{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T22:19:03Z","timestamp":1790893143216,"version":"4.1.0"},"reference-count":64,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2019,9,16]],"date-time":"2019-09-16T00:00:00Z","timestamp":1568592000000},"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: Chronic obstructive pulmonary disease (COPD) is a life limiting condition with a long list of serious psychosocial consequences, aggravating with illness progression. In advanced stages, chronic respiratory failure often develops, which might undermine mental health and reduce activity. The study objective was to review the recent studies concerning psychosocial interventions dedicated to patients with severe COPD. Materials and Methods: The PubMed database was searched for terms, such as \u2018COPD and long-term oxygen therapy, non-invasive ventilation, severe or respiratory failure\u2019 and \u2018psychological or psychosocial or mental health and intervention.\u2019 Studies were included that described patients with stable, severe COPD and the outcomes of psychosocial interventions. Results and Conclusions: Thirty-four studies were identified and divided into four thematic groups: home medical support, exercise, self-management and mental health. The number of studies that focused on mental health preservation in severe COPD was very limited; i.e., none refer directly to those treated with respiratory failure. Improving patients\u2019 self-efficacy gave promising effects to the acceptance of palliative care, pulmonary rehabilitation completion and mental health. Physical activity might be recommended to be included in interventions for mental health enhancement, although little is known about the role of the particular forms of exercise. An increasing beneficial use of new technologies for psychosocial interventions was noted. Psychosocial interventions applied in advanced COPD underline the roles of self-efficacy, telehealth and physical activity in physical and mental health preservation. However, all of the above elements need to be independently tested on more homogenous groups of patients and have the possible modes of their treatment analysed.<\/jats:p>","DOI":"10.3390\/medicina55090597","type":"journal-article","created":{"date-parts":[[2019,9,17]],"date-time":"2019-09-17T04:23:36Z","timestamp":1568694216000},"page":"597","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":26,"title":["Psychosocial Interventions for Patients with Severe COPD\u2014An Up-to-Date Literature Review"],"prefix":"10.3390","volume":"55","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0221-4494","authenticated-orcid":false,"given":"Marta","family":"Rzadkiewicz","sequence":"first","affiliation":[{"name":"Department of Medical Psychology and Medical Communication, Medical University of Warsaw, 00-575 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacek","family":"Nasi\u0142owski","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2019,9,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1056\/NEJMoa021322","article-title":"The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease","volume":"350","author":"Celli","year":"2004","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2373","DOI":"10.2147\/COPD.S137872","article-title":"Identification and distribution of COPD phenotypes in clinical practice according to Spanish COPDGuidelines: The Fenepoc study","volume":"12","author":"Rubio","year":"2017","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"911","DOI":"10.1016\/S2213-2600(16)00097-7","article-title":"Management of chronic obstructive pulmonary disease beyond the lungs","volume":"4","author":"Vanfleteren","year":"2016","journal-title":"Lancet Respir. Med."},{"key":"ref_4","unstructured":"GOLD (2019, May 25). Available online: https:\/\/goldcopd.org\/."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"00012","DOI":"10.1183\/23120541.00012-2018","article-title":"Noninvasive ventilation in stable hypercapnic COPD: What is the evidence?","volume":"4","author":"Duiverman","year":"2018","journal-title":"ERJ Open Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1111\/jan.13472","article-title":"Factors associated with change in health-related quality of life among individuals treated with long-term mechanical ventilation, a 6-year follow-up study","volume":"74","author":"Markussen","year":"2018","journal-title":"J. Adv. Nurs."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"V\u00e9ron, C., Pautex, S., Weber, C., Janssens, J.P., and Cedraschi, C. (2018). Recollection of participating in a trial: A qualitative study of patients with severe and very severe chronic obstructive pulmonary disease. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0204701"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2295","DOI":"10.2147\/COPD.S109700","article-title":"What else should we know about experiencing COPD? A narrative review in search of patients\u2019 psychological burden alleviation","volume":"11","author":"Rzadkiewicz","year":"2016","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"544","DOI":"10.4187\/respcare.05282","article-title":"Spiritual Well-Being and Correlated Factors in Subjects with Advanced COPD or Lung Cancer","volume":"62","author":"Hasegawa","year":"2017","journal-title":"Respir Care"},{"key":"ref_10","unstructured":"Dix, O., and Glickman, M. (2019, March 26). NCHSPCS: Feeling Better: Psychosocial Care in Specialist Palliative Care, Available online: https:\/\/www.scie-socialcareonline.org.uk\/feeling-better-psychosocial-care-in-specialist-palliative-care-a-discussion-paper\/r\/a11G000000180wgIAA."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1080\/15412555.2017.1417373","article-title":"The Unmet Needs of People with Chronic Obstructive Pulmonary Disease: A Systematic Review of Qualitative Findings","volume":"15","author":"Clari","year":"2018","journal-title":"COPD J. Chronic Obstr. Pulm. Dis"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Miranda, D.G., Peces, E.M.S., Babarro, A.A., S\u00e1nchez, M.C.P., and Cerdeira, M.V. (2016). HOLD study (Home care Obstructive Lung Disease): Natural history of patients with advanced COPD. BMC Palliat. Care, 15.","DOI":"10.1186\/s12904-016-0104-9"},{"key":"ref_13","first-page":"CD011682","article-title":"Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease","volume":"8","author":"Lenferink","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1159\/000367635","article-title":"Efficacy of psychosocial interventions on psychological and physical health outcomes in chronic obstructive pulmonary disease: A systematic review and meta-analysis","volume":"84","author":"Jacobsen","year":"2015","journal-title":"Psychother. Psychosom."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Janssen, D.J., Wouters, E.F., Schols, J.M., and Spruit, M.A. (2008). Self-perceived symptoms and care needs of patients with severe to very severe chronic obstructive pulmonary disease, congestive heart failure or chronic renal failure and its consequences for their closest relatives: The research protocol. BMC Palliat. Care, 7.","DOI":"10.1186\/1472-684X-7-5"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1016\/j.rmed.2013.12.003","article-title":"A home telehealth program for patients with severe COPD: The PROMETE study","volume":"108","author":"Soriano","year":"2014","journal-title":"Respir. Med."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Janssens, J.-P., Weber, C., Herrmann, F.R., Cantero, C., Pessina, A., Matis, C., Merlet Viollet, R., Boiche-Brouillard, L., Stirnemann, J., and Pautex, S. (2019). Can Early Introduction of Palliative Care Limit Intensive Care, Emergency and Hospital Admissions in Patients with Severe Chronic Obstructive Pulmonary Disease? A Pilot Randomized Study. Respiration.","DOI":"10.1159\/000495312"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1089\/jpm.2012.0285","article-title":"Implementing a palliative care trial in advanced COPD: A feasibility assessment (the COPD IMPACT study)","volume":"16","author":"Horton","year":"2013","journal-title":"J. Palliat. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2795","DOI":"10.2147\/COPD.S141974","article-title":"Proactive palliative care for patients with COPD (PROLONG): A pragmatic cluster controlled trial","volume":"12","author":"Duenk","year":"2017","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1256","DOI":"10.1089\/jpm.2013.0669","article-title":"Outpatient palliative care for chronic obstructive pulmonary disease: A case series","volume":"17","author":"Schroedl","year":"2014","journal-title":"J. Palliat. Med."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Smallwood, N., Moran, T., Thompson, M., Eastman, P., Le, B., and Philip, J. (2019). Integrated respiratory and palliative care leads to high levels of satisfaction: A survey of patients and carers. BMC Palliat. Care, 18.","DOI":"10.1186\/s12904-019-0390-0"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"979","DOI":"10.1016\/S2213-2600(14)70226-7","article-title":"An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: A randomised controlled trial","volume":"2","author":"Higginson","year":"2014","journal-title":"Lancet Respir. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1089\/jpm.2018.0321","article-title":"Tele-Assisted Palliative Homecare for Advanced Chronic Obstructive Pulmonary Disease: A Feasibility Study","volume":"22","author":"Vitacca","year":"2019","journal-title":"J. Palliat. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1258\/jtt.2009.090907","article-title":"Home telemonitoring and quality of life in stable, optimised chronic obstructive pulmonary disease","volume":"16","author":"Lewis","year":"2010","journal-title":"J. Telemed. Telecare"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1016\/j.jpainsymman.2007.11.008","article-title":"Access to services for patients with chronic obstructive pulmonary disease: The invisibility of breathlessness","volume":"36","author":"Gysels","year":"2008","journal-title":"J. Pain Symptom Manag."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2199","DOI":"10.3389\/fpsyg.2018.02199","article-title":"Emotional Distress of Patients at End-of-Life and Their Caregivers: Interrelation and Predictors","volume":"9","author":"Barreto","year":"2018","journal-title":"Front. Psychol."},{"key":"ref_27","first-page":"600","article-title":"Palliative Care Provision for Patients with Advanced Chronic Obstructive Pulmonary Disease: A Systematic Integrative Literature Review","volume":"15","author":"Riglietti","year":"2019","journal-title":"COPD J. Chronic Obstr. Pulm. Dis."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e739","DOI":"10.3399\/bjgp12X658269","article-title":"Telehealthcare for chronic obstructive pulmonary disease: Cochrane Review and meta-analysis","volume":"62","author":"McLean","year":"2012","journal-title":"Br. J. Gen. Pract."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1177\/1357633X14566575","article-title":"A randomised clinical trial of the effectiveness of home-based health care with telemonitoringin patients with COPD","volume":"21","author":"McDowell","year":"2015","journal-title":"J Telemed. Telecare"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1183\/13993003.00025-2016","article-title":"Definition of a COPD self-management intervention: International Expert Group consensus","volume":"48","author":"Effing","year":"2016","journal-title":"Eur. Respir. J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1038\/s41533-017-0069-z","article-title":"Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: Views of patients and healthcare professionals","volume":"28","author":"Russell","year":"2018","journal-title":"NPJ Prim. Care Respir. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1177\/1479972316687208","article-title":"Clinical-effectiveness of self-management interventions in chronic obstructive pulmonary disease: An overview of reviews","volume":"14","author":"Murphy","year":"2017","journal-title":"Chronic Respir. Dis."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e1060","DOI":"10.1136\/bmj.e1060","article-title":"Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: Randomised controlled trial","volume":"344","author":"Bucknall","year":"2012","journal-title":"BMJ"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1016\/j.rmed.2016.11.009","article-title":"Efficacy of a minimal home-based psychoeducative intervention in patients with advanced COPD: A randomised controlled trial","volume":"121","author":"Bove","year":"2016","journal-title":"Respir. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/hta19360","article-title":"Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): An evidence synthesis and economic analysis","volume":"19","author":"Jordan","year":"2015","journal-title":"Health Technol. Assess."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1705","DOI":"10.2147\/COPD.S133317","article-title":"Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits: A systematic review and meta-analysis","volume":"12","author":"Newham","year":"2017","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e144","DOI":"10.2196\/jmir.7116","article-title":"Self-Management Support Using a Digital Health System Compared with Usual Care for Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial","volume":"19","author":"Farmer","year":"2017","journal-title":"J. Med. Internet Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.4187\/respcare.04984","article-title":"Effect of a Motivational Interviewing-Based Health Coaching on Quality of Life in Subjects with COPD","volume":"62","author":"Rehman","year":"2017","journal-title":"Respir. Care"},{"key":"ref_39","first-page":"CD011425","article-title":"Computer and mobile technology interventions for self-management in chronic obstructive pulmonary disease","volume":"5","author":"McCabe","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e000051","DOI":"10.1136\/bmjresp-2014-000051","article-title":"An evaluation of factors associated with completion and benefit from pulmonary rehabilitation in COPD","volume":"1","author":"Boutou","year":"2014","journal-title":"BMJ Open Respir. Res."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1159\/000436979","article-title":"Effect of a Three-Week Inpatient Rehabilitation Program on 544 Consecutive Patients with Very Severe COPD: A Retrospective Analysis","volume":"90","author":"Greulich","year":"2015","journal-title":"Respiration"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"709","DOI":"10.4187\/respcare.02626","article-title":"Physical Training and Noninvasive Ventilation in COPD Patients: A Meta-Analysis","volume":"59","author":"Ricci","year":"2014","journal-title":"Respir. Care"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1159\/000493691","article-title":"Non-Invasive Ventilation as an Adjunct to Exercise Training in Chronic Ventilatory Failure: A Narrative Review","volume":"97","author":"Vitacca","year":"2019","journal-title":"Respiration"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1041","DOI":"10.1589\/jpts.26.1041","article-title":"Difference in the Effect of Outpatient Pulmonary Rehabilitation Due to Variation in the Intervention Frequency: Intervention Centering on Home-based Exercise","volume":"26","author":"Chigira","year":"2014","journal-title":"J. Phys. Ther. Sci."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Simonelli, C., Vitacca, M., Vignoni, M., Ambrosino, N., and Paneroni, M. (2019). Effectiveness of manual therapy in COPD: A systematic review of randomised controlled trials. Pulmonol.","DOI":"10.1016\/j.pulmoe.2018.12.008"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"870","DOI":"10.1089\/tmj.2014.0198","article-title":"In-Home Pulmonary Telerehabilitation for Patients with Chronic Obstructive Pulmonary Disease: A Pre-experimental Study on Effectiveness, Satisfaction, and Adherence","volume":"21","author":"Marquis","year":"2015","journal-title":"Telemed. J. E Health"},{"key":"ref_47","first-page":"125","article-title":"Whole-body vibration improves functional capacity and quality of life in patients with severe chronic obstructive pulmonary disease (COPD): A pilot study","volume":"10","author":"Teixeira","year":"2015","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_48","first-page":"CD011434","article-title":"Upper limb exercise training for COPD","volume":"11","author":"McKeough","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Burkow, T.M., Vognild, L.K., Johnsen, E., Risberg, M.J., Bratvold, A., Breivik, E., Krogstad, T., and Hjalmarsen, A. (2015). Comprehensive pulmonary rehabilitation in home-based online groups: A mixed method pilot study in COPD. BMC Res. Notes, 8.","DOI":"10.1186\/s13104-015-1713-8"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1186\/2049-6958-8-41","article-title":"A pulmonary rehabilitation program reduces levels of anxiety and depression in COPD patients","volume":"8","author":"Tselebis","year":"2013","journal-title":"Multidiscip. Respir. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1111\/j.1471-6712.2011.00921.x","article-title":"Relapse of health related quality of life and psychological health in patients with chronic obstructive pulmonary disease 6 months after rehabilitation","volume":"26","author":"Espnes","year":"2012","journal-title":"Scand. J. Caring Sci."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Russo, P., Prinzi, G., Kisialiou, A., Cardaci, V., Stirpe, E., Conti, V., Fini, M., and Bonassi, S. (2017). Action plans and coping dstrategies in elderly COPD patients influence the result of pulmonary rehabilitation: An observational study. Eur. J. Phys. Rehabil. Med.","DOI":"10.23736\/S1973-9087.17.04501-4"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1016\/j.jpainsymman.2005.06.007","article-title":"A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease","volume":"31","author":"Solano","year":"2006","journal-title":"J. Pain Symptom Manag."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"297","DOI":"10.2147\/NDT.S79354","article-title":"Strategies to improve anxiety and depression in patients with COPD: A mental health perspective","volume":"12","author":"Tselebis","year":"2016","journal-title":"Neuropsychiatr. Dis. Treat."},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Coventry, P.A., Bower, P., Keyworth, C., Kenning, C., Knopp, J., Garrett, C., Hind, D., Malpass, A., and Dickens, C. (2013). The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: Systematic review and meta-analysis. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0060532"},{"key":"ref_56","first-page":"CD012347","article-title":"Psychological therapies for the treatment of depression in chronic obstructive pulmonary disease","volume":"3","author":"Pollok","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_57","first-page":"CD010673","article-title":"Psychological therapies for the treatment of anxiety disorders in chronic obstructive pulmonary disease","volume":"3","author":"Usmani","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.jpsychores.2017.05.013","article-title":"Home-based COPD psychoeducation: A qualitative study of the patients\u2019 experiences","volume":"98","author":"Bove","year":"2017","journal-title":"J. Psychosom. Res."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"439","DOI":"10.2147\/COPD.S30145","article-title":"Evidence for cognitive-behavioral strategies improving dyspnea and related distress in COPD","volume":"8","author":"Norweg","year":"2013","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"711","DOI":"10.4187\/respcare.03671","article-title":"Influence of ambient music on perceived exertion during a pulmonary rehabilitation session: A randomized crossover study","volume":"60","author":"Reychler","year":"2015","journal-title":"Respir. Care"},{"key":"ref_61","doi-asserted-by":"crossref","unstructured":"Markussen, H., Lehmann, S., Nilsen, R.M., and Natvig, G.K. (2019). Health-related quality of life as predictor for mortality in patients treated with longterm mechanical ventilation. BMC Pulm. Med., 19.","DOI":"10.1186\/s12890-018-0768-4"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"e000309","DOI":"10.1136\/bmjresp-2018-000309","article-title":"Understanding changes in dyspnoea perception in obstructive lung disease after mindfulness training","volume":"5","author":"Malpass","year":"2018","journal-title":"BMJ Open Respir. Res."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/0738-3991(96)00862-2","article-title":"Meta-analysis of the effects of psychoeducational care in adults with chronic obstructive pulmonary disease","volume":"29","author":"Devine","year":"1996","journal-title":"Patient Educ. Couns."},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Wytrychiewicz, K., Pankowski, D., Bargiel-Matusiewicz, K., D\u0105browski, J., and Fal, A.M. (2019). The role of psychological and medical variables in the process of adaptation to life with chronic illness in a group of COPD outpatients. Psychol. Health Med., 1\u201312.","DOI":"10.1080\/13548506.2019.1619789"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/55\/9\/597\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T13:20:46Z","timestamp":1760188846000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/55\/9\/597"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,9,16]]},"references-count":64,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2019,9]]}},"alternative-id":["medicina55090597"],"URL":"https:\/\/doi.org\/10.3390\/medicina55090597","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,9,16]]}}}