{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,9]],"date-time":"2026-05-09T20:03:49Z","timestamp":1778357029435,"version":"3.51.4"},"reference-count":57,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2025,5,22]],"date-time":"2025-05-22T00:00:00Z","timestamp":1747872000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001659","name":"German Research Foundation","doi-asserted-by":"publisher","award":["SP945\/2-1"],"award-info":[{"award-number":["SP945\/2-1"]}],"id":[{"id":"10.13039\/501100001659","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001659","name":"German Research Foundation","doi-asserted-by":"publisher","award":["BE4500\/4-1"],"award-info":[{"award-number":["BE4500\/4-1"]}],"id":[{"id":"10.13039\/501100001659","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001659","name":"German Research Foundation","doi-asserted-by":"publisher","award":["USA\/1071425"],"award-info":[{"award-number":["USA\/1071425"]}],"id":[{"id":"10.13039\/501100001659","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Alexander von Humboldt Foundation","award":["SP945\/2-1"],"award-info":[{"award-number":["SP945\/2-1"]}]},{"name":"Alexander von Humboldt Foundation","award":["BE4500\/4-1"],"award-info":[{"award-number":["BE4500\/4-1"]}]},{"name":"Alexander von Humboldt Foundation","award":["USA\/1071425"],"award-info":[{"award-number":["USA\/1071425"]}]},{"name":"Open Access Fund of Trier University","award":["SP945\/2-1"],"award-info":[{"award-number":["SP945\/2-1"]}]},{"name":"Open Access Fund of Trier University","award":["BE4500\/4-1"],"award-info":[{"award-number":["BE4500\/4-1"]}]},{"name":"Open Access Fund of Trier University","award":["USA\/1071425"],"award-info":[{"award-number":["USA\/1071425"]}]},{"name":"German Research Foundation (DFG)","award":["SP945\/2-1"],"award-info":[{"award-number":["SP945\/2-1"]}]},{"name":"German Research Foundation (DFG)","award":["BE4500\/4-1"],"award-info":[{"award-number":["BE4500\/4-1"]}]},{"name":"German Research Foundation (DFG)","award":["USA\/1071425"],"award-info":[{"award-number":["USA\/1071425"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Background: Women experience higher rates of adverse events and first rehospitalization after left ventricular assist device (LVAD) implantation compared with men. This study investigated the role of sex and preimplant psychosocial risk in recurrent hospitalizations. Methods: Data from 20,123 INTERMACS patients (21.3% women) were analyzed. Cumulative transition rates (e.g., home to hospitalization) were estimated and Andersen\u2013Gill models, adjusted for covariates, examined the association between sex, preimplant psychosocial risk, and cumulative transition hazards for rehospitalization. State occupation probabilities, the mean number of hospitalizations, and the cumulative average length of hospital stay were calculated and stratified by sex and psychosocial risk. Results: Psychosocial risk preimplant was more prevalent in men than in women (21.4% vs. 17.5%, p &lt; 0.001). The interaction of female sex and psychosocial risk increased rehospitalization hazards, independently of covariates [HRadj 1.11, 95% CI (1.01\u20131.22), p = 0.036]. One-year postimplant, women with vs. without psychosocial risk had 2.2 vs. 1.8 hospitalizations, while men experienced 1.8 vs. 1.7 hospitalizations, respectively. Women with vs. without psychosocial risk spent 20 vs.16 days hospitalized, and men 15 vs. 14 days (all p &lt; 0.001). Conclusions: Preimplant psychosocial risk independently contributed to recurrent hospitalizations post-LVAD, particularly affecting women. The early identification and management of these factors may reduce rehospitalizations and improve clinical outcomes.<\/jats:p>","DOI":"10.3390\/jcdd12060198","type":"journal-article","created":{"date-parts":[[2025,5,22]],"date-time":"2025-05-22T04:32:37Z","timestamp":1747888357000},"page":"198","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Psychosocial Risk and Recurrent Hospitalizations in Women and Men Following LVAD Implantation: A Multi-State Analysis of the INTERMACS Registry"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3493-1378","authenticated-orcid":false,"given":"Lisa-Marie","family":"Maukel","sequence":"first","affiliation":[{"name":"Department of Health Psychology, Trier University, 54296 Trier, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandra","family":"Schmeller","sequence":"additional","affiliation":[{"name":"Institute of Statistics, Ulm University, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gerdi","family":"Weidner","sequence":"additional","affiliation":[{"name":"Department of Biology, San Francisco State University, San Francisco, CA 94132, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jan","family":"Beyersmann","sequence":"additional","affiliation":[{"name":"Institute of Statistics, Ulm University, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4600-2859","authenticated-orcid":false,"given":"Heike","family":"Spaderna","sequence":"additional","affiliation":[{"name":"Department of Health Psychology, Trier University, 54296 Trier, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1016\/j.athoracsur.2021.12.011","article-title":"Twelfth Interagency Registry for Mechanically Assisted Circulatory Support report: Readmissions after left ventricular assist device","volume":"113","author":"Shah","year":"2022","journal-title":"Ann. Thorac. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1016\/j.athoracsur.2020.12.038","article-title":"The Society of Thoracic Surgeons Intermacs 2020 annual report","volume":"111","author":"Molina","year":"2021","journal-title":"Ann. Thorac. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1161\/CIR.0000000000001303","article-title":"2025 Heart disease and stroke statistics: A report of US and global data from the American Heart Association","volume":"151","author":"Martin","year":"2025","journal-title":"Circulation"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e241","DOI":"10.1016\/j.amjmed.2020.09.038","article-title":"Epidemiologic characterization of heart failure with reduced or preserved ejection fraction populations identified using medicare claims","volume":"134","author":"Desai","year":"2021","journal-title":"Am. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e031021","DOI":"10.1161\/JAHA.123.031021","article-title":"Disparities by sex, race, and ethnicity in use of left ventricular assist devices and heart transplants among patients with heart failure with reduced ejection fraction","volume":"13","author":"Rose","year":"2024","journal-title":"J. Am. Heart Assoc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"612","DOI":"10.1016\/j.jchf.2019.03.012","article-title":"REVIVAL of the sex disparities debate: Are women denied, never referred, or ineligible for heart replacement therapies?","volume":"7","author":"Khazanie","year":"2019","journal-title":"JACC Heart Fail."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e006082","DOI":"10.1161\/CIRCHEARTFAILURE.119.006082","article-title":"Sex-based differences in left ventricular assist device utilization: Insights from the Nationwide Inpatient Sample 2004 to 2016","volume":"12","author":"Joshi","year":"2019","journal-title":"Circ. Heart Fail."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1016\/j.athoracsur.2019.12.005","article-title":"The Society of Thoracic Surgeons Intermacs 2019 annual report: The changing landscape of devices and indications","volume":"109","author":"Teuteberg","year":"2020","journal-title":"Ann. Thorac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1054","DOI":"10.1002\/ehf2.14261","article-title":"Sex-related differences in left ventricular assist device utilization and outcomes: Results from the PCHF-VAD registry","volume":"10","author":"Radhoe","year":"2023","journal-title":"ESC Heart Fail."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1016\/j.jchf.2020.04.015","article-title":"Sex differences in patients receiving left ventricular assist devices for end-stage heart failure","volume":"8","author":"Gruen","year":"2020","journal-title":"JACC Heart Fail."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1557","DOI":"10.1016\/j.healun.2023.06.013","article-title":"Adverse events after left ventricular assist device implantation linked to psychosocial risk in women and men","volume":"42","author":"Maukel","year":"2023","journal-title":"J. Heart Lung Transplant."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.healun.2017.06.016","article-title":"Gender differences and outcomes in left ventricular assist device support: The European Registry for Patients with Mechanical Circulatory Support","volume":"37","author":"Magnussen","year":"2018","journal-title":"J. Heart Lung Transplant."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e023294","DOI":"10.1161\/JAHA.121.023294","article-title":"Sex differences in recovery and device replacement after left ventricular assist device implantation as destination therapy","volume":"11","author":"Maukel","year":"2022","journal-title":"J. Am. Heart Assoc."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e006910","DOI":"10.1161\/CIRCHEARTFAILURE.120.006910","article-title":"Psychosocial risk and its association with outcomes in continuous-flow left ventricular assist device patients","volume":"13","author":"DeFilippis","year":"2020","journal-title":"Circ. Heart Fail."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1097\/TP.0000000000003287","article-title":"The preimplantation psychosocial evaluation and prediction of clinical outcomes during mechanical circulatory support: What information is most prognostic?","volume":"105","author":"Dew","year":"2021","journal-title":"Transplantation"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/j.cardfail.2024.03.011","article-title":"Association of psychosocial risk factors with quality of life and readmissions 1 year after LVAD implantation","volume":"31","author":"Wang","year":"2024","journal-title":"J. Card. Fail."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.1016\/j.cjca.2017.07.012","article-title":"Economic evaluation of left ventricular assist devices for patients with end stage heart failure who are ineligible for cardiac transplantation","volume":"33","author":"Chew","year":"2017","journal-title":"Can. J. Cardiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1016\/j.jchf.2016.09.008","article-title":"Cost-effectiveness of left ventricular assist devices in ambulatory patients with advanced heart failure","volume":"5","author":"Banerjee","year":"2017","journal-title":"JACC Heart Fail."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e004628","DOI":"10.1161\/CIRCHEARTFAILURE.117.004628","article-title":"Thirty-day readmissions after left ventricular assist device implantation in the United States: Insights from the Nationwide Readmissions Database","volume":"11","author":"Agrawal","year":"2018","journal-title":"Circ. Heart Fail."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1002\/ccd.30892","article-title":"Sex-based differences in left ventricular assist device clinical outcomes","volume":"103","author":"Imburgio","year":"2024","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e228127","DOI":"10.1001\/jamasurg.2022.8127","article-title":"Association of days alive and out of the hospital after ventricular assist device implantation with adverse events and quality of life","volume":"158","author":"Noly","year":"2023","journal-title":"JAMA Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"780","DOI":"10.1016\/j.athoracsur.2019.07.032","article-title":"Gender differences in outcomes after implantation of left ventricular assist devices","volume":"109","author":"Ahmed","year":"2020","journal-title":"Ann. Thorac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1080","DOI":"10.1016\/j.healun.2017.07.005","article-title":"Eighth annual INTERMACS report: Special focus on framing the impact of adverse events","volume":"36","author":"Kirklin","year":"2017","journal-title":"J. Heart Lung Transplant."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e006058","DOI":"10.1161\/CIRCHEARTFAILURE.119.006058","article-title":"Psychosocial evaluation of candidates for heart transplant and ventricular assist devices: Beyond the current consensus","volume":"12","author":"Bui","year":"2019","journal-title":"Circ. Heart Fail."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1016\/j.healun.2018.03.005","article-title":"Consensus Document: The 2018 ISHLT\/APM\/AST\/ICCAC\/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support","volume":"37","author":"Dew","year":"2018","journal-title":"J. Heart Lung Transplant."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Ozga, A.-K., Kieser, M., and Rauch, G. (2018). A systematic comparison of recurrent event models for application to composite endpoints. BMC Med. Res. Methodol., 18.","DOI":"10.1186\/s12874-017-0462-x"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1002\/pst.2167","article-title":"Methodological challenges in the analysis of recurrent events for randomised controlled trials with application to cardiovascular events in LEADER","volume":"21","author":"Furberg","year":"2022","journal-title":"Pharm. Stat."},{"key":"ref_28","first-page":"1","article-title":"Mice: Multivariate imputation by chained equations in R","volume":"45","year":"2011","journal-title":"J. Stat. Softw."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1002\/pst.1739","article-title":"Statistical issues in the analysis of adverse events in time-to-event data","volume":"15","author":"Allignol","year":"2016","journal-title":"Pharm. Stat."},{"key":"ref_30","first-page":"110","article-title":"Statistical inference for state occupation and transition probabilities in non-Markov multi-state models subject to both random left-truncation and right-censoring","volume":"25","author":"Allignol","year":"2023","journal-title":"Econom. Stat."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1002\/pst.2356","article-title":"Comparison of nonparametric estimators of the expected number of recurrent events","volume":"23","author":"Erdmann","year":"2024","journal-title":"Pharm. Stat."},{"key":"ref_32","unstructured":"R Development Core Team (2018). R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1093\/aje\/kwac173","article-title":"Sex and gender multidimensionality in epidemiologic research","volume":"192","author":"Bauer","year":"2023","journal-title":"Am. J. Epidemiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2841","DOI":"10.1016\/S0140-6736(16)32392-3","article-title":"Editorial policies for sex and gender analysis","volume":"388","author":"Schiebinger","year":"2016","journal-title":"Lancet"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2440","DOI":"10.1016\/S0140-6736(19)30652-X","article-title":"Gender inequality and restrictive gender norms: Framing the challenges to health","volume":"393","author":"Heise","year":"2019","journal-title":"Lancet"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1038\/s41569-022-00797-4","article-title":"Gender medicine: Effects of sex and gender on cardiovascular disease manifestation and outcomes","volume":"20","author":"Gebhard","year":"2023","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.jacc.2015.10.067","article-title":"Sex versus gender-related characteristics: Which predicts outcome after acute coronary syndrome in the young?","volume":"67","author":"Pelletier","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1097\/TP.0b013e3181c35255","article-title":"Heart transplantation in women with dilated cardiomyopathy","volume":"89","author":"Petrov","year":"2010","journal-title":"Transplantation"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e14502","DOI":"10.1111\/ctr.14502","article-title":"Association of race and gender with primary caregiver relationships and eligibility for advanced heart failure therapies","volume":"36","author":"Steinberg","year":"2022","journal-title":"Clin. Transplant."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e2011044","DOI":"10.1001\/jamanetworkopen.2020.11044","article-title":"Association of gender and race with allocation of advanced heart failure therapies","volume":"3","author":"Breathett","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"416","DOI":"10.1097\/JCN.0000000000000695","article-title":"Patterns of heart failure dyadic illness management: The important role of gender","volume":"35","author":"Lee","year":"2020","journal-title":"J. Cardiovasc. Nurs."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1016\/j.cjca.2021.02.005","article-title":"The importance of gender to understand sex differences in cardiovascular disease","volume":"37","author":"Connelly","year":"2021","journal-title":"Can. J. Cardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1007\/s11897-021-00502-5","article-title":"Racial\/ethnic and gender disparities in heart failure with reduced ejection fraction","volume":"18","author":"Mwansa","year":"2021","journal-title":"Curr. Heart Fail. Rep."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2385","DOI":"10.1016\/S0140-6736(21)00684-X","article-title":"The Lancet women and cardiovascular disease Commission: Reducing the global burden by 2030","volume":"397","author":"Vogel","year":"2021","journal-title":"Lancet"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1207","DOI":"10.1016\/j.healun.2018.06.004","article-title":"Impact of body mass index on adverse events after implantation of left ventricular assist devices: An IMACS registry analysis","volume":"37","author":"Forest","year":"2018","journal-title":"J. Heart Lung Transplant."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1177\/0391398820948874","article-title":"Association of cigarette smoking and adverse events in left ventricular assist device patients","volume":"44","author":"Youmans","year":"2021","journal-title":"Int. J. Artif. Organs"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"873","DOI":"10.1161\/CIR.0000000000000228","article-title":"Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association","volume":"132","author":"Havranek","year":"2015","journal-title":"Circulation"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1540","DOI":"10.1016\/j.jacc.2016.07.743","article-title":"Cardiac recovery during long-term left ventricular assist device support","volume":"68","author":"Drakos","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"3599","DOI":"10.1093\/eurheartj\/ehab368","article-title":"2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure","volume":"42","author":"McDonagh","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_50","first-page":"e876","article-title":"2022 ACC\/AHA\/HFSA guideline for the management of heart failure","volume":"145","author":"Heidenreich","year":"2022","journal-title":"Circulation"},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Nahl\u00e9n Bose, C. (2023). A meta-review of systematic reviews and meta-analyses on outcomes of psychosocial interventions in heart failure. Front. Psychiatry, 14.","DOI":"10.3389\/fpsyt.2023.1095665"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1097\/PSY.0000000000001073","article-title":"Psychosocial interventions for patients with heart failure and their impact on depression, anxiety, quality of life, morbidity, and mortality: A systematic review and meta-analysis","volume":"84","author":"Chernoff","year":"2022","journal-title":"Psychosom. Med."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1161\/CIRCOUTCOMES.108.812859","article-title":"Stress reduction prolongs life in women with coronary disease: The stockholm women\u2019s intervention trial for coronary disease (SWITCHD)","volume":"2","author":"Schneiderman","year":"2009","journal-title":"Circ. Cardiovasc. Qual. Outcomes"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1016\/j.hrtlng.2019.02.003","article-title":"Assessment of pre-operative psychosocial function among people receiving left ventricular assist devices: A national survey of US LVAD programs","volume":"48","author":"Clancy","year":"2019","journal-title":"Heart Lung"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1320","DOI":"10.1016\/j.jchf.2023.04.017","article-title":"Mortality, outcomes, costs, and use of medicines following a first heart failure hospitalization: EVOLUTION HF","volume":"11","author":"Bozkurt","year":"2023","journal-title":"JACC Heart Fail."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1016\/j.jchf.2022.03.007","article-title":"Hospitalization patterns and impact of a magnetically-levitated left ventricular assist device in the MOMENTUM 3 Trial","volume":"10","author":"Vidula","year":"2022","journal-title":"JACC Heart Fail."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.1111\/aor.14763","article-title":"Unplanned hospital readmissions following HeartMate 3 implantation: Readmission rates, causes, and impact on survival","volume":"48","author":"Shih","year":"2024","journal-title":"Artif. Organs"}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/12\/6\/198\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:38:09Z","timestamp":1760031489000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/12\/6\/198"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,22]]},"references-count":57,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["jcdd12060198"],"URL":"https:\/\/doi.org\/10.3390\/jcdd12060198","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,22]]}}}