{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:37:10Z","timestamp":1760060230208,"version":"build-2065373602"},"reference-count":56,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2025,8,19]],"date-time":"2025-08-19T00:00:00Z","timestamp":1755561600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Postnatal cytomegalovirus (pCMV) infection is typically asymptomatic in term infants but poses significant risks to very preterm and very low birth weight (VLBW) infants. The primary mode of transmission of pCMV is breast milk from seropositive mothers. Here, we present the case of a 29-week preterm female who contracted pCMV and began to manifest symptoms at day of life (DOL) 50. She developed respiratory compromise, massive ascites, and was extremely ill. The patient was managed with ganciclovir (GCV), intravenous immunoglobulins (IVIG), and percutaneous drainage of the ascites. She gradually improved and was discharged after a 5-month neonatal intensive care unit (NICU) stay. After presenting the case, we review the clinical manifestations of pCMV, and particularly its less well-recognized gastrointestinal manifestations, including ascites. We then outline guidelines for treatment and prevention. Clinicians should consider pCMV in VLBW and extremely premature infants presenting with thrombocytopenia, colitis, or ascites, especially in the second and third months of life.<\/jats:p>","DOI":"10.3390\/jcm14165854","type":"journal-article","created":{"date-parts":[[2025,8,19]],"date-time":"2025-08-19T10:59:01Z","timestamp":1755601141000},"page":"5854","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Ascites and Enterocolitis in a Preterm Infant with Acquired CMV Infection: A Case Study and Review of the Literature"],"prefix":"10.3390","volume":"14","author":[{"given":"Keren","family":"Nathan","sequence":"first","affiliation":[{"name":"Department of Pediatric Infectious Disease, Bnai Zion Medical Center, Haifa 3339419, Israel"},{"name":"Technion Israel Institute of Technology, Rappaport, Haifa 3525422, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ellen","family":"Bamberger","sequence":"additional","affiliation":[{"name":"Department of Pediatric Infectious Disease, Bnai Zion Medical Center, Haifa 3339419, Israel"},{"name":"Technion Israel Institute of Technology, Rappaport, Haifa 3525422, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel","family":"Dubin","sequence":"additional","affiliation":[{"name":"Technion Israel Institute of Technology, Rappaport, Haifa 3525422, Israel"},{"name":"Department of Pediatric Surgery, Bnai Zion Medical Center, Haifa 3339419, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morya","family":"Shneider","sequence":"additional","affiliation":[{"name":"Technion Israel Institute of Technology, Rappaport, Haifa 3525422, Israel"},{"name":"Department of Neonatology, Bnai Zion Medical Center, Haifa 3339419, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Narmin","family":"Shehade Smair","sequence":"additional","affiliation":[{"name":"Technion Israel Institute of Technology, Rappaport, Haifa 3525422, Israel"},{"name":"Department of Pediatric Gastroenterology, Bnai Zion Medical Center, Haifa 3339419, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rasha","family":"Zoabi Safadi","sequence":"additional","affiliation":[{"name":"Technion Israel Institute of Technology, Rappaport, Haifa 3525422, Israel"},{"name":"Department of Neonatology, Bnai Zion Medical Center, Haifa 3339419, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Kimberlin, D.W., Banerjee, R., Barnett, E.D., Lynfield, R., and Sawyer, M.H. (2024). Cytomegalovirus Infection. Red Book: 2024\u20132027 Report of the Committee on Infectious Diseases, The Committee on Infectious Diseases of the American Academy of Pediatrics.","DOI":"10.1542\/9781610027373"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1136\/archdischild-2019-317650","article-title":"Postnatally acquired cytomegalovirus infection in extremely premature infants: How best to manage?","volume":"105","author":"Kadambari","year":"2020","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e205441","DOI":"10.1001\/jamapediatrics.2020.5441","article-title":"Sensitivity of Dried Blood Spot Testing for Detection of Congenital Cytomegalovirus Infection","volume":"175","author":"Dollard","year":"2021","journal-title":"JAMA Pediatr."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1016\/S0140-6736(00)04043-5","article-title":"Epidemiology of transmission of cytomegalovirus from mother to preterm infant by breastfeeding","volume":"357","author":"Hamprecht","year":"2001","journal-title":"Lancet"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.clp.2016.11.012","article-title":"Postnatal Cytomegalovirus Infection Through Human Milk in Preterm Infants","volume":"44","author":"Hamprecht","year":"2017","journal-title":"Clin. Perinatol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1172","DOI":"10.1111\/j.1469-0691.2010.03140.x","article-title":"Transmission of cytomegalovirus via breast milk to the prematurely born infant: A systematic review","volume":"16","author":"Kurath","year":"2010","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1038\/jp.2010.150","article-title":"Transmission of cytomegalovirus via breast milk in extremely premature infants","volume":"31","author":"Hayashi","year":"2011","journal-title":"J. Perinatol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1097\/INF.0000000000003531","article-title":"Postnatal Cytomegalovirus Infection: Is it Important? A 10-Year Retrospective Case-control Study of Characteristics and Outcomes in Very Preterm and Very Low Birth Weight Infants","volume":"41","author":"Minihan","year":"2022","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1159\/000529241","article-title":"NSW and the ACT Neonatal Intensive Care Units (NICUS) Group Symptomatic Postnatal Cytomegalovirus Infection in Less than 32-Week Preterm Infants: 13-Year Retrospective Multicenter Case-Control Study","volume":"120","author":"Tapawan","year":"2023","journal-title":"Neonatology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e153785","DOI":"10.1001\/jamapediatrics.2015.3785","article-title":"Postnatal Cytomegalovirus Infection and the Risk for Bronchopulmonary Dysplasia","volume":"169","author":"Kelly","year":"2015","journal-title":"JAMA Pediatr."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/rmv.2117","article-title":"Impact of breast milk-acquired cytomegalovirus infection in premature infants: Pathogenesis, prevention, and clinical consequences?","volume":"30","author":"Osterholm","year":"2020","journal-title":"Rev. Med. Virol."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Jackson, J.W., and Sparer, T. (2018). There Is Always Another Way! Cytomegalovirus\u2019 Multifaceted Dissemination Schemes. Viruses, 10.","DOI":"10.20944\/preprints201807.0013.v1"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1054","DOI":"10.1001\/jamapediatrics.2014.1360","article-title":"Blood Transfusion and Breast Milk Transmission of Cytomegalovirus in Very Low-Birth-Weight Infants: A Prospective Cohort Study","volume":"168","author":"Josephson","year":"2014","journal-title":"JAMA Pediatr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1016\/j.tmrv.2010.11.004","article-title":"Prevention of Transfusion-Transmitted Cytomegalovirus in Low\u2013Birth Weight Infants (\u22641500 g) Using Cytomegalovirus-Seronegative and Leukoreduced Transfusions","volume":"25","author":"Josephson","year":"2011","journal-title":"Transfus. Med. Rev."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1586\/14787210.2014.966080","article-title":"Predictors of severity for postnatal cytomegalovirus infection in preterm infants and implications for treatment","volume":"12","author":"Gunkel","year":"2014","journal-title":"Expert. Rev. Anti Infect. Ther."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"689","DOI":"10.1002\/jmv.23511","article-title":"Maternal and neonatal anti-cytomegalovirus IgG level and risk of postnatal cytomegalovirus transmission in preterm infants","volume":"85","author":"Nijman","year":"2013","journal-title":"J. Med. Virol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e1937","DOI":"10.1542\/peds.2013-0076","article-title":"Breast Milk\u2013Acquired Cytomegalovirus Infection and Disease in VLBW and Premature Infants","volume":"131","author":"Lanzieri","year":"2013","journal-title":"Pediatrics"},{"key":"ref_18","unstructured":"Takemoto, K., Oshiro, M., Sato, Y., Yamamoto, H., Ito, M., Hayashi, S., Kato, E., Kato, Y., and Hayakawa, M. (2021). Outcomes in Symptomatic Preterm Infants with Postnatal Cytomegalovirus Infection, Nagoya University Graduate School of Medicine, School of Medicine."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1998","DOI":"10.1086\/324345","article-title":"Cytomegalovirus Infection of Extremely Low\u2013Birth Weight Infants via Breast Milk","volume":"33","author":"Maschmann","year":"2001","journal-title":"Clin. Infect. Dis."},{"key":"ref_20","unstructured":"(2025, March 02). Postnatal CMV Infection and Antiviral Treatment in Extremely Premature Infants: A 12-Year Retrospective Analysis. Available online: https:\/\/oce-ovid-com.carmelmc.idm.oclc.org\/article\/00006454-202302000-00015\/HTML."},{"key":"ref_21","unstructured":"(2025, July 27). Postnatal Human Cytomegalovirus Infection in Preterm Infants Has Long-Term Neuropsychological Sequelae\u2014ClinicalKey, Available online: https:\/\/www-clinicalkey-com.carmelmc.idm.oclc.org\/#!\/content\/playContent\/1-s2.0-S0022347614010403?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0022347614010403%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1097\/INF.0000000000003072","article-title":"Long-term Outcomes after Postnatal Cytomegalovirus Infection in Low Birthweight Preterm Infants: A Systematic Review","volume":"40","author":"Stark","year":"2021","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.jcv.2016.08.289","article-title":"Intestinal manifestations of postnatal and congenital cytomegalovirus infection in term and preterm infants","volume":"83","author":"Goelz","year":"2016","journal-title":"J. Clin. Virol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"F367","DOI":"10.1136\/adc.2003.032821","article-title":"Gastrointestinal manifestations of postnatal cytomegalovirus infection in infants admitted to a neonatal intensive care unit over a five year period","volume":"89","author":"Cheong","year":"2004","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Alsaied, A., Islam, N., and Thalib, L. (2020). Global incidence of Necrotizing Enterocolitis: A systematic review and Meta-analysis. BMC Pediatr., 20.","DOI":"10.1186\/s12887-020-02231-5"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Altobelli, E., Angeletti, P.M., Verrotti, A., and Petrocelli, R. (2020). The Impact of Human Milk on Necrotizing Enterocolitis: A Systematic Review and Meta-Analysis. Nutrients, 12.","DOI":"10.3390\/nu12051322"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.jcv.2017.05.022","article-title":"High prevalence of cytomegalovirus infection in surgical intestinal specimens from infants with necrotizing enterocolitis and spontaneous intestinal perforation: A retrospective observational study","volume":"93","author":"Omarsdottir","year":"2017","journal-title":"J. Clin. Virol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1016\/j.jpeds.2019.07.038","article-title":"Detection of Cytomegalovirus in Intestinal Tissue of Infants with Necrotizing Enterocolitis or Spontaneous Intestinal Perforation","volume":"214","author":"Shimamura","year":"2019","journal-title":"J. Pediatr."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e2022060876","DOI":"10.1542\/peds.2022-060876","article-title":"Viral Infections and Neonatal Necrotizing Enterocolitis: A Meta-analysis","volume":"152","author":"Mani","year":"2023","journal-title":"Pediatrics"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1136\/archdischild-2018-316613","article-title":"Observational study of cytomegalovirus from breast milk and necrotising enterocolitis","volume":"105","author":"Patel","year":"2020","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e1428","DOI":"10.1542\/peds.2013-0087","article-title":"Asymptomatic DNAemia Heralds CMV-Associated NEC: Case Report, Review, and Rationale for Preemption","volume":"132","author":"Tengsupakul","year":"2013","journal-title":"Pediatrics"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1038\/sj.jp.7211042","article-title":"Cytomegalovirus-associated Necrotizing Enterocolitis in a Preterm Twin After Breastfeeding","volume":"24","author":"Gessler","year":"2004","journal-title":"J. Perinatol."},{"key":"ref_33","first-page":"180","article-title":"Recommendations for Diagnosis and Prevention of Cytomegalovirus-Associated Necrotizing Enterocolitis in Breast-Fed Preterm Infants","volume":"27","author":"Pham","year":"2022","journal-title":"J. Pediatr. Pharmacol. Ther."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1093\/jpids\/pis060","article-title":"Cytomegalovirus Enterocolitis Mimicking Necrotizing Enterocolitis: Case Reports and Review of the Literature","volume":"2","author":"Farrow","year":"2013","journal-title":"J. Pediatr. Infect. Dis. Soc."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Morimoto, M., Sawada, H., Yodoya, N., Ohashi, H., Toriyabe, K., Hanaki, R., Sugiura, K., Toyoda, H., Matsushita, K., and Koike, Y. (2020). Refractory Ileal Perforations in a Cytomegalovirus-Infected Premature Neonate Resolved After Ganciclovir Therapy. Front. Pediatr., 8.","DOI":"10.3389\/fped.2020.00352"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1007\/s12519-011-0307-3","article-title":"Cytomegalovirus enterocolitis presenting as abdominal compartment syndrome in a premature neonate","volume":"8","author":"Lee","year":"2012","journal-title":"World J. Pediatr."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1159\/000260137","article-title":"Severe Postnatally Acquired Cytomegalovirus Infection Presenting with Colitis, Pneumonitis and Sepsis-Like Syndrome in an Extremely Low Birthweight Infant","volume":"97","author":"Fischer","year":"2010","journal-title":"Neonatology"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/j.jcv.2014.01.022","article-title":"Severe postnatal CMV colitis with an extensive colonic stenosis in a 2-month-old male immunocompetent term infant infected via breast milk","volume":"59","author":"Novakova","year":"2014","journal-title":"J. Clin. Virol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1080\/00365521.2019.1706763","article-title":"Cytomegalovirus enteritis with intractable diarrhea in infants from a tertiary care center in China","volume":"55","author":"Wang","year":"2020","journal-title":"Scand. J. Gastroenterol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1097\/MPG.0b013e3181aecb7f","article-title":"Oral Gancyclovir Therapy for Immunocompetent Infants with Cytomegalovirus-associated Hemorrhagic or Intractable Enterocolitis","volume":"50","author":"Nigro","year":"2010","journal-title":"J. Pediatr. Gastroenterol. Nutr."},{"key":"ref_41","first-page":"E66","article-title":"A Case of an Extremely Preterm Infant with Intussusception Triggered by Acquired Cytomegalovirus Infection","volume":"70","author":"Naito","year":"2024","journal-title":"Kobe J. Med. Sci."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1055\/s-2007-992350","article-title":"Diagnostic Evaluation of Neonatal Ascites","volume":"24","author":"Aslam","year":"2007","journal-title":"Am. J. Perinatol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e467","DOI":"10.1097\/INF.0000000000004465","article-title":"A Preterm Baby With Ascites Related to Congenital CMV Infection","volume":"43","author":"Albusaidi","year":"2024","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1007\/BF00441550","article-title":"Recurrent ascites in an infant with perinatally acquired cytomegalovirus infection","volume":"148","author":"Levy","year":"1989","journal-title":"Eur. J. Pediatr."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1179\/146532808X335705","article-title":"Fetal ascites owing to congenital cytomegalovirus: Response to ganciclovir","volume":"28","author":"Basu","year":"2008","journal-title":"Ann. Trop. Paediatr."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Fujioka, K., Morioka, I., Nishida, K., Morizane, M., Tanimura, K., Deguchi, M., Iijima, K., and Yamada, H. (2017). Pulmonary Hypoplasia Caused by Fetal Ascites in Congenital Cytomegalovirus Infection Despite Fetal Therapy. Front. Pediatr., 5.","DOI":"10.3389\/fped.2017.00241"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1056\/NEJMoa1404599","article-title":"Valganciclovir for Symptomatic Congenital Cytomegalovirus Disease","volume":"372","author":"Kimberlin","year":"2015","journal-title":"N. Engl. J. Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/S0022-3476(03)00192-6","article-title":"Effect of ganciclovir therapy on hearing in symptomatic congenital cytomegalovirus disease involving the central nervous system: A randomized, controlled trial","volume":"143","author":"Kimberlin","year":"2003","journal-title":"J. Pediatr."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Sunada, M., Kinoshita, D., Furukawa, N., Kihara, M., Nishimura, A., Moriuchi, M., and Moriuchi, H. (2016). Therapeutic drug monitoring of ganciclovir for postnatal cytomegalovirus infection in an extremely low birth weight infant: A case report. BMC Pediatr., 16.","DOI":"10.1186\/s12887-016-0683-x"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e2021054272","DOI":"10.1542\/peds.2021-054272","article-title":"Committee on Fetus and Newborn Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant","volume":"148","author":"Parker","year":"2021","journal-title":"Pediatrics"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"482","DOI":"10.1097\/INF.0000000000000619","article-title":"Cytomegalovirus infection and neonatal outcome in extremely preterm infants after freezing of maternal milk","volume":"34","author":"Omarsdottir","year":"2015","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1089\/bfm.2016.0107","article-title":"Evaluation of the Freeze\u2013Thawing Method in Reducing Viral Load of Cytomegalovirus in Breast Milk of Mothers of Preterm Infants","volume":"11","author":"Hosseini","year":"2016","journal-title":"Breastfeed. Med."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1038\/s41372-025-02254-9","article-title":"Strategies to reduce CMV infectivity in breastmilk to preterm babies\u2014Impact on transmission, nutrients, and bioactivity: A systematic review and meta-analysis","volume":"45","author":"Singh","year":"2025","journal-title":"J. Perinatol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1093\/cid\/ciy945","article-title":"Short-term Pasteurization of Breast Milk to Prevent Postnatal Cytomegalovirus Transmission in Very Preterm Infants","volume":"69","author":"Bapistella","year":"2019","journal-title":"Clin. Infect. Dis."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"104798","DOI":"10.1016\/j.jcv.2021.104798","article-title":"Pooled saliva CMV DNA detection: A viable laboratory technique for universal CMV screening of healthy newborns","volume":"138","author":"Shlonsky","year":"2021","journal-title":"J. Clin. Virol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1437","DOI":"10.1007\/s00247-025-06271-w","article-title":"Sonographic depiction of intestinal wall defects in infants and young children with intestinal perforation","volume":"55","author":"Traubici","year":"2025","journal-title":"Pediatr. Radiol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/16\/5854\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:30:44Z","timestamp":1760034644000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/16\/5854"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,19]]},"references-count":56,"journal-issue":{"issue":"16","published-online":{"date-parts":[[2025,8]]}},"alternative-id":["jcm14165854"],"URL":"https:\/\/doi.org\/10.3390\/jcm14165854","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,8,19]]}}}