{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,12]],"date-time":"2025-10-12T03:43:10Z","timestamp":1760240590029,"version":"build-2065373602"},"reference-count":54,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2019,8,7]],"date-time":"2019-08-07T00:00:00Z","timestamp":1565136000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and objectives: Obstructive sleep apnea syndrome (OSAS) and heart failure (HF) are increasing in prevalence with a greater impact on the health system. The aim of this study was to assess the particularities of patients with OSAS and HF, focusing on the new class of HF with mid-range ejection fraction (HFmrEF, EF = 40%\u201349%), and comparing it with reduced EF (HFrEF, EF &lt; 40%) and preserved EF (HFpEF, EF \u2265 50%). Materials and Methods: A total of 143 patients with OSAS and HF were evaluated in three sleep labs of \u201cVictor Babes\u201d Hospital and Cardiovascular Institute, Timisoara, Western Romania. We collected socio-demographic data, anthropometric sleep-related measurements, symptoms through sleep questionnaires and comorbidity-related data. We performed blood tests, cardio-respiratory polygraphy and echocardiographic measurements. Patients were divided into three groups depending on ejection fraction. Results: Patients with HFmrEF were older (p = 0.0358), with higher values of the highest systolic blood pressure (mmHg) (p = 0.0016), higher serum creatinine (p = 0.0013), a lower glomerular filtration rate (p = 0.0003), higher glycemic levels (p = 0.008) and a larger left atrial diameter (p = 0.0002). Regarding comorbidities, data were presented as percentage, HFrEF vs. HFmrEF vs. HFpEF. Higher prevalence of diabetes mellitus (52.9 vs. 72.7 vs. 40.2, p = 0.006), chronic kidney disease (17.6 vs. 57.6 vs. 21.5, p &lt; 0.001), tricuspid insufficiency (76.5 vs. 84.8 vs.59.1, p = 0.018) and aortic insufficiency (35.3 vs.42.4 vs. 20.4, p = 0.038) were observed in patients with HFmrEF, whereas chronic obstructive pulmonary disease(COPD) (52.9 vs. 24.2 vs.18.3, p = 0.009), coronary artery disease(CAD) (82.4 vs. 6.7 vs. 49.5, p = 0.026), myocardial infarction (35.3 vs. 24.2 vs. 5.4, p &lt; 0.001) and impaired parietal heart kinetics (70.6 vs. 68.8 vs. 15.2, p &lt; 0.001) were more prevalent in patients with HFrEF. Conclusions: Patients with OSAS and HF with mid-range EF may represent a new group with increased risk of developing life-long chronic kidney disease, diabetes mellitus, tricuspid and aortic insufficiency. COPD, myocardial infarction, impaired parietal kinetics and CAD are most prevalent comorbidities in HFrEF patients but they are closer in prevalence to HFmrEF than HFpEF.<\/jats:p>","DOI":"10.3390\/medicina55080449","type":"journal-article","created":{"date-parts":[[2019,8,7]],"date-time":"2019-08-07T10:56:38Z","timestamp":1565175398000},"page":"449","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Particularities of Older Patients with Obstructive Sleep Apnea and Heart Failure with Mid-Range Ejection Fraction"],"prefix":"10.3390","volume":"55","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3387-8293","authenticated-orcid":false,"given":"Carmen Loredana","family":"Ardelean","sequence":"first","affiliation":[{"name":"University of Medicine and Pharmacy, Dr Victor Babes, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sorin","family":"Pescariu","sequence":"additional","affiliation":[{"name":"Cardiology Department, University of Medicine and Pharmacy, Dr Victor Babes, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel Florin","family":"Lighezan","sequence":"additional","affiliation":[{"name":"Cardiology Department, University of Medicine and Pharmacy, Dr Victor Babes, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roxana","family":"Pleava","sequence":"additional","affiliation":[{"name":"University of Medicine and Pharmacy, Dr Victor Babes, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9215-5154","authenticated-orcid":false,"given":"Sorin","family":"Ursoniu","sequence":"additional","affiliation":[{"name":"Department of Public Health and Health Management, University of Medicine and Pharmacy, Dr Victor Babes, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Valentin","family":"Nadasan","sequence":"additional","affiliation":[{"name":"Department of Hygiene and Environmental Health, University of Medicine and Pharmacy, Sciences and Technology of Targu Mures, Gheorghe Marinescu 38, 540139 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8897-8342","authenticated-orcid":false,"given":"Stefan","family":"Mihaicuta","sequence":"additional","affiliation":[{"name":"Pneumology Department, University of Medicine and Pharmacy, Dr Victor Babes, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2019,8,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1702616","DOI":"10.1183\/13993003.02616-2017","article-title":"Challenges and perspectives in obstructive sleep apnea: Report by an ad hoc working group of the Sleep Disordered Breathing Group of the European Respiratory Society and the European Sleep Research Society","volume":"52","author":"Randerath","year":"2018","journal-title":"Eur. Respir. J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1016\/j.cardfail.2008.11.015","article-title":"Prevalence and Physiological Predictors of Sleep Apnea in Patients With Heart Failure and Systolic Dysfunction","volume":"15","author":"Yumino","year":"2009","journal-title":"J. Card. Fail."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"967","DOI":"10.1161\/01.STR.0000208215.49243.c3","article-title":"Sleep-disordered breathing and acute ischemic stroke: Diagnosis, risk factors, treatment, evolution, and long-term clinical outcome","volume":"37","author":"Bassetti","year":"2006","journal-title":"Stroke"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2271","DOI":"10.1097\/00004872-200112000-00022","article-title":"High prevalence of unrecognized sleep apnea in drug-resistant hypertension","volume":"19","author":"Logan","year":"2001","journal-title":"J. Hypertens."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1625","DOI":"10.1016\/j.jacc.2006.12.046","article-title":"Influence of Obstructive Sleep Apnea on Mortality in Patients With Heart Failure","volume":"49","author":"Wang","year":"2007","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"38","DOI":"10.5664\/jcsm.27076","article-title":"The Current Prevalence of Sleep Disordered Breathing in Congestive Heart Failure Patients Treated with Beta-Blockers","volume":"4","author":"Macdonald","year":"2008","journal-title":"J. Clin. Sleep Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1183\/09031936.00027406","article-title":"Sleep apnea as an independent risk factor for cardiovascular disease: Current evidence, basic mechanisms and research priorities","volume":"29","author":"McNicholas","year":"2007","journal-title":"Eur. Respir. J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1671","DOI":"10.1161\/01.CIR.0000061757.12581.15","article-title":"Sleep apnea and heart failure: Part I: Obstructive sleep apnea","volume":"107","author":"Bradley","year":"2003","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1007\/s40675-016-0047-y","article-title":"Sleep-Disordered Breathing in Patients with Heart Failure","volume":"2","author":"Randerath","year":"2016","journal-title":"Curr. Sleep Med. Rep."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"15015","DOI":"10.1038\/nrdp.2015.15","article-title":"Obstructive sleep apnea syndrome","volume":"1","author":"Levy","year":"2015","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e3289","DOI":"10.7717\/peerj.3289","article-title":"Network science meets respiratory medicine for OSAS phenotyping and severity prediction","volume":"5","author":"Mihaicuta","year":"2017","journal-title":"PeerJ"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"170069","DOI":"10.1183\/16000617.0069-2017","article-title":"Personalised medicine in sleep respiratory disorders: Focus on obstructive sleep apnoea diagnosis and treatment","volume":"26","author":"Bonsignore","year":"2017","journal-title":"Eur. Respir. Rev."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Saaresranta, T., Hedner, J., Bonsignore, M.R., Riha, R.L., McNicholas, W.T., Penzel, T., Anttalainen, U., Kvamme, J.A., Pretl, M., and Sliwinski, P. (2016). Clinical Phenotypes and Comorbidity in European Sleep Apnoea Patients. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0163439"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1002\/ejhf.483","article-title":"Epidemiology of heart failure: The prevalence of heart failure and ventricular dysfunction in older adults over time. A systematic review","volume":"18","author":"Hoes","year":"2016","journal-title":"Eur. J. Heart Fail."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1600959","DOI":"10.1183\/13993003.00959-2016","article-title":"Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep","volume":"49","author":"Randerath","year":"2017","journal-title":"Eur. Respir. J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.jchf.2013.10.006","article-title":"Developing Therapies for Heart Failure with Preserved Ejection Fraction: Current State and Future Directions","volume":"2","author":"Butler","year":"2014","journal-title":"JACC Hear. Fail."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2129","DOI":"10.1093\/eurheartj\/ehw128","article-title":"ESC Scientific Document Group; 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC","volume":"37","author":"Ponikowski","year":"2016","journal-title":"Eur. Heart J."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1111\/j.1365-2869.2011.00987.x","article-title":"Standard procedures for adults in accredited sleep medicine centres in Europe. Executive Committee of the Assembly of the National Sleep Societies; Board of the European Sleep Research Society, Regensburg, Germany","volume":"21","author":"Fischer","year":"2012","journal-title":"J. Sleep Res."},{"key":"ref_19","first-page":"597","article-title":"The AASM Scoring Manual four years later","volume":"8","year":"2012","journal-title":"J. Clin. Sleep Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"604","DOI":"10.7326\/0003-4819-150-9-200905050-00006","article-title":"A new equation to estimate glomerular filtration rate","volume":"150","author":"Levey","year":"2009","journal-title":"Ann. Intern Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1016\/j.echo.2010.05.010","article-title":"Guidelines for the echocardiographic assessment of the right heart in adults: A report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography","volume":"23","author":"Rudski","year":"2010","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1093\/ejechocard\/jeq030","article-title":"European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: Aortic and pulmonary regurgitation (native valve disease)","volume":"11","author":"Lancellotti","year":"2010","journal-title":"Eur. J. Echocardiogr."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"721","DOI":"10.1016\/j.ahj.2014.07.008","article-title":"Outcomes in patients with heart failure with preserved, borderline, and reduced ejection fraction in the Medicare population","volume":"168","author":"Cheng","year":"2014","journal-title":"Am. Hear. J."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1016\/j.jchf.2016.02.017","article-title":"Precipitating clinical factors, heart failure characterization, and outcomes in patients hospitalized with heart failure with reduced, borderline, and preserved ejection fraction","volume":"4","author":"Kapoor","year":"2016","journal-title":"JACC Heart Fail."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1258","DOI":"10.1002\/ejhf.807","article-title":"Characterization of heart failure patients with mid-range left ventricular ejection fraction-a report from the CHART-2 Study","volume":"19","author":"Tsuji","year":"2017","journal-title":"Eur. J. Hear. Fail."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e002303","DOI":"10.1161\/JAHA.115.002303","article-title":"Magnitude of and Prognostic Factors Associated With 1-Year Mortality after Hospital Discharge for Acute Decompensated Heart Failure Based on Ejection Fraction Findings","volume":"4","author":"Coles","year":"2015","journal-title":"J. Am. Heart Assoc."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1161\/CIRCULATIONAHA.109.901801","article-title":"A Prospective Study of Obstructive Sleep Apnea and Incident Coronary Heart Disease and Heart Failure: The Sleep Heart Health Study","volume":"122","author":"Gottlieb","year":"2010","journal-title":"Circulation"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1635","DOI":"10.1093\/eurheartj\/ehs092","article-title":"European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice","volume":"33","author":"Perk","year":"2012","journal-title":"Eur. Heart J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1164\/rccm.201205-0894OC","article-title":"Differing Effects of Obstructive and Central Sleep Apneas on Stroke Volume in Patients with Heart Failure","volume":"187","author":"Yumino","year":"2013","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1716","DOI":"10.1001\/archinte.166.16.1716","article-title":"Sleepiness and sleep in patients with both systolic heart failure and obstructive sleep apnea","volume":"166","author":"Arzt","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1016\/S0140-6736(05)71141-7","article-title":"Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study","volume":"365","author":"Marin","year":"2005","journal-title":"Lancet"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1007\/s00392-018-1282-7","article-title":"Sleep-disordered breathing in patients with cardiovascular diseases cannot be detected by ESS, STOP-BANG, and Berlin questionnaires","volume":"107","author":"Reuter","year":"2018","journal-title":"Clin. Res. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Top\u00eerceanu, A., Udrescu, M., Udrescu, L., Ardelean, C., Dan, R., Reisz, D., and Mihaicuta, S. (2018). SAS score: Targeting high-specificity for efficient population-wide monitoring of obstructive sleep apnea. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0202042"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"607","DOI":"10.2337\/diacare.28.3.607","article-title":"Blood Glucose and Heart Failure in Nondiabetic Patients","volume":"28","author":"Nielson","year":"2005","journal-title":"Diabetes Care"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1016\/j.ccl.2010.04.004","article-title":"The Effects of Heart Failure on Renal Function","volume":"28","author":"Udani","year":"2010","journal-title":"Cardiol. Clin."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"45","DOI":"10.21037\/jtd.2017.12.12","article-title":"Obstructive sleep apnea and chronic kidney disease: Open questions on a potential public health problem","volume":"10","author":"Marrone","year":"2018","journal-title":"J. Thorac. Dis."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"c140","DOI":"10.1159\/000232594","article-title":"Albuminuria and Renal Function in Obese Adults Evaluated for Obstructive Sleep Apnea","volume":"113","author":"Agrawal","year":"2009","journal-title":"Nephron Clin. Pr."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1093\/ndt\/gfp403","article-title":"Prevalence of chronic kidney disease in patients with suspected sleep apnea","volume":"25","author":"Fleischmann","year":"2010","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1180","DOI":"10.1111\/resp.13372","article-title":"Obstructive sleep apnea independently predicts lipid levels: Data from the European Sleep Apnea Database","volume":"23","author":"Basoglu","year":"2018","journal-title":"Respirology"},{"key":"ref_40","first-page":"252","article-title":"Association between left atrial enlargement and obstructive sleep apnea in a general population of 71-year-old men","volume":"27","author":"Fu","year":"2018","journal-title":"J. Sleep Res."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"832","DOI":"10.1016\/j.amjcard.2005.05.031","article-title":"Usefulness of Left Atrial Volume in Predicting First Congestive Heart Failure in Patients \u226565 Years of Age With Well-Preserved Left Ventricular Systolic Function","volume":"96","author":"Takemoto","year":"2005","journal-title":"Am. J. Cardiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1016\/j.jacc.2013.10.055","article-title":"Left Atrial Size and Function: Role in Prognosis","volume":"63","author":"Hoit","year":"2014","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1093\/eurheartj\/ehy641","article-title":"Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: A systematic review and meta-analysis","volume":"40","author":"Wang","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jcmg.2007.10.008","article-title":"Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: A prospective study","volume":"1","author":"Detaint","year":"2008","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"S4253","DOI":"10.21037\/jtd.2018.10.117","article-title":"Comorbid obstructive sleep apnea and chronic obstructive pulmonary disease and the risk of cardiovascular disease","volume":"10","author":"McNicholas","year":"2018","journal-title":"J. Thorac. Dis."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"739","DOI":"10.1111\/jsr.12426","article-title":"ESADA study group. Chronic kidney disease in European patients with obstructive sleep apnea: The ESADA cohort study","volume":"25","author":"Marrone","year":"2016","journal-title":"J. Sleep Res."},{"key":"ref_47","first-page":"e003875","article-title":"Significance of ischemic heart disease in patients with heart failure and preserved, midrange, and reduced ejection fraction: A nationwide cohort study","volume":"10","author":"Vedin","year":"2017","journal-title":"Circulation"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"297","DOI":"10.2459\/JCM.0000000000000653","article-title":"Characteristics and outcome for heart failure patients with mid-range ejection fraction","volume":"19","author":"Wang","year":"2018","journal-title":"J. Cardiovasc. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1770","DOI":"10.1093\/eurheartj\/ehy005","article-title":"Mortality associated with heart failure with preserved vs. reduced ejection fraction in a prospective international multi-ethnic cohort study","volume":"39","author":"Lam","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1574","DOI":"10.1002\/ejhf.813","article-title":"Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: An analysis of the ESC Heart Failure Long-Term Registry","volume":"19","author":"Chioncel","year":"2017","journal-title":"Eur. J. Hear. Fail."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.ijcard.2017.03.032","article-title":"MUSIC and REDINSCOR I research groups. Mid-range left ventricular ejection fraction: Clinical profile and cause of death in ambulatory patients with chronic heart failure","volume":"240","author":"Vazquez","year":"2017","journal-title":"Int. J. Cardiol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1016\/j.ijcard.2017.07.101","article-title":"Heart failure with mid-range ejection fraction in patients admitted to internal medicine departments: Findings from the RICA registry","volume":"255","author":"Manzano","year":"2018","journal-title":"Int. J. Cardiol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1624","DOI":"10.1002\/ejhf.945","article-title":"A comprehensive population-based characterization of heart failure with mid-range ejection fraction","volume":"19","author":"Koh","year":"2017","journal-title":"Eur. J. Heart Fail."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1016\/S2213-2600(18)30059-6","article-title":"Challenges in obstructive sleep apnoea","volume":"6","author":"McNicholas","year":"2018","journal-title":"Lancet Respir. Med."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/55\/8\/449\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T13:09:24Z","timestamp":1760188164000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/55\/8\/449"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,8,7]]},"references-count":54,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2019,8]]}},"alternative-id":["medicina55080449"],"URL":"https:\/\/doi.org\/10.3390\/medicina55080449","relation":{},"ISSN":["1648-9144"],"issn-type":[{"type":"electronic","value":"1648-9144"}],"subject":[],"published":{"date-parts":[[2019,8,7]]}}}