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, Medical University of Innsbruck, 6020 Innsbruck, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"name":"on behalf of the Austrian HIV Cohort Study Group","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1016\/S0140-6736(03)13802-0","article-title":"Decline in the AIDS and Death Rates in the EuroSIDA Study: An Observational Study","volume":"362","author":"Mocroft","year":"2003","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1267","DOI":"10.1016\/S0140-6736(03)14570-9","article-title":"Determinants of Survival Following HIV-1 Seroconversion after the Introduction of HAART","volume":"362","author":"Porter","year":"2003","journal-title":"Lancet Lond. Engl."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1097\/01.aids.0000196178.73174.24","article-title":"Deaths in the Era of HAART: Contribution of Late Presentation, Treatment Exposure, Resistance and Abnormal Laboratory Markers","volume":"20","author":"Sabin","year":"2006","journal-title":"AIDS"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1016\/S0140-6736(05)67022-5","article-title":"Long-Term Effectiveness of Potent Antiretroviral Therapy in Preventing AIDS and Death: A Prospective Cohort Study","volume":"366","author":"Sterne","year":"2005","journal-title":"Lancet"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/S0140-6736(04)16589-6","article-title":"Predictors of Trend in CD4-Positive T-Cell Count and Mortality among HIV-1-Infected Individuals with Virological Failure to All Three Antiretroviral-Drug Classes","volume":"364","author":"Ledergerber","year":"2004","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1097\/01.COH.0000194106.12816.b1","article-title":"The CD4 Lymphocyte Count and Risk of Clinical Progression","volume":"1","author":"Phillips","year":"2006","journal-title":"Curr. Opin. HIV AIDS"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1016\/S0140-6736(03)14229-8","article-title":"Prognostic Importance of Initial Response in HIV-1 Infected Patients Starting Potent Antiretroviral Therapy: Analysis of Prospective Studies","volume":"362","author":"Sterne","year":"2003","journal-title":"Lancet Lond. Engl."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"401","DOI":"10.7326\/0003-4819-133-6-200009190-00007","article-title":"Clinical Outcome of Patients with HIV-1 Infection According to Immunologic and Virologic Response after 6 Months of Highly Active Antiretroviral Therapy","volume":"133","author":"Grabar","year":"2000","journal-title":"Ann. Intern. Med."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Antiretroviral Therapy Cohort Collaboration (ART-CC), Lanoy, E., May, M., Mocroft, A., Phillip, A., Justice, A., Ch\u00eane, G., Furrer, H., Sterling, T., and Monforte, A.D. (2009). Prognosis of Patients Treated with CART from 36 Months after Initiation, According to Current and Previous CD4 Cell Count and Plasma HIV-1 RNA Measurements. AIDS Lond. Engl., 23, 2199\u20132208.","DOI":"10.1097\/QAD.0b013e3283305a00"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1571","DOI":"10.1093\/cid\/ciw183","article-title":"Mortality According to CD4 Count at Start of Combination Antiretroviral Therapy Among HIV-Infected Patients Followed for up to 15 Years After Start of Treatment: Collaborative Cohort Study","volume":"62","author":"May","year":"2016","journal-title":"Clin. Infect. Dis."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"The Opportunistic Infections Project Team of the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord (2012). CD4 Cell Count and the Risk of AIDS or Death in HIV-Infected Adults on Combination Antiretroviral Therapy with a Suppressed Viral Load: A Longitudinal Cohort Study from COHERE. PLoS Med., 9.","DOI":"10.1371\/journal.pmed.1001194"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1097\/QAI.0b013e3181b62933","article-title":"Effect of Baseline CD4 Cell Counts on the Clinical Significance of Short-Term Immunologic Response to Antiretroviral Therapy in Individuals With Virologic Suppression","volume":"52","author":"Moore","year":"2009","journal-title":"JAIDS J. Acquir. Immune Defic. Syndr."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"The Antiretroviral Therapy Cohort Collaboration (2010). Causes of Death in HIV-1\u2014Infected Patients Treated with Antiretroviral Therapy, 1996\u20132006: Collaborative Analysis of 13 HIV Cohort Studies. Clin. Infect. Dis., 50, 1387\u20131396.","DOI":"10.1086\/652283"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1097\/QAI.0b013e31817efb54","article-title":"Changes in Causes of Death Among Adults Infected by HIV Between 2000 and 2005: The \u201cMortalit\u00e9 2000 and 2005\u201d Surveys (ANRS EN19 and Mortavic)","volume":"48","author":"Lewden","year":"2008","journal-title":"JAIDS J. Acquir. Immune Defic. Syndr."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"The Data Collection on Adverse Events of Anti-HIV drugs (D:A:D) Study Group (2010). Factors Associated with Specific Causes of Death amongst HIV-Positive Individuals in the D:A:D Study. AIDS, 24, 1537\u20131548.","DOI":"10.1097\/QAD.0b013e32833a0918"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1097\/QAD.0000000000000078","article-title":"Cause-Specific Mortality among HIV-Infected Individuals, by CD4+ Cell Count at HAART Initiation, Compared with HIV-Uninfected Individuals","volume":"28","author":"Wada","year":"2014","journal-title":"AIDS"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1097\/01.qai.0000233310.90484.16","article-title":"Mortality in the Highly Active Antiretroviral Therapy Era: Changing Causes of Death and Disease in the HIV Outpatient Study","volume":"43","author":"Palella","year":"2006","journal-title":"JAIDS J. Acquir. Immune Defic. Syndr."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Leierer, G., Grabmeier-Pfistershammer, K., Steuer, A., Geit, M., Sarcletti, M., Haas, B., Kanatschnig, M., Rappold, M., Zangerle, R., and Ledergerber, B. (2015). Factors Associated with Low-Level Viraemia and Virological Failure: Results from the Austrian HIV Cohort Study. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0142923"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"ofw089","DOI":"10.1093\/ofid\/ofw089","article-title":"A Single Quantifiable Viral Load Is Predictive of Virological Failure in Human Immunodeficiency Virus (HIV)-Infected Patients on Combination Antiretroviral Therapy: The Austrian HIV Cohort Study","volume":"3","author":"Leierer","year":"2016","journal-title":"Open Forum Infect. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1097\/EDE.0b013e31821b5332","article-title":"The Coding Causes of Death in HIV (CoDe) Project: Initial Results and Evaluation of Methodology","volume":"22","author":"Kowalska","year":"2011","journal-title":"Epidemiol. Camb. Mass"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Grinsztejn, B., Luz, P.M., Pacheco, A.G., Santos, D.V.G., Velasque, L., Moreira, R.I., Guimar\u00e3es, M.R.C., Nunes, E.P., Lemos, A.S., and Ribeiro, S.R. (2013). Changing Mortality Profile among HIV-Infected Patients in Rio de Janeiro, Brazil: Shifting from AIDS to Non-AIDS Related Conditions in the HAART Era. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0059768"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1007\/s15010-012-0386-7","article-title":"All-Cause Mortality in Hospitalized HIV-Infected Patients at an Acute Tertiary Care Hospital with a Comprehensive Outpatient HIV Care Program in New York City in the Era of Highly Active Antiretroviral Therapy (HAART)","volume":"41","author":"Kim","year":"2013","journal-title":"Infection"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1743","DOI":"10.1097\/QAD.0b013e32832e9b78","article-title":"Non-AIDS-Defining Deaths and Immunodeficiency in the Era of Combination Antiretroviral Therapy","volume":"23","author":"Marin","year":"2009","journal-title":"AIDS Lond. Engl."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1097\/QAI.0b013e3181a4ecf5","article-title":"Temporal Changes in Causes of Death among HIV-Infected Patients in the HAART Era in Rio de Janeiro, Brazil","volume":"51","author":"Pacheco","year":"2009","journal-title":"J. Acquir. Immune Defic. Syndr."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1097\/01.aids.0000216375.99560.a2","article-title":"Effective Therapy Has Altered the Spectrum of Cause-Specific Mortality Following HIV Seroconversion","volume":"20","author":"Smit","year":"2006","journal-title":"AIDS Lond. Engl."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1111\/j.1468-1293.2008.00600.x","article-title":"Trends of Mortality and Causes of Death among HIV-Infected Patients in Taiwan, 1984\u20132005","volume":"9","author":"Yang","year":"2008","journal-title":"HIV Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/S1473-3099(11)70112-8","article-title":"HIV in Europe\u2014No Longer Business as Usual","volume":"11","author":"Morris","year":"2011","journal-title":"Lancet Infect. Dis."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Raffetti, E., Postorino, M.C., Castelli, F., Casari, S., Castelnuovo, F., Maggiolo, F., Di Filippo, E., D\u2019Avino, A., Gori, A., and Ladisa, N. (2016). The Risk of Late or Advanced Presentation of HIV Infected Patients Is Still High, Associated Factors Evolve but Impact on Overall Mortality Is Vanishing over Calendar Years: Results from the Italian MASTER Cohort. BMC Public Health, 16.","DOI":"10.1186\/s12889-016-3477-z"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1111\/j.1468-1293.2010.00857.x","article-title":"Late Presentation of HIV Infection: A Consensus Definition","volume":"12","author":"Antinori","year":"2011","journal-title":"HIV Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1111\/j.1468-1293.2012.01051.x","article-title":"Decreasing Mortality and Changing Patterns of Causes of Death in the Swiss HIV Cohort Study","volume":"14","author":"Weber","year":"2013","journal-title":"HIV Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e614","DOI":"10.1016\/S2352-3018(21)00158-2","article-title":"Cancer Risk in Adolescents and Young Adults Living with HIV in South Africa: A Nationwide Cohort Study","volume":"8","author":"Ruffieux","year":"2021","journal-title":"Lancet HIV"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"756","DOI":"10.1093\/cid\/cit369","article-title":"Incidence and Timing of Cancer in HIV-Infected Individuals Following Initiation of Combination Antiretroviral Therapy","volume":"57","author":"Yanik","year":"2013","journal-title":"Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Trickey, A., May, M.T., Vehreschild, J., Obel, N., Gill, M.J., Crane, H., Boesecke, C., Samji, H., Grabar, S., and Cazanave, C. (2016). Cause-Specific Mortality in HIV-Positive Patients Who Survived Ten Years after Starting Antiretroviral Therapy. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0160460"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study","volume":"76","author":"Roth","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1815","DOI":"10.1056\/NEJMoa0807252","article-title":"Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival","volume":"360","author":"Kitahata","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1708","DOI":"10.1016\/S0140-6736(03)14844-1","article-title":"Effect of Antiretroviral Therapy on Liver-Related Mortality in Patients with HIV and Hepatitis C Virus Coinfection","volume":"362","author":"Qurishi","year":"2003","journal-title":"Lancet"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1632","DOI":"10.1001\/archinte.166.15.1632","article-title":"Liver-Related Deaths in Persons Infected with the Human Immunodeficiency Virus: The D:A:D Study","volume":"166","author":"Weber","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1097\/00126334-199912010-00008","article-title":"A Comparison of Exposure Groups in the EuroSIDA Study: Starting Highly Active Antiretroviral Therapy (HAART), Response to HAART, and Survival","volume":"22","author":"Mocroft","year":"1999","journal-title":"J. Acquir. Immune Defic. Syndr."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Strategies for Management of Antiretroviral Therapy (SMART) Study Group, El-Sadr, W.M., Lundgren, J.D., Neaton, J.D., Gordin, F., Abrams, D., Arduino, R.C., Babiker, A., Burman, W., and Clumeck, N. (2006). CD4+ Count-Guided Interruption of Antiretroviral Treatment. N. Engl. J. Med., 355, 2283\u20132296.","DOI":"10.1056\/NEJMoa062360"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2126","DOI":"10.1097\/00002030-200309260-00017","article-title":"Emergence of HIV-1 Mutated Strains after Interruption of Highly Active Antiretroviral Therapy in Chronically Infected Patients","volume":"17","author":"Daniel","year":"2003","journal-title":"AIDS Lond. Engl."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1763","DOI":"10.1097\/00002030-199909100-00021","article-title":"Sociodemographic and Psychological Variables Influencing Adherence to Antiretroviral Therapy","volume":"13","author":"Gordillo","year":"1999","journal-title":"AIDS Lond. Engl."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"767","DOI":"10.1097\/00002030-200203290-00012","article-title":"Longitudinal Assessment of the Effects of Drug and Alcohol Abuse on HIV-1 Treatment Outcomes in an Urban Clinic","volume":"16","author":"Lucas","year":"2002","journal-title":"AIDS Lond. Engl."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/23\/12532\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:36:57Z","timestamp":1760168217000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/23\/12532"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,28]]},"references-count":42,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["ijerph182312532"],"URL":"https:\/\/doi.org\/10.3390\/ijerph182312532","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,28]]}}}