{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T22:24:33Z","timestamp":1791671073759,"version":"4.3.4"},"reference-count":48,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2025,8,11]],"date-time":"2025-08-11T00:00:00Z","timestamp":1754870400000},"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>Background: Cirrhosis represents an advanced stage of hepatic fibrosis, and the metabolic changes resulting from liver dysfunction can cause impairment in physical capacity and quality of life. This study aimed to evaluate the effect of 12 weeks of resistance exercise on inflammatory markers, oxidative stress, physical conditioning, and quality of life in patients with liver cirrhosis. Methods: A total of 38 patients paired in the exercise (EG) and control (CG) groups participated in this study. The EG submitted to two weekly sessions of a program composed of resistance exercises. We evaluated the inflammatory markers (IL-6, IL-10, and TNF-\u03b1), oxidative stress (carbonylated protein, total thiols, enzyme superoxide dismutase, and catalase activity), body composition, handgrip strength (HGS), total volume of training, cardiorespiratory capacity (VO2, VCO2, and VEpeak), exercise capacity, and quality of life. Results: Regarding the EG, when comparing the follow-up period to the baseline, significant differences (p &lt; 0.05) were found in BMI, HGS, total training volume, cardiorespiratory capacity variables, the 6 min walk test, and quality of life. Improvements were observed, without significant differences, in the inflammatory profile, oxidative stress, and one of the markers of liver function. The CG showed a significant decrease (p &lt; 0.05) in HGS and cardiorespiratory capacity after the intervention. Conclusions: In patients with liver cirrhosis, a resistance exercise program improved physical fitness and quality of life, without adverse events. In addition, it seems that this type of training can bring some benefit to the inflammatory profile and oxidative stress of this population.<\/jats:p>","DOI":"10.3390\/ijerph22081257","type":"journal-article","created":{"date-parts":[[2025,8,11]],"date-time":"2025-08-11T09:59:13Z","timestamp":1754906353000},"page":"1257","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["A Resistance Training Program on Patients with Liver Cirrhosis: A Randomized Clinical Trial"],"prefix":"10.3390","volume":"22","author":[{"given":"Amanda","family":"Brown","sequence":"first","affiliation":[{"name":"Federal Institute of Southeast Minas Gerais\u2014Campus Barbacena, Barbacena 36205-018, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ingrid","family":"Dias","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jefferson","family":"da Silva Novaes","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"},{"name":"Strength Training Laboratory (LABFOR), Universidade Federal de Juiz de Fora, Juiz de Fora 36036-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0156-4030","authenticated-orcid":false,"given":"Leandro","family":"Sant\u2019Ana","sequence":"additional","affiliation":[{"name":"Strength Training Laboratory (LABFOR), Universidade Federal de Juiz de Fora, Juiz de Fora 36036-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruno Perez","family":"Felix","sequence":"additional","affiliation":[{"name":"Undergraduate Program in Physical Therapy, IBMR University Center, Rio de Janeiro 22631-002, Brazil"},{"name":"Postgraduate Program in Rehabilitation Science (PPGCR), Centro Universit\u00e1rio Augusto Motta, Rio de Janeiro 21032-060, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2273-8893","authenticated-orcid":false,"given":"Fabio","family":"Cahu\u00ea","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3720-4387","authenticated-orcid":false,"given":"Anderson","family":"Brito-Azevedo","sequence":"additional","affiliation":[{"name":"Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro 22241-220, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3817-0529","authenticated-orcid":false,"given":"Michel Silva","family":"Reis","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"},{"name":"Postgraduate Program in Rehabilitation Science (PPGCR), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21949-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8598-4878","authenticated-orcid":false,"given":"Agnaldo Jos\u00e9","family":"Lopes","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Rehabilitation Science (PPGCR), Centro Universit\u00e1rio Augusto Motta, Rio de Janeiro 21032-060, Brazil"},{"name":"Pulmonary and Tisiology Department, Pedro Ernesto University Hospital (HUPE), Piquet Carneiro University Policlinic (PPC), Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20950-003, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4344-6710","authenticated-orcid":false,"given":"Ver\u00f4nica","family":"Salerno","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Sim\u00e3o","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1866-553X","authenticated-orcid":false,"given":"Est\u00eav\u00e3o Rios","family":"Monteiro","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Physical Education (PPGEF), Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-599, Brazil"},{"name":"Undergraduate Program in Physical Therapy, IBMR University Center, Rio de Janeiro 22631-002, Brazil"},{"name":"Postgraduate Program in Rehabilitation Science (PPGCR), Centro Universit\u00e1rio Augusto Motta, Rio de Janeiro 21032-060, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renata de Mello","family":"Perez","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21044-020, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,11]]},"reference":[{"key":"ref_1","first-page":"145","article-title":"Personalized adapted physical activity before liver transplantation: Acceptability and results","volume":"99","author":"Tabouret","year":"2014","journal-title":"Transplantation"},{"key":"ref_2","unstructured":"American College of Sports Medicine (2016). ACSMs Exercise Management for Persons with Chronic Diseases and Disabilities, Human Kinetics. [4th ed.]."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1007\/s00535-023-02060-0","article-title":"Resistance exercise in combination with aerobic exercise reduces the incidence of serious events in patients with liver cirrhosis: A meta-analysis of randomized controlled trials","volume":"59","author":"Kawaguchi","year":"2024","journal-title":"J. Gastroenterol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1249","DOI":"10.1002\/hep.28740","article-title":"Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure","volume":"64","author":"Stauber","year":"2016","journal-title":"Hepatology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"676","DOI":"10.26444\/aaem\/144380","article-title":"Oxidative stress-induced growth inhibitor 1 in alcohol-induced liver cirrhosis","volume":"28","author":"Sak","year":"2021","journal-title":"Ann. Agric. Environ. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1378","DOI":"10.1016\/j.jhep.2016.01.035","article-title":"The pro-inflammatory effects of miR-155 promote liver fibrosis and alcohol-induced steatohepatitis","volume":"64","author":"Bala","year":"2016","journal-title":"J. Hepatol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"20739","DOI":"10.1021\/acsnano.2c07796","article-title":"Reactive Oxygen Species-Responsive Polypeptide Drug Delivery System Targeted Activated Hepatic Stellate Cells to Ameliorate Liver Fibrosis","volume":"16","author":"Hao","year":"2022","journal-title":"ACS Nano"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1093\/ijnp\/pyx017","article-title":"Modulating Oxidative Stress Relieves Stress-Induced Behavioral and Cognitive Impairments in Rats","volume":"20","author":"Solanki","year":"2017","journal-title":"Int. J. Neuropsychopharmacol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1080\/15438627.2014.975807","article-title":"Effect of moderate and high resistance training intensity on indices of inflammatory and oxidative stress","volume":"23","author":"Azizbeigi","year":"2015","journal-title":"Res. Sports Med."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Arazi, H., Taati, B., and Suzuki, K. (2018). A Review of the Effects of Leucine Metabolite (\u03b2-Hydroxy-\u03b2-methylbutyrate) Supplementation and Resistance Training on Inflammatory Markers: A New Approach to Oxidative Stress and Cardiovascular Risk Factors. Antioxidants, 7.","DOI":"10.20944\/preprints201808.0503.v1"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2339","DOI":"10.1111\/sms.13227","article-title":"Effect of endurance versus resistance training on local muscle and systemic inflammation and oxidative stress in COPD","volume":"28","author":"Thaning","year":"2018","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2214","DOI":"10.1249\/MSS.0b013e31829afc33","article-title":"Exercise reduces inflammation and oxidative stress in obesity-related liver diseases","volume":"45","author":"Oh","year":"2013","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1016\/j.jdiacomp.2018.09.008","article-title":"Glycemic, inflammatory and oxidative stress responses to different high-intensity training protocols in type 1 diabetes: A randomized clinical trial","volume":"32","author":"Farinha","year":"2018","journal-title":"J. Diabetes Complicat."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Corr\u00eaa, H.L., Moura, S.R.G., Neves, R.V.P., Tzanno-Martins, C., Souza, M.K., Haro, A.S., Costa, F., Silva, J.A.B., Stone, W., and Honorato, F.S. (2020). Resistance training improves sleep quality, redox balance and inflammatory profile in maintenance hemodialysis patients: A randomized controlled trial. Sci. Rep., 10.","DOI":"10.1038\/s41598-020-68602-1"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.ab.2014.04.034","article-title":"Simplified 2,4-dinitrophenylhydrazine spectrophotometric assay for quantification of carbonyls in oxidized proteins","volume":"458","author":"Mesquita","year":"2014","journal-title":"Anal. Biochem."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1922","DOI":"10.1249\/MSS.0000000000000605","article-title":"Resistance Exercise Training Alters Mitochondrial Function in Human Skeletal Muscle","volume":"47","author":"Porter","year":"2015","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Groennebaek, T., and Vissing, K. (2017). Impact of Resistance Training on Skeletal Muscle Mitochondrial Biogenesis, Content, and Function. Front. Physiol., 8.","DOI":"10.3389\/fphys.2017.00713"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"259","DOI":"10.4162\/nrp.2010.4.4.259","article-title":"Effects of resistance training on the inflammatory response","volume":"4","author":"Calle","year":"2010","journal-title":"Nutr. Res. Pract."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Kim, S.D., and Yeun, Y.R. (2022). Effects of Resistance Training on C-Reactive Protein and Inflammatory Cytokines in Elderly Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int. J. Environ. Res. Public. Health, 19.","DOI":"10.3390\/ijerph19063434"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"American College of Sports Medicine (2009). ACSM Position Stand: Progression Models in Resistance Training for Healthy Adults. Med. Sci. Sports Exerc., 41, 687\u2013708.","DOI":"10.1249\/MSS.0b013e3181915670"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/S0076-6879(84)05016-3","article-title":"Catalase in vitro","volume":"105","author":"Aebi","year":"1984","journal-title":"Methods Enzymol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3170","DOI":"10.1016\/S0021-9258(19)45228-9","article-title":"The role of superoxide anion in the autoxidation of epinephrine and a simple assay for superoxide dismutase","volume":"247","author":"Misra","year":"1972","journal-title":"J. Biol. Chem."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"104","DOI":"10.11606\/issn.2317-0190.v14i2a102799","article-title":"Teste de for\u00e7a de preens\u00e3o utilizando o dinam\u00f4metro Jammar","volume":"14","author":"Figueiredo","year":"2007","journal-title":"Acta Fisiatr."},{"key":"ref_24","unstructured":"Neder, J.A., and Nery, L.E. (2002). Fisiologia Cl\u00ednica do Exerc\u00edcio: Teoria e Pr\u00e1tica, Artes M\u00e9dicas. [1st ed.]."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"ATS\u2014American Thoracic Society (2002). Guidelines for the 6-minute walk test. Am. J. Crit. Care, 166, 111\u2013117.","DOI":"10.1164\/ajrccm.166.1.at1102"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1097\/00005650-199206000-00002","article-title":"The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection","volume":"30","author":"Sherbourne","year":"1992","journal-title":"Med. Care"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1590\/S1413-78522013000400004","article-title":"Avalia\u00e7\u00e3o da qualidade de vida com o instrumento SF-36 em lombalgia cr\u00f4nica","volume":"21","author":"Adorno","year":"2013","journal-title":"Acta Ortop. Bras."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1681","DOI":"10.3748\/wjg.v12.i11.1681","article-title":"Interleukin-10 and chronic liver disease","volume":"12","author":"Zhang","year":"2006","journal-title":"World J. Gastroenterol."},{"key":"ref_29","first-page":"297","article-title":"Interleukins in chronic liver disease: Lessons learned from experimental mouse models","volume":"7","author":"Hammerich","year":"2014","journal-title":"Clin. Exp. Gastroenterol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"8082","DOI":"10.3748\/wjg.v20.i25.8082","article-title":"Oxidative stress as a crucial factor in liver diseases","volume":"20","author":"Michalak","year":"2014","journal-title":"World J. Gastroenterol."},{"key":"ref_31","first-page":"2460","article-title":"Antioxidant status of erythrocytes from patients with cirrhosis","volume":"46","author":"Kacmaz","year":"1999","journal-title":"Hepatogastroenterology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/S0753-3322(05)80037-X","article-title":"Chronomics of circulating plasma lipid peroxides and antioxidant enzymes and other related molecules in cirrhosis of liver. In the memory of late Shri Chetan Singh","volume":"59","author":"Singh","year":"2005","journal-title":"Biomed. Pharmacother."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2","DOI":"10.4161\/oxim.3.1.10476","article-title":"Markers of oxidative stress in erythrocytes and plasma during aging in humans","volume":"3","author":"Pandey","year":"2010","journal-title":"Oxid. Med. Cell Longev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"867","DOI":"10.1093\/clinchem\/41.6.867","article-title":"Prognostic role of antioxidant enzymes in sepsis: Preliminary assessment","volume":"41","author":"Warner","year":"1995","journal-title":"Clin. Chem."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1547","DOI":"10.1152\/japplphysiol.00798.2019","article-title":"Exercise and physical activity in cirrhosis: Opportunities or perils","volume":"128","author":"Dasarathy","year":"2020","journal-title":"J. Appl. Physiol. (1985)"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1113\/expphysiol.1989.sp003268","article-title":"Physiological changes in skeletal muscle as a result of strength training","volume":"74","author":"Jones","year":"1989","journal-title":"Q. J. Exp. Physiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1179","DOI":"10.1016\/j.cgh.2019.07.058","article-title":"Resistance Training Increases Muscle Strength and Muscle Size in Patients with Liver Cirrhosis","volume":"18","author":"Aamann","year":"2019","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1002\/lt.22472","article-title":"Exercise capacity and muscle strength in patients with cirrhosis","volume":"18","author":"Jones","year":"2012","journal-title":"Liver Transpl."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1416","DOI":"10.1097\/MEG.0000000000000986","article-title":"Efficacy of branched-chain amino acid supplementation and walking exercise for preventing sarcopenia in patients with liver cirrhosis","volume":"29","author":"Hiraoka","year":"2017","journal-title":"Eur. J. Gastroenterol. Hepatol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Kumar, N.T.A., Oliver, J.L., Lloyd, R., Pedley, J.S., and Radnor, J.M. (2021). The Influence of Growth, Maturation and Resistance Training on Muscle-Tendon and Neuromuscular Adaptations: A Narrative Review. Sports, 9.","DOI":"10.3390\/sports9050059"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Matos, F., Amaral, J., Martinez, E., Can\u00e1rio-Lemos, R., Moreira, T., Cavalcante, J., Peixoto, R., Pinheiro, B.N., Scipi\u00e3o Junior, L., and Uchoa, P. (2022). Changes in Muscle Thickness after 8 Weeks of Strength Training, Electromyostimulation, and Both Combined in Healthy Young Adults. Int. J. Environ. Res. Public. Health, 19.","DOI":"10.3390\/ijerph19063184"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Lacio, M., Vieira, J.G., Trybulski, R., Campos, Y., Santana, D., Elias Filho, J., Novaes, J., Vianna, J.M., and Wilk, M. (2021). Effects of Resistance Training Performed with Different Loads in Untrained and Trained Male Adult Individuals on Maximal Strength and Muscle Hypertrophy: A Systematic Review. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph182111237"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Deliceo\u011flu, G., Kabak, B., \u00c7ak\u0131r, V.O., Ceylan, H.I., Raul-Ioan, M., Alexe, D.I., and Stefanica, V. (2024). Respiratory Muscle Strength as a Predictor of VO2max and Aerobic Endurance in Competitive Athletes. Appl. Sci., 14.","DOI":"10.3390\/app14198976"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1097\/HCR.0b013e3182642688","article-title":"Effects of muscular strength on cardiovascular risk factors and prognosis","volume":"32","author":"Artero","year":"2012","journal-title":"J. Cardiopulm. Rehabil. Prev."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1002\/lt.22167","article-title":"Six-Minute Walk Distance Predicts Mortality in Liver Transplant Candidates","volume":"16","author":"Carey","year":"2010","journal-title":"Liver Transpl."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1053\/gast.2001.21193","article-title":"Factors Associated with Poor Health-Related Quality of Life of Patients with Cirrhosis","volume":"120","author":"Marchesini","year":"2001","journal-title":"Gastroenterology"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1966","DOI":"10.1007\/s10620-014-3086-6","article-title":"Randomized pilot study: Effects of an exercise programme and leucine supplementation in patients with cirrhosis","volume":"59","author":"Torrades","year":"2014","journal-title":"Dig. Dis. Sci."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1920","DOI":"10.1016\/j.cgh.2014.04.016","article-title":"Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis","volume":"12","author":"Zenith","year":"2014","journal-title":"Clin. Gastroenterol. Hepatol."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/22\/8\/1257\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:24:31Z","timestamp":1760034271000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/22\/8\/1257"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,11]]},"references-count":48,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8]]}},"alternative-id":["ijerph22081257"],"URL":"https:\/\/doi.org\/10.3390\/ijerph22081257","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,11]]}}}