{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T08:24:34Z","timestamp":1781598274503,"version":"3.54.5"},"reference-count":47,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2024,5,9]],"date-time":"2024-05-09T00:00:00Z","timestamp":1715212800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Universitat Rovira i Virgili"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background:\u00a0Clostridioides difficile infections (CDI) vary in severity from mild diarrhea to life-threatening conditions like pseudomembranous colitis or toxic megacolon, often leading to sepsis and death. The COVID-19 pandemic prompted changes in healthcare practices, potentially affecting CDI incidence, though reported data are inconclusive. We studied factors influencing CDI incidence and outcomes at a university hospital throughout the COVID-19 pandemic years. Methods: We conducted a retrospective study on all adult hospitalized CDI cases from 1 January 2020 to 31 December 2022 in Hospital Universitari de Sant Joan in Reus. We collected demographic information, comorbid conditions, and concurrent infections. Results: While overall CDI and COVID-19 rates decreased in 2022, a notable increase in CDI infections was observed among oncological patients and those undergoing some aggressive treatments, such as colonoscopies or gastroscopies. The prevalence of comorbidities remained unmodified, and there were declines in prior gastrointestinal surgeries and proton pump inhibitor prescriptions. Factors associated with patient fatality or prolonged hospitalization included older age, cancer, chronic kidney disease, higher Charlson and McCabe indices, elevated C-reactive protein, and low albumin concentrations. Conclusions: Our study shows the evolving landscape of CDI during the COVID-19 pandemic and emphasizes the impact of delayed diagnoses and treatments exacerbated by telemedicine adoption. Identified risk factors for CDI-related mortality or prolonged hospital stays underscore the importance of targeted interventions in high-risk populations.<\/jats:p>","DOI":"10.3390\/jcm13102799","type":"journal-article","created":{"date-parts":[[2024,5,9]],"date-time":"2024-05-09T10:31:16Z","timestamp":1715250676000},"page":"2799","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Retrospective Analysis of Clostridioides difficile Infection Rates and Outcomes in Hospitalized Patients during the COVID-19 Pandemic: A Unicenter Study in Reus, Spain"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0714-8414","authenticated-orcid":false,"given":"Simona","family":"Iftimie","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana F.","family":"L\u00f3pez-Azcona","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mireia","family":"Corchero-Valverde","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Peralta-V\u00e1zquez","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laia Revuelta","family":"L\u00f3pez-Cord\u00f3n","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carles","family":"Garc\u00eda-Cervera","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lu\u00eds Manuel","family":"Fern\u00e1ndez-Dom\u00ednguez","sequence":"additional","affiliation":[{"name":"Laboratori de Refer\u00e8ncia Camp de Tarragona i Terres de l\u2019Ebre, Hospital Universitari de Sant Joan, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3165-3640","authenticated-orcid":false,"given":"Jordi","family":"Camps","sequence":"additional","affiliation":[{"name":"Unitat de Recerca Biom\u00e8dica, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2749-4541","authenticated-orcid":false,"given":"Jorge","family":"Joven","sequence":"additional","affiliation":[{"name":"Unitat de Recerca Biom\u00e8dica, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5441-6333","authenticated-orcid":false,"given":"Antoni","family":"Castro","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Institut d\u2019Investigaci\u00f3 Sanit\u00e0ria Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,5,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1732","DOI":"10.1056\/NEJMoa1801550","article-title":"Changes in prevalence of health care-associated infections in U.S. Hospitals","volume":"379","author":"Magill","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1007\/s10096-019-03539-6","article-title":"Clostridium difficile infection: Review","volume":"38","author":"Czepiel","year":"2019","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"293","DOI":"10.4253\/wjge.v2.i8.293","article-title":"Toxic megacolon associated Clostridium difficile colitis","volume":"2","author":"Sayedy","year":"2010","journal-title":"World J. Gastrointest. Endosc."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1320","DOI":"10.1056\/NEJMoa1910215","article-title":"Trends in U.S. burden of Clostridioides difficile infection and outcomes","volume":"382","author":"Guh","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"126","DOI":"10.37201\/req\/135.2020","article-title":"Economic burden of recurrent Clostridioides difficile infection in adults admitted to Spanish hospitals. A multicentre retrospective observational study","volume":"34","author":"Bouza","year":"2021","journal-title":"Rev. Esp. Quimioter."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1016\/S0213-005X(12)70090-3","article-title":"Prevalence of nosocomial infections in acute care hospitals in Catalonia (VINCat Program)","volume":"30","author":"Olona","year":"2012","journal-title":"Enferm. Infecc. Microbiol. Clin."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Sopena, N., Freixas, N., Bella, F., P\u00e9rez, J., Hornero, A., Limon, E., Gudiol, F., and Pujol, M. (2019). Impact of a training program on the surveillance of Clostridioides difficile infection. Epidemiol. Infect., 147.","DOI":"10.1017\/S0950268819001080"},{"key":"ref_8","first-page":"287","article-title":"Clostridium difficile infection","volume":"373","author":"Leffler","year":"2015","journal-title":"N. Engl. J. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1093\/cid\/ciy149","article-title":"Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)","volume":"66","author":"McDonald","year":"2018","journal-title":"Clin. Infect. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1055\/s-0040-1701229","article-title":"Clostridium difficile infection: An epidemiology update","volume":"33","author":"Regenbogen","year":"2020","journal-title":"Clin. Colon Rectal. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Di Bella, S., Sanson, G., Monticelli, J., Zerbato, V., Principe, L., Giuffr\u00e8, M., Pipitone, G., and Luzzati, R. (2024). Clostridioides difficile infection: History, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin. Microbiol. Rev.","DOI":"10.1128\/cmr.00135-23"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Fu, Y., Luo, Y., and Grinspan, A.M. (2021). Epidemiology of community-acquired and recurrent Clostridioides difficile infection. Therap. Adv. Gastroenterol., 14.","DOI":"10.1177\/17562848211016248"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1165","DOI":"10.1017\/ice.2020.1223","article-title":"Hospital-onset Clostridioides difficile infections during the COVID-19 pandemic","volume":"42","author":"Luo","year":"2021","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1016\/j.ajic.2020.10.019","article-title":"Unintended consequences of infection prevention and control measures during COVID-19 pandemic","volume":"49","author":"Wee","year":"2021","journal-title":"Am. J. Infect. Control"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Gerhards, C., Steingass, M., Heininger, A., Lange, B., Hetjens, M., Gerigk, M., Neumaier, M., Evliyaoglu, O., and Kittel, M. (2024). The impact of clinical factors and SARS-CoV-2 variants on antibody production in vaccinated German healthcare professionals infected either with the delta or the omicron variant. Vaccines, 12.","DOI":"10.3390\/vaccines12020163"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1017\/ice.2020.454","article-title":"Impact of the coronavirus disease 2019 (COVID-19) pandemic on nosocomial Clostridioides difficile infection","volume":"42","author":"Pintor","year":"2021","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1017\/ice.2021.3","article-title":"The other \u2018C\u2019: Hospital-acquired Clostridioides difficile infection during the coronavirus disease 2019 (COVID-19) pandemic","volume":"43","author":"Hazel","year":"2022","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"640","DOI":"10.1016\/j.ajic.2020.09.010","article-title":"Impact of COVID-19 prevention measures on risk of health care-associated Clostridium difficile infection","volume":"49","author":"Bentivegna","year":"2021","journal-title":"Am. J. Infect. Control"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"966","DOI":"10.1016\/j.ajic.2020.12.008","article-title":"Substantial reduction of healthcare facility-onset Clostridioides difficile infection (HO-CDI) rates after conversion of a hospital for exclusive treatment of COVID-19 patients","volume":"49","year":"2021","journal-title":"Am. J. Infect. Control"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Iftimie, S., L\u00f3pez-Azcona, A.F., Vallverd\u00fa, I., Hern\u00e1ndez-Flix, S., de Febrer, G., Parra, S., Hern\u00e1ndez-Aguilera, A., Riu, F., Joven, J., and Andreychuk, N. (2021). First and second waves of coronavirus disease-19: A comparative study in hospitalized patients in Reus, Spain. PLoS ONE, 16.","DOI":"10.1101\/2020.12.10.20246959"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Iftimie, S., L\u00f3pez-Azcona, A.F., Lozano-Olmo, M.J., Hern\u00e1ndez-Aguilera, A., Sarr\u00e0-Moret\u00f3, S., Joven, J., Camps, J., and Castro, A. (2022). Characteristics of hospitalized patients with SARS-CoV-2 infection during successive waves of the COVID-19 pandemic in a reference hospital in Spain. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-22145-9"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Iftimie, S., L\u00f3pez-Azcona, A.F., Lozano-Olmo, M.J., Naval-Ferrando, \u00c0., Domingo-Cort\u00e9s, V., Casta\u00f1\u00e9, H., Jim\u00e9nez-Franco, A., Hern\u00e1ndez-Aguilera, A., Guilarte, C., and Riu, F. (2023). Retrospective analysis of vaccination status and predominant viral variants in patients hospitalized with COVID-19 in Reus, Spain. Viruses, 15.","DOI":"10.3390\/v15040886"},{"key":"ref_23","unstructured":"(2024, May 06). Manual VINCat. Available online: https:\/\/catsalut.gencat.cat\/web\/.content\/minisite\/vincat\/documents\/manuals\/Manual-VINCat-2019.pdf."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1016\/0002-9343(80)90101-1","article-title":"Gram-negative bacteremia. III. Reassessment of etiology, epidemiology and ecology in 612 patients","volume":"68","author":"Kreger","year":"1980","journal-title":"Am. J. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1003","DOI":"10.7326\/0003-4819-117-12-1003","article-title":"Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly","volume":"117","author":"Berkman","year":"1992","journal-title":"Ann. Intern. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"S63","DOI":"10.1016\/j.cmi.2016.03.010","article-title":"European Society of Clinical Microbiology and Infectious Diseases: Update of the diagnostic guidance document for Clostridium difficile infection","volume":"22","author":"Crobach","year":"2016","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Iftimie, S., L\u00f3pez-Azcona, A.F., Vicente-Miralles, M., Descarrega-Reina, R., Hern\u00e1ndez-Aguilera, A., Riu, F., Sim\u00f3, J.M., Garrido, P., Joven, J., and Camps, J. (2020). Risk factors associated with mortality in hospitalized patients with SARS-CoV-2 infection. A prospective, longitudinal, unicenter study in Reus, Spain. PLoS ONE, 15.","DOI":"10.1101\/2020.05.29.122986"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1017\/ice.2023.171","article-title":"Describing the monthly variability of hospital-onset Clostridioides difficile during early coronavirus disease 2019 (COVID-19) using electronic health record data","volume":"45","author":"Lang","year":"2023","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.gastha.2021.08.005","article-title":"Risk of healthcare-associated Clostridioides difficile infection during pandemic preparation: A retrospective cohort study","volume":"1","author":"Suarez","year":"2022","journal-title":"Gastro. Hep. Adv."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Wright, L.M., Skinner, A.M., Cheknis, A., McBurney, C., Ge, L., Pacheco, S.M., Leehey, D., Gerding, D.N., and Johnson, S. (2023). Effect of the COVID-19 pandemic on rates and epidemiology of Clostridioides difficile infection in one VA hospital. Antibiotics, 12.","DOI":"10.20944\/preprints202306.0636.v1"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"622","DOI":"10.1002\/jgh3.12497","article-title":"Prevalence and impact of Clostridioides difficile infection among hospitalized patients with coranavirus disease 2019","volume":"5","author":"Allegretti","year":"2021","journal-title":"JGH Open"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Sinnathamby, E.S., Mason, J.W., Flanagan, C.J., Pearl, N.Z., Burroughs, C.R., De Witt, A.J., Wenger, D.M., Klapper, V.G., Ahmadzadeh, S., and Varrassi, G. (2023). Clostridioides difficile infection: A clinical review of pathogenesis, clinical considerations, and treatment strategies. Cureus, 15.","DOI":"10.7759\/cureus.51167"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1080\/17843286.2023.2250624","article-title":"Impact of the COVID-19 pandemic on Clostridioides difficile infection in a tertiary healthcare institution in Belgium","volume":"78","author":"Tossens","year":"2023","journal-title":"Acta Clin."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1302","DOI":"10.1016\/j.ajic.2023.08.019","article-title":"The impact of the COVID-19 pandemic on hospital-acquired infections at a comprehensive cancer center","volume":"51","author":"Spallone","year":"2023","journal-title":"Am. J. Infect. Control"},{"key":"ref_35","first-page":"5","article-title":"The management of Clostridioides difficile infection: From empirism to evidence","volume":"97","author":"Deac","year":"2024","journal-title":"Med. Pharm. Rep."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Abubakar, U., Awaisu, A., Khan, A.H., and Alam, K. (2023). Impact of COVID-19 pandemic on healthcare-associated infections: A systematic review and meta-analysis. Antibiotics, 12.","DOI":"10.3390\/antibiotics12111600"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"699","DOI":"10.15585\/mmwr.mm6923e1","article-title":"Impact of the COVID-19 pandemic on emergency department visits\u2014United States, January 1, 2019-May 30, 2020","volume":"69","author":"Hartnett","year":"2020","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"S4","DOI":"10.1097\/MLR.0000000000001812","article-title":"Impact of COVID-19 on trends in outpatient clinic utilization: A tale of 2 departments","volume":"61","author":"McCracken","year":"2023","journal-title":"Med. Care"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"671","DOI":"10.2471\/BLT.20.264044","article-title":"Impact of COVID-19 response on global surgical volumes: An ongoing observational study","volume":"98","author":"Long","year":"2020","journal-title":"Bull. World Health Organ."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1419","DOI":"10.1001\/jamacardio.2020.3629","article-title":"Case rates, treatment approaches, and outcomes in acute myocardial infarction during the coronavirus disease 2019 pandemic","volume":"5","author":"Gluckman","year":"2020","journal-title":"JAMA Cardiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"243","DOI":"10.23938\/ASSN.0957","article-title":"Analysis of the evolution of patients attended in Spanish emergency departments during the first wave of the pandemic","volume":"44","author":"Jacob","year":"2021","journal-title":"An. Sist. Sanit. Navar."},{"key":"ref_42","unstructured":"World Health Organization (2024, March 27). Promoting Antimicrobial Stewardship to Tackle Antimicrobial Resistance. Available online: https:\/\/www.who.int\/europe\/activities\/promoting-antimicrobial-stewardship-to-tackle-antimicrobial-resistance."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Vintila, B.I., Arseniu, A.M., Morgovan, C., Butuca, A., B\u00eerlu\u021biu, V., Dobrea, C.M., Rus, L.L., Ghibu, S., Bereanu, A., and Arseniu, R. (2024). A real-world study on the clinical characteristics, outcomes, and relationship between antibiotic exposure and Clostridioides difficile infection. Antibiotics, 13.","DOI":"10.3390\/antibiotics13020144"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1099\/jmm.0.058479-0","article-title":"Mortality in patients with Clostridium difficile infection correlates with host pro-inflammatory and humoral immune responses","volume":"62","author":"Solomon","year":"2013","journal-title":"J. Med. Microbiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e77","DOI":"10.1086\/653012","article-title":"Predictors of death after Clostridium difficile infection: A report on 128 strain-typed cases from a teaching hospital in the United Kingdom","volume":"50","author":"Wilson","year":"2010","journal-title":"Clin. Infect. Dis."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1111\/apt.13546","article-title":"Clostridium difficile associated risk of death score (CARDS): A novel severity score to predict mortality among hospitalised patients with C. difficile infection","volume":"43","author":"Kassam","year":"2016","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.bj.2018.12.002","article-title":"Risk factors and outcomes of Clostridium difficile infection in hospitalized patients","volume":"42","author":"Lee","year":"2019","journal-title":"Biomed. J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/10\/2799\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:43:04Z","timestamp":1760107384000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/10\/2799"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,5,9]]},"references-count":47,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2024,5]]}},"alternative-id":["jcm13102799"],"URL":"https:\/\/doi.org\/10.3390\/jcm13102799","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,5,9]]}}}