{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T05:14:50Z","timestamp":1790313290924,"version":"4.1.0"},"reference-count":51,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2022,4,26]],"date-time":"2022-04-26T00:00:00Z","timestamp":1650931200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004336","name":"Novartis","doi-asserted-by":"publisher","award":["non-promotional grant"],"award-info":[{"award-number":["non-promotional grant"]}],"id":[{"id":"10.13039\/100004336","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100005188","name":"AAIR Charity","doi-asserted-by":"publisher","award":["charitable grant"],"award-info":[{"award-number":["charitable grant"]}],"id":[{"id":"10.13039\/501100005188","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Difficult asthma describes asthma in which comorbidities, inadequate treatment, suboptimal inhaler technique and\/or poor adherence impede good asthma control. The association of anxiety and depression with difficult asthma outcomes (exacerbations, hospital admissions, asthma control, etc.) is unclear. This study assessed the clinical associations of anxiety and depression with difficult asthma outcomes in patients with a specialist diagnosis of difficult asthma. Using real-world data, we retrospectively phenotyped patients from the Wessex Asthma Cohort of Difficult Asthma (N = 441) using clinical diagnoses of anxiety and depression against those without anxiety or depression (controls). Additionally, we stratified patients by severity of psychological distress using the Hospital Anxiety and Depression Scale (HADS). We found that depression and\/or anxiety were reported in 43.1% of subjects and were associated with worse disease-related questionnaire scores. Each psychological comorbidity group showed differential associations with difficult asthma outcomes. Anxiety alone (7.9%) was associated with dysfunctional breathing and more hospitalisations [anxiety, median (IQR): 0 (2) vs. controls: 0 (0)], while depression alone (11.6%) was associated with obesity and obstructive sleep apnoea. The dual anxiety and depression group (23.6%) displayed multimorbidity, worse asthma outcomes, female predominance and earlier asthma onset. Worse HADS-A scores in patients with anxiety were associated with worse subjective outcomes (questionnaire scores), while worse HADS-D scores in patients with depression were associated with worse objective (ICU admissions and maintenance oral corticosteroid requirements) and subjective outcomes. In conclusion, anxiety and depression are common in difficult asthma but exert differential detrimental effects. Difficult asthma patients with dual anxiety and depression experience worse asthma outcomes alongside worse measures of psychological distress. There is a severity-gradient association of HADS scores with worse difficult asthma outcomes. Collectively, our findings highlight the need for holistic, multidisciplinary approaches that promote early identification and management of anxiety and depression in difficult asthma patients.<\/jats:p>","DOI":"10.3390\/jpm12050686","type":"journal-article","created":{"date-parts":[[2022,4,26]],"date-time":"2022-04-26T11:45:55Z","timestamp":1650973555000},"page":"686","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["The Detrimental Clinical Associations of Anxiety and Depression with Difficult Asthma Outcomes"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2546-156X","authenticated-orcid":false,"given":"Wei","family":"Fong","sequence":"first","affiliation":[{"name":"School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK"},{"name":"David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5750-2648","authenticated-orcid":false,"given":"Ishmail","family":"Rafiq","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Harvey","sequence":"additional","affiliation":[{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0792-8939","authenticated-orcid":false,"given":"Sabina","family":"Stanescu","sequence":"additional","affiliation":[{"name":"Department of Psychology, University of Southampton, Southampton SO17 1BJ, 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UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heena","family":"Mistry","sequence":"additional","affiliation":[{"name":"School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK"},{"name":"David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK"},{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1684-9207","authenticated-orcid":false,"given":"Mohammed","family":"Kyyaly","sequence":"additional","affiliation":[{"name":"School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK"},{"name":"David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight PO30 5TG, UK"},{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5335-5129","authenticated-orcid":false,"given":"Clair","family":"Barber","sequence":"additional","affiliation":[{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Freeman","sequence":"additional","affiliation":[{"name":"School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK"},{"name":"Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK"},{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom","family":"Wilkinson","sequence":"additional","affiliation":[{"name":"School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK"},{"name":"Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK"},{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ratko","family":"Djukanovic","sequence":"additional","affiliation":[{"name":"School of Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK"},{"name":"Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK"},{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paddy","family":"Dennison","sequence":"additional","affiliation":[{"name":"NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton SO16 6YD, UK"},{"name":"Department of Respiratory Medicine, 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Pediatr."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1016\/j.jadohealth.2007.05.023","article-title":"The prevalence of DSM-IV anxiety and depressive disorders in youth with asthma compared with controls","volume":"41","author":"Katon","year":"2007","journal-title":"J. Adolesc. Health"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1097\/MCP.0b013e328341005f","article-title":"Anxiety and depression in asthma","volume":"17","author":"Marco","year":"2011","journal-title":"Curr. Opin. Pulm. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1038\/s41533-019-0149-3","article-title":"A systematic review of psychological, physical health factors, and quality of life in adult asthma","volume":"29","author":"Stanescu","year":"2019","journal-title":"NPJ Prim. Care Respir. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.21037\/jtd.2016.04.68","article-title":"Co-morbid psychological dysfunction is associated with a higher risk of asthma exacerbations: A systematic review and meta-analysis","volume":"8","author":"Zhang","year":"2016","journal-title":"J. Thorac. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"6460379","DOI":"10.1155\/2018\/6460379","article-title":"Effects of Comorbidities on Asthma Hospitalization and Mortality Rates: A Systematic Review","volume":"2018","author":"Mahdavian","year":"2018","journal-title":"Can. Respir. J."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1039","DOI":"10.1378\/chest.130.4.1039","article-title":"What Is Worse for Asthma Control and Quality of Life: Depressive Disorders, Anxiety Disorders, or Both?","volume":"130","author":"Lavoie","year":"2006","journal-title":"Chest"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"594","DOI":"10.1016\/j.jad.2019.06.031","article-title":"Suicidality among patients with asthma: A systematic review and meta-analysis","volume":"256","author":"Zhang","year":"2019","journal-title":"J. Affect. Disord."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.jaip.2017.06.034","article-title":"Anxiety Contributes to Poorer Asthma Outcomes in Inner-City Black Adolescents","volume":"6","author":"Shams","year":"2018","journal-title":"J. Allergy Clin. Immunol. Pract."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1369","DOI":"10.1111\/all.13370","article-title":"Comorbid \u201ctreatable traits\u201d in difficult asthma: Current evidence and clinical evaluation","volume":"73","author":"Tay","year":"2018","journal-title":"Allergy"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1384","DOI":"10.1111\/resp.12838","article-title":"Comorbidities in difficult asthma are independent risk factors for frequent exacerbations, poor control and diminished quality of life","volume":"21","author":"Tay","year":"2016","journal-title":"Respirology"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1016\/j.jaip.2019.07.009","article-title":"The Relationship of Psychological Factors and Asthma Control to Health-Related Quality of Life","volume":"8","year":"2020","journal-title":"J. Allergy Clin. Immunol. Pract."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1056\/NEJMp2008017","article-title":"Mental Health and the COVID-19 Pandemic","volume":"383","author":"Pfefferbaum","year":"2020","journal-title":"New Engl. J. Med."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Azim, A., Mistry, H., Freeman, A., Barber, C., Newell, C., Gove, K., Thirlwall, Y., Harvey, M., Bentley, K., and Knight, D. (2019). Protocol for the Wessex AsThma CoHort of difficult asthma (WATCH): A pragmatic real-life longitudinal study of difficult asthma in the clinic. BMC Pulm. Med., 19.","DOI":"10.1186\/s12890-019-0862-2"},{"key":"ref_15","unstructured":"Asthma, and British Thoracic Society (2020, December 29). Better Lung Health for All. Available online: https:\/\/www.brit-thoracic.org.uk\/quality-improvement\/guidelines\/asthma\/."},{"key":"ref_16","unstructured":"GINA Severe Asthma (2021, April 14). Pocket Guide. Available online: https:\/\/ginasthma.org\/wp-content\/uploads\/2019\/04\/GINA-Severe-asthma-Pocket-Guide-v2.0-wms-1.pdf."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1111\/j.1600-0447.1983.tb09716.x","article-title":"The hospital anxiety and depression scale","volume":"67","author":"Zigmond","year":"1983","journal-title":"Acta Psychiatr. Scand."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1097\/00001648-199001000-00010","article-title":"No Adjustments Are Needed for Multiple Comparisons","volume":"1","author":"Rothman","year":"1990","journal-title":"Epidemiology"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1016\/j.jaip.2019.07.023","article-title":"Spreading the Word: Comorbidity of Asthma and Depression Is Not Just the Product of a Vulnerable Personality","volume":"8","author":"Vargas","year":"2020","journal-title":"J. Allergy Clin. Immunol. Practice"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3396","DOI":"10.1016\/j.jaip.2020.05.053","article-title":"New Perspectives on Difficult Asthma; Sex and Age of Asthma-Onset Based Phenotypes","volume":"8","author":"Azim","year":"2020","journal-title":"J. Allergy Clin. Immunol. Pract."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1016\/j.psychres.2009.04.015","article-title":"Depression and obesity: A meta-analysis of community-based studies","volume":"178","author":"Wit","year":"2010","journal-title":"Psychiatry Res."},{"key":"ref_22","first-page":"211","article-title":"Sleeping too Close Together: Obesity and Obstructive Sleep Apnea in Childhood and Adolescence","volume":"15","author":"Mathew","year":"2014","journal-title":"Paediatr. Respir. Rev."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Clair, C., Chiolero, A., Faeh, D., Cornuz, J., Marques-Vidal, P., Paccaud, F., Mooser, V., Waeber, G., and Vollenweider, P. (2011). Dose-dependent positive association between cigarette smoking, abdominal obesity and body fat: Cross-sectional data from a population-based survey. BMC Public Health, 11.","DOI":"10.1186\/1471-2458-11-23"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1016\/S2215-0366(18)30459-0","article-title":"Does smoking cause poor mental health?","volume":"6","author":"Taylor","year":"2019","journal-title":"Lancet Psychiatry"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1186\/2045-7022-2-18","article-title":"Dysfunctional breathing phenotype in adults with asthma\u2014Incidence and risk factors","volume":"2","author":"Agache","year":"2012","journal-title":"Clin. Transl. Allergy"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1901509","DOI":"10.1183\/13993003.01509-2019","article-title":"Targeting treatable traits in severe asthma: A randomised controlled trial","volume":"55","author":"McDonald","year":"2020","journal-title":"Eur. Respir. J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"S11","DOI":"10.5694\/mja18.00196","article-title":"Managing comorbid conditions in severe asthma","volume":"209","author":"Bardin","year":"2018","journal-title":"Med. J. Aust."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"00039","DOI":"10.1183\/23120541.00039-2016","article-title":"A multidisciplinary team case management approach reduces the burden of frequent asthma admissions","volume":"2","author":"Burke","year":"2016","journal-title":"ERJ Open Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1953","DOI":"10.1016\/j.jaip.2018.02.002","article-title":"Anxiety, Depression, and Asthma Control: Changes After Standardized Treatment","volume":"6","author":"Sastre","year":"2018","journal-title":"J. Allergy Clin. Immunol. Pract."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1080\/02770903.2020.1841791","article-title":"The impact of clinical and psychological factors on asthma control: The experience of a single asthma center in Poland","volume":"59","author":"Przybyszowski","year":"2022","journal-title":"J. Asthma"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1111\/j.1440-1843.2008.01310.x","article-title":"The association of comorbid anxiety and depression with asthma-related quality of life and symptom perception in adults","volume":"13","author":"Deshmukh","year":"2008","journal-title":"Respirology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e35952","DOI":"10.32872\/cpe.v1i4.35952","article-title":"Symptom Perception From a Predictive Processing Perspective","volume":"1","author":"Pezzulo","year":"2019","journal-title":"Clin. Psychol. Eur."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1175","DOI":"10.1007\/s11606-011-1704-y","article-title":"Depression and medication adherence in the treatment of chronic diseases in the United States: A meta-analysis","volume":"26","author":"Grenard","year":"2011","journal-title":"J. Gen. Intern. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1016\/j.jad.2014.04.027","article-title":"Comorbidity between depression and asthma via immune-inflammatory pathways: A meta-analysis","volume":"166","author":"Jiang","year":"2014","journal-title":"J. Affect. Disord."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1111\/j.1440-1843.2011.02093.x","article-title":"Obesity and obstructive sleep apnoea: Mechanisms for increased collapsibility of the passive pharyngeal airway","volume":"17","author":"Isono","year":"2012","journal-title":"Respirology"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"034003","DOI":"10.1088\/1752-7163\/ab0ece","article-title":"Basic characteristics and clinical value of FeNO in smoking asthmatics\u2014A systematic review","volume":"13","author":"Csonka","year":"2019","journal-title":"J. Breath Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1378\/chest.12-0872","article-title":"Obesity-Associated Severe Asthma Represents a Distinct Clinical Phenotype: Analysis of the British Thoracic Society Difficult Asthma Registry Patient Cohort According to BMI","volume":"143","author":"Gibeon","year":"2013","journal-title":"Chest"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"905","DOI":"10.3109\/02770903.2014.1003155","article-title":"Case series: The application of \u201cthird wave\u201d cognitive behavioural therapies in difficult to treat asthma","volume":"52","author":"Fellows","year":"2015","journal-title":"J. Asthma"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1734","DOI":"10.1007\/s12671-020-01391-w","article-title":"Feasibility and Acceptability of a Group Mindfulness Intervention in a Difficult Asthma Clinic","volume":"11","author":"Ainsworth","year":"2020","journal-title":"Mindfulness"},{"key":"ref_40","first-page":"227","article-title":"Comorbidity of depressive and anxiety disorders: Challenges in diagnosis and assessment","volume":"26","author":"Wu","year":"2014","journal-title":"Shanghai Arch. Psychiatry"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1016\/j.biopsych.2019.04.028","article-title":"Sex Differences in Vulnerability and Resilience to Stress Across the Life Span","volume":"86","author":"Hodes","year":"2019","journal-title":"Biol. Psychiatry"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1019","DOI":"10.1111\/cea.13882","article-title":"Real-world Omalizumab and Mepolizumab treated Difficult Asthma Phenotypes and their Clinical Outcomes","volume":"51","author":"Fong","year":"2021","journal-title":"Clin. Exp. Allergy"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1016\/S0163-8343(99)00005-5","article-title":"Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression?","volume":"21","author":"Gaynes","year":"1999","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/0165-0327(90)90070-O","article-title":"Anxiety and depression in a community sample: The influence of comorbidity on social functioning","volume":"18","author":"Hecht","year":"1990","journal-title":"J. Affect. Disord."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1176\/ajp.145.8.976","article-title":"Psychiatric disorder in a sample of the general population with and without chronic medical conditions","volume":"145","author":"Wells","year":"1988","journal-title":"Am. J. Psychiatry"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1700765","DOI":"10.1183\/13993003.00765-2017","article-title":"\u201cI have lost in every facet of my life\u201d: The hidden burden of severe asthma","volume":"50","author":"Foster","year":"2017","journal-title":"Eur. Respir. J."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1016\/j.anai.2015.08.007","article-title":"The impact of anxiety and depression on outpatients with asthma","volume":"115","author":"Ciprandi","year":"2015","journal-title":"Ann. Allergy Asthma Immunol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e825","DOI":"10.1038\/tp.2016.92","article-title":"Cytokine production capacity in depression and anxiety","volume":"6","author":"Vogelzangs","year":"2016","journal-title":"Transl. Psychiatry"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1604","DOI":"10.1016\/j.jaip.2018.01.010","article-title":"A Randomized, Double-Blind, Placebo-Controlled Trial of Escitalopram in Patients with Asthma and Major Depressive Disorder","volume":"6","author":"Brown","year":"2018","journal-title":"J. Allergy Clin. Immunol. Pract."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1097\/ACI.0000000000000440","article-title":"Phenotypes\/endotypes-driven treatment in asthma","volume":"18","author":"Braido","year":"2018","journal-title":"Curr. Opin. Allergy Clin. Immunol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1007\/s40259-017-0242-5","article-title":"Asthma Phenotypes and Endotypes: Implications for Personalised Therapy","volume":"31","author":"Dean","year":"2017","journal-title":"BioDrugs"}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/12\/5\/686\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:01:13Z","timestamp":1760137273000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/12\/5\/686"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,4,26]]},"references-count":51,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2022,5]]}},"alternative-id":["jpm12050686"],"URL":"https:\/\/doi.org\/10.3390\/jpm12050686","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,4,26]]}}}