{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T09:07:52Z","timestamp":1785143272540,"version":"3.55.0"},"reference-count":55,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,7,26]],"date-time":"2026-07-26T00:00:00Z","timestamp":1785024000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Pers. Med.","JPM"],"abstract":"<jats:p>Background\/objective: Down syndrome (DS) is characterized by premature aging, with comorbidities observed in the older population without DS, a high prevalence of multimorbidity and cognitive decline. The use of multiple medications further increases clinical complexity. The objective of this paper is to evaluate anticholinergic use and the anticholinergic burden (ACB) in a sample of persons with DS. Methods: cross-sectional retrospective study involving community-dwelling persons with DS, afferent to the DS clinics of the Fondazione Policlinico Universitario \u201cA. Gemelli\u201d (Rome, Italy). Individuals were assessed through a standardized clinical protocol. ACB was evaluated according to the anticholinergic cognitive burden scale, with a score \u2265 3 indicating high risk of anticholinergic side effects. Results: 337 individuals were taking \u2265 1 chronic medication, mean age was 37.7 (\u00b114.6), 158 (43.8%) were females. 143 (39.6%) individuals took \u2265 1 medication with known anticholinergic burden, 51 (14.1%) individuals showed high risk ACB score. High risk ACB score prevalence increased with age (&lt;18 years n = 0, 0%; 18\u201339 years n = 14, 8.2%; 40+ years n = 37, 22.3% p &lt; 0.001). Polypharmacy was more prevalent among individuals with high ACB score (n = 20, 39.2% vs. n = 23, 7.4%, p &lt; 0.001). The most prevalent drugs in individuals with high risk ACB score were antipsychotics (n = 34, 66.6% vs. n = 17, 33.3%, p &lt; 0.001). The most prevalent comorbid condition was psychosis (n = 34, 66.6% vs. n = 16, 33.3%, p &lt; 0.001). Discussion: individuals with DS show a high prevalence of anticholinergic drug use, increasing with age and associated with polypharmacy and psychiatric conditions. These medications are directly addressing the underlying psychiatric or neurological conditions in DS, rather than causing them. Nevertheless, these medications are often essential for managing psychiatric disorders, simultaneously increasing ACB, posing a risk of exacerbating pre-existing vulnerabilities (e.g., cognitive decline), which warrants the need for a more personalized strategy. Conclusions: A thorough assessment of drug history is mandatory in the DS population, to apply deprescribing, pharmacological switches, non-pharmacological approaches, to lower or even prevent high ACB, promoting overall a personalized and tailored approach to this population.<\/jats:p>","DOI":"10.3390\/jpm16080398","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T08:15:56Z","timestamp":1785140156000},"page":"398","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Anticholinergic Burden in Individuals with Down Syndrome: An Examination of Risk and Clinical Implications"],"prefix":"10.3390","volume":"16","author":[{"given":"Emanuele Rocco","family":"Villani","sequence":"first","affiliation":[{"name":"Dipartimento dell\u2019 Integrazione, Unit\u00e0 Operativa Complessa Geriatria Territoriale, Azienda Unit\u00e0 Sanitaria Locale Modena, 41122 Modena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosa","family":"Liperoti","sequence":"additional","affiliation":[{"name":"Department of Geriatric, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"},{"name":"Department of Geriatric, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8638-7565","authenticated-orcid":false,"given":"Laura","family":"Franza","sequence":"additional","affiliation":[{"name":"Clinical Experimental Medicine, Universit\u00e0 degli Studi di Modena e Reggio Emilia, 41122 Modena, Italy"},{"name":"Dipartimento di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria, 41125 Modena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca Maria","family":"Secciani","sequence":"additional","affiliation":[{"name":"Scuola di Specializzazione in Pediatria, Alma Mater Studiorum\u2014Universit\u00e0 di Bologna, 40126 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonella","family":"Di Paola","sequence":"additional","affiliation":[{"name":"Department of Geriatrics, Centro Medicina dell\u2019 Invecchiamento, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3400-4491","authenticated-orcid":false,"given":"Graziano","family":"Onder","sequence":"additional","affiliation":[{"name":"Department of Geriatric, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9837-7003","authenticated-orcid":false,"given":"Angelo","family":"Carf\u00ec","sequence":"additional","affiliation":[{"name":"Department of Geriatrics, Centro Medicina dell\u2019 Invecchiamento, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1038\/s41572-019-0143-7","article-title":"Down syndrome","volume":"6","author":"Antonarakis","year":"2020","journal-title":"Nat. Rev. Dis. Prim."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1111\/j.1532-5415.2012.03925.x","article-title":"Frailty and disability in older adults with intellectual disabilities: Results from the healthy ageing and intellectual disability study","volume":"60","author":"Evenhuis","year":"2012","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1735","DOI":"10.1002\/ajmg.a.61636","article-title":"The burden of chronic disease, multimorbidity, and polypharmacy in adults with Down syndrome","volume":"182","author":"Romano","year":"2020","journal-title":"Am. J. Med. Genet. A"},{"key":"ref_4","first-page":"CD013540","article-title":"Anticholinergic burden (prognostic factor) for prediction of dementia or cognitive decline in older adults with no known cognitive syndrome","volume":"5","author":"Edwards","year":"2021","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"105636","DOI":"10.1016\/j.archger.2024.105636","article-title":"Prevalence of strong anticholinergic use in residents with and without cognitive impairment and frailty: Analysis from 106 nursing homes in 12 Asia-Pacific and European countries","volume":"128","author":"Cross","year":"2025","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_6","unstructured":"(2026, April 22). Evaluating the Use of Anticholinergic Burden (ACB) Score in the Elderly|British Geriatrics Society. Available online: https:\/\/www.bgs.org.uk\/evaluating-the-use-of-anticholinergic-burden-acb-score-in-the-elderly."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Brar, G., Mulryan, N., and Sheerin, F. (2024). Anticholinergic Burden in People with Intellectual Disabilities. The Palgrave Encyclopedia of Disability, Palgrave Macmillan.","DOI":"10.1007\/978-3-031-40858-8_251-1"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"797","DOI":"10.3233\/JAD-170920","article-title":"The Behavioral and Psychological Symptoms of Dementia in Down Syndrome (BPSD-DS) Scale: Comprehensive Assessment of Psychopathology in Down Syndrome","volume":"63","author":"Dekker","year":"2018","journal-title":"J. Alzheimers Dis."},{"key":"ref_9","unstructured":"(2026, April 22). ICD-10 Version:2019. Available online: https:\/\/icd.who.int\/browse10\/2019\/en."},{"key":"ref_10","first-page":"1417","article-title":"Assessing and Measuring Chronic Multimorbidity in the Older Population: A Proposal for Its Operationalization","volume":"72","author":"Vetrano","year":"2017","journal-title":"J. Gerontol. A Biol. Sci. Med. Sci."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e010505","DOI":"10.1136\/bmjopen-2015-010505","article-title":"Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: A cross-sectional observational nationwide study","volume":"6","author":"Peklar","year":"2016","journal-title":"BMJ Open"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1093\/oxfordjournals.aje.a115101","article-title":"The Impact of Confounder Selection Criteria on Effect Estimation","volume":"129","author":"Mickey","year":"1989","journal-title":"Am. J. Epidemiol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Harrell, F.E. (2015). Regression Modeling Strategies: With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis, Springer. Available online: https:\/\/link.springer.com\/book\/10.1007\/978-3-319-19425-7.","DOI":"10.1007\/978-3-319-19425-7"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1002\/bimj.201700067","article-title":"Variable Selection\u2014A Review and Recommendations for the Practicing Statistician","volume":"60","author":"Heinze","year":"2018","journal-title":"Biom. J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/1751-0473-3-17","article-title":"Purposeful selection of variables in logistic regression","volume":"3","author":"Bursac","year":"2008","journal-title":"Source Code Biol. Med."},{"key":"ref_16","unstructured":"Wickham, H., Chang, W., Henry, L., Pedersen, T.L., Takahashi, K., Wilke, C., Woo, K., Yutani, H., and Dunnington, D. (2026, April 22). ggplot2: Create Elegant Data Visualisations Using the Grammar of Graphics. Available online: https:\/\/cran.r-project.org\/web\/packages\/ggplot2\/index.html."},{"key":"ref_17","unstructured":"Wickham, H., Fran\u00e7ois, R., Henry, L., M\u00fcller, K., and Vaughan, D. (2025, February 24). dplyr: A Grammar of Data Manipulation. Available online: https:\/\/cran.r-project.org\/web\/packages\/dplyr\/index.html."},{"key":"ref_18","unstructured":"Wickham, H. (2026, April 22). RStudio. tidyverse: Easily Install and Load the \u2018Tidyverse\u2019. Available online: https:\/\/cran.r-project.org\/web\/packages\/tidyverse\/index.html."},{"key":"ref_19","unstructured":"Gohel, D., Moog, S., and Heckmann, M. (2025, February 24). officer: Manipulation of Microsoft Word and PowerPoint Documents. Available online: https:\/\/cran.r-project.org\/web\/packages\/officer\/index.html."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Tiranaprakij, P., Srisuma, S., Putthipokin, K., and Ruangritchankul, S. (2025). Anticholinergic burden and clinical outcomes among older adults admitted in a tertiary hospital: A prospective cohort study. PLoS ONE, 20.","DOI":"10.1371\/journal.pone.0332946"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1185","DOI":"10.1080\/14740338.2018.1546841","article-title":"An update on the clinical consequences of polypharmacy in older adults: A narrative review","volume":"17","author":"Wastesson","year":"2018","journal-title":"Expert Opin. Drug Saf."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1357","DOI":"10.1016\/j.jamda.2020.03.027","article-title":"Impact of Anticholinergic Burden on Cognitive Performance: A Cohort Study of Community-Dwelling Older Adults","volume":"21","author":"Nishtala","year":"2020","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1097\/YCO.0000000000000233","article-title":"Pharmacotherapy for mental health problems in people with intellectual disability","volume":"29","author":"Ji","year":"2016","journal-title":"Curr. Opin. Psychiatry"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"44539","DOI":"10.1038\/s41598-025-28362-2","article-title":"Anticholinergic burden and its associated factors among adult outpatients in a resource-limited setting: A cross-sectional study","volume":"15","author":"Gebreyohannes","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1080\/19315864.2024.2447232","article-title":"Factors Associated with the Use of Psychotropic Medication in a Norwegian Community-Based Sample of Adults with Intellectual Disability","volume":"18","author":"Pedersen","year":"2025","journal-title":"J. Ment. Health Res. Intellect. Disabil."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"j3896","DOI":"10.1136\/bmj.j3896","article-title":"Psychotropic prescribing in people with intellectual disability and challenging behaviour","volume":"358","author":"Sheehan","year":"2017","journal-title":"BMJ"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e70649","DOI":"10.1002\/alz.70649","article-title":"Anticholinergics, executive function, and cognitive\/behavioral changes in Down syndrome","volume":"21","author":"Lee","year":"2025","journal-title":"Alzheimers Dement."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e453","DOI":"10.1016\/S2468-2667(23)00057-9","article-title":"Multiple morbidity across the lifespan in people with Down syndrome or intellectual disabilities: A population-based cohort study using electronic health records","volume":"8","author":"Baksh","year":"2023","journal-title":"Lancet Public Health"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1186\/s11689-019-9306-9","article-title":"Health comorbidities and cognitive abilities across the lifespan in Down syndrome","volume":"12","author":"Startin","year":"2020","journal-title":"J. Neurodev. Disord."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"De Vreese, L.P., Mantesso, U., De Bastiani, E., Marangoni, A., Weger, E., and Gomiero, T. (2018). Anticholinergic burden in adult and elderly people with intellectual disabilities: Results from an Italian multicenter cross-sectional study. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0205897"},{"key":"ref_31","first-page":"e71868","article-title":"A Review of Risk Factors for Polypharmacy: Age, Level of Education, and Physician\u2019s Attitude","volume":"16","author":"Majewski","year":"2024","journal-title":"Cureus"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2929","DOI":"10.1007\/s00198-017-4133-x","article-title":"Bone mineral density in adults with Down syndrome","volume":"28","author":"Liperoti","year":"2017","journal-title":"Osteoporos. Int."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2106","DOI":"10.1002\/jbmr.4402","article-title":"Cognitive decline is associated with an accelerated rate of bone loss and increased fracture risk in women: A prospective study from the Canadian Multicentre Osteoporosis Study","volume":"36","author":"Bliuc","year":"2021","journal-title":"J. Bone Miner. Res."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"113098","DOI":"10.1016\/j.bbr.2020.113098","article-title":"Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia","volume":"402","author":"Yoshida","year":"2021","journal-title":"Behav. Brain Res."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Pistorio, S., Scotto di Tella, G., Canzanella, V., Merenda, R., Cuomo, G., Iacotucci, P., Carnovale, V., Bencivenga, L., Vargas, M., and Manes, A. (2025). Anticholinergic burden and behavioral and psychological symptoms in older patients with cognitive impairment. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1505007"},{"key":"ref_36","unstructured":"(2026, April 22). Down Syndrome as a Model for Investigating Alzheimer\u2019s Disease. ACNR, Advances in Clinical Neuroscience and Rehabilitation. Available online: https:\/\/acnr.co.uk\/articles\/down-syndrome-as-a-model-for-investigating-alzheimers-disease\/."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Adams, D., Hastings, R.P., Maidment, I., and Langdon, P.E. (2025). Factors supporting optimisation of psychotropic deprescribing in people with intellectual disabilities within the UK: A modified Delphi study. Front. Psychiatry, 16.","DOI":"10.3389\/fpsyt.2025.1652988"},{"key":"ref_38","first-page":"CD015405","article-title":"Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment","volume":"12","author":"Alharthi","year":"2023","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Tesfaye, Z.T., Horsa, B.A., and Yismaw, M.B. (2026). Impact of pharmacist-led deprescribing interventions on medication related outcomes among older adults: A systematic review and meta-analysis. BMC Geriatr., 26.","DOI":"10.1186\/s12877-025-06964-9"},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Pascucci, A., Gerber, F., Besson, M., and Kosel, M. (2025). Antipsychotic medication for behaviors that challenge in individuals with intellectual disabilities: A clinically informed review. Front. Psychiatry, 16.","DOI":"10.3389\/fpsyt.2025.1609408"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1111\/1440-1630.12645","article-title":"Scope of occupational therapy practice for adults with both Down syndrome and dementia: A cross-sectional survey","volume":"67","author":"Raj","year":"2020","journal-title":"Aust. Occup. Ther. J."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2236","DOI":"10.1111\/bcp.16123","article-title":"Assessing the anticholinergic cognitive burden classification of putative anticholinergic drugs using drug properties","volume":"90","author":"Phutietsile","year":"2024","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"118","DOI":"10.18773\/austprescr.2022.031","article-title":"The anticholinergic burden: From research to practice","volume":"45","author":"Hilmer","year":"2022","journal-title":"Aust. Prescr."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1016\/j.pnpbp.2018.01.023","article-title":"Meta regression: Relationship between antipsychotic receptor binding profiles and side-effects","volume":"84","author":"Olten","year":"2018","journal-title":"Prog. Neuro-Psychopharmacol. Biol. Psychiatry"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"77","DOI":"10.64719\/pb.4345","article-title":"Paroxetine\u2014The Antidepressant from Hell? Probably Not, But Caution Required","volume":"46","author":"Nevels","year":"2016","journal-title":"Psychopharmacol. Bull."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1038\/s41598-025-34439-9","article-title":"Utility of the Swedish Anticholinergic Burden Scale in a memory clinic setting: A comparison with the Anticholinergic Cognitive Burden scale","volume":"16","author":"Rube","year":"2026","journal-title":"Sci. Rep."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1771","DOI":"10.1111\/jgs.70352","article-title":"Anticholinergic Medication Burden Scales: A Systematic Review","volume":"74","author":"Vennard","year":"2026","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"2096","DOI":"10.1124\/dmd.110.035550","article-title":"Expression of the Anthracycline-Metabolizing Enzyme Carbonyl Reductase 1 in Hearts from Donors with Down Syndrome","volume":"38","author":"Kalabus","year":"2010","journal-title":"Drug Metab. Dispos."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"601","DOI":"10.3233\/JAD-2011-110860","article-title":"Variants in CYP17 and CYP19 Cytochrome P450 genes are associated with onset of Alzheimer\u2019s disease in women with Down syndrome","volume":"28","author":"Chace","year":"2012","journal-title":"J. Alzheimers Dis."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e00775","DOI":"10.1002\/prp2.775","article-title":"The role of sex, age and genetic polymorphisms of CYP enzymes on the pharmacokinetics of anticholinergic drugs","volume":"9","author":"Trenaman","year":"2021","journal-title":"Pharmacol. Res. Perspect."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1111\/jir.12588","article-title":"Adults with Down syndrome: A comprehensive approach to manage complexity","volume":"63","author":"Vetrano","year":"2019","journal-title":"J. Intellect. Disabil. Res."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e65","DOI":"10.1016\/j.ejim.2015.08.014","article-title":"Anticholinergic risk: Use and limitations of anticholinergic scales","volume":"26","year":"2015","journal-title":"Eur. J. Intern. Med."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1399","DOI":"10.1001\/jamaneurol.2018.2210","article-title":"Prevalence of Aging, Dementia, and Multimorbidity in Older Adults With Down Syndrome","volume":"75","author":"Bayen","year":"2018","journal-title":"JAMA Neurol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"e018292","DOI":"10.1136\/bmjopen-2017-018292","article-title":"Prevalence of physical conditions and multimorbidity in a cohort of adults with intellectual disabilities with and without Down syndrome: Cross-sectional study","volume":"8","author":"Kinnear","year":"2018","journal-title":"BMJ Open"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1002\/phar.1880","article-title":"Pharmacotherapeutic Considerations for Individuals with Down Syndrome","volume":"37","author":"Hefti","year":"2017","journal-title":"Pharmacotherapy"}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/16\/8\/398\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T08:27:41Z","timestamp":1785140861000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/16\/8\/398"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,26]]},"references-count":55,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["jpm16080398"],"URL":"https:\/\/doi.org\/10.3390\/jpm16080398","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,26]]}}}