{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,1]],"date-time":"2026-11-01T02:55:19Z","timestamp":1793501719229,"version":"4.5.0"},"reference-count":58,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T00:00:00Z","timestamp":1783036800000},"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: The rising rate of cesarean delivery worldwide has led to an increasing number of women considering their options for birth after a previous cesarean section. Vaginal birth after cesarean (VBAC) offers potential maternal benefits but remains associated with concerns regarding maternal and neonatal safety. This systematic review and meta-analysis aimed to evaluate VBAC success rates and compare maternal and neonatal outcomes associated with trial of labor after cesarean (TOLAC) and elective repeat cesarean delivery (ERCD). Materials and Methods: A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed\/MEDLINE, Embase, and CENTRAL were searched for studies published between January 2010 and January 2026. Pooled proportions were calculated for VBAC success rates, while pooled risk ratios (RRs) with 95% confidence intervals (CIs) were used to evaluate comparative outcomes when sufficient data were available. Results: Thirty-one studies, including one randomized controlled trial and thirty observational studies, were included. The overall VBAC success rate was 67.7% (95% CI 61.8\u201373.6%), although substantial heterogeneity was observed across studies (I2 = 98.7%). No evidence of significant small-study effects was identified. Women undergoing TOLAC had a higher, although imprecisely estimated, risk of uterine rupture compared with those undergoing ERCD (RR 6.86, 95% CI 0.72\u201365.07). No statistically significant differences were found for maternal transfusion (RR 2.08, 95% CI 0.43\u201310.14) or postpartum hemorrhage (RR 1.47, 95% CI 0.04\u201355.03). Neonatal outcomes were reported inconsistently and could not be reliably pooled. Conclusions: VBAC may be an appropriate option for carefully selected women after individualized assessment of the likelihood of successful vaginal birth and the potential risks associated with TOLAC. However, the available evidence is based predominantly on observational studies, and the certainty of evidence for most comparative outcomes remains low or very low. These findings support individualized counselling and shared decision-making while highlighting the need for larger, well-designed comparative studies with standardized outcome reporting.<\/jats:p>","DOI":"10.3390\/medicina62071286","type":"journal-article","created":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T09:34:11Z","timestamp":1783071251000},"page":"1286","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Trial of Labor After Cesarean and Vaginal Birth After Cesarean: A Systematic Review and Meta-Analysis of Maternal and Neonatal Outcomes"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4007-7961","authenticated-orcid":false,"given":"Elitsa","family":"Gyokova","sequence":"first","affiliation":[{"name":"Department of Obsterics and Gynecology, Faculty of Medicine, Medical University\u2014Pleven, 5800 Pleven, Bulgaria"},{"name":"Clinic of Obstetrics and Gynecology, University Hospital \u201cSaint Marina\u2019\u2019, 5800 Pleven, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0329-6081","authenticated-orcid":false,"given":"Eleonora","family":"Hristova-Atanasova","sequence":"additional","affiliation":[{"name":"Department of Social Medicine and Public Health, Faculty of Public Health, Medical University\u2014Plovdiv, 4002 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7719-382X","authenticated-orcid":false,"given":"Angel","family":"Yordanov","sequence":"additional","affiliation":[{"name":"Department of Gynaecological Oncology, Medical University\u2014Pleven, 5800 Pleven, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eva","family":"Tsoneva","sequence":"additional","affiliation":[{"name":"Department of Reproductive Medicine, Specialized Hospital for Active Treatment of Obstetrics and Gynaecology Dr Shterev, 1330 Sofia, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-7643-5879","authenticated-orcid":false,"given":"Zlatko","family":"Kirovakov","sequence":"additional","affiliation":[{"name":"Faculty of Public Health and Health Care, Burgas State University \u201cProf. D-R Assen Zlatarov\u201d, 8000 Burgas, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1002\/ijgo.70406","article-title":"FIGO good practice recommendations for vaginal birth after cesarean section","volume":"171","author":"Barnea","year":"2025","journal-title":"Int. J. Gynecol. Obstet."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e005671","DOI":"10.1136\/bmjgh-2021-005671","article-title":"Trends and projections of caesarean section rates: Global and regional estimates","volume":"6","author":"Betran","year":"2021","journal-title":"BMJ Glob. Health"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"7882","DOI":"10.1038\/s41598-023-34856-8","article-title":"Vaginal birth after cesarean section and its associated factors in Ethiopia: A systematic review and meta-analysis","volume":"13","author":"Addisu","year":"2023","journal-title":"Sci. Rep."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Betr\u00e1n, A.P., Ye, J., Moller, A.-B., Zhang, J., G\u00fclmezoglu, A.M., and Torloni, M.R. (2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990\u20132014. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0148343"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1111\/1471-0528.13526","article-title":"The WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates","volume":"123","author":"Betran","year":"2016","journal-title":"BJOG"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Uno, K., Mayama, M., Yoshihara, M., Takeda, T., Tano, S., Suzuki, T., Kishigami, Y., and Oguchi, H. (2020). Reasons for previous Cesarean deliveries impact a woman\u2019s independent decision of delivery mode and the success of trial of labor after Cesarean. BMC Pregnancy Childbirth, 20.","DOI":"10.1186\/s12884-020-2833-2"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Fitzpatrick, K.E., Quigley, M.A., and Kurinczuk, J.J. (2022). Planned mode of birth after previous cesarean section: A structured review of the evidence on the associated outcomes for women and their children in high-income setting. Front. Med., 9.","DOI":"10.3389\/fmed.2022.920647"},{"key":"ref_8","first-page":"100","article-title":"Opinions of pregnant women about vaginal birth after caesarean section","volume":"26","author":"Mamuk","year":"2022","journal-title":"Afr. J. Reprod. Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1053\/beog.2000.0152","article-title":"Psychological aspects of caesarean section","volume":"15","author":"Clement","year":"2001","journal-title":"Best Pract. Res. Clin. Obstet. Gynaecol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1267","DOI":"10.1097\/AOG.0b013e3181df925f","article-title":"Vaginal Birth After Cesarean: New Insights on Maternal and Neonatal Outcomes","volume":"115","author":"Guise","year":"2010","journal-title":"Obstet. Gynecol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1016\/j.ajog.2004.12.082","article-title":"Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option?","volume":"192","author":"Macones","year":"2005","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"203","DOI":"10.24061\/2413-4260.XV.3.57.2025.28","article-title":"Perinatal Aspects of Cesarean Section in Full-Term Pregnancy: A Comprehensive Review","volume":"15","author":"Korchynska","year":"2025","journal-title":"Neonatol. H\u00ecr. Perinat. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"3768","DOI":"10.1080\/14767058.2020.1765332","article-title":"Determinants of cesarean-related complications: High number of repeat cesarean, operation type or placental pathologies?","volume":"34","author":"Simsek","year":"2021","journal-title":"J. Matern Fetal Neonatal Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"262.e1","DOI":"10.1016\/j.ajog.2011.06.035","article-title":"Impact of multiple cesarean deliveries on maternal morbidity: A systematic review","volume":"205","author":"Marshall","year":"2011","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1226","DOI":"10.1097\/01.AOG.0000219750.79480.84","article-title":"Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries","volume":"107","author":"Silver","year":"2006","journal-title":"Obstet. Gynecol."},{"key":"ref_16","first-page":"CD004224","article-title":"Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth","volume":"2013","author":"Dodd","year":"2013","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Fitzpatrick, K.E., Kurinczuk, J.J., Alfirevic, Z., Spark, P., Brocklehurst, P., and Knight, M. (2012). Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-Control Study. PLoS Med., 9.","DOI":"10.1371\/journal.pmed.1001184"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1007\/s00404-014-3444-9","article-title":"Pregnancy outcomes of induced labor in women with previous cesarean section: A systematic review and meta-analysis","volume":"291","author":"Rossi","year":"2015","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1016\/j.ajog.2006.06.045","article-title":"Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery?","volume":"195","author":"Cahill","year":"2006","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2581","DOI":"10.1056\/NEJMoa040405","article-title":"Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery","volume":"351","author":"Landon","year":"2004","journal-title":"New Engl. J. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1097\/01.AOG.0000223871.69852.31","article-title":"Trial of Labor or Repeat Cesarean Delivery in Women With Morbid Obesity and Previous Cesarean Delivery","volume":"108","author":"Hibbard","year":"2006","journal-title":"Obstet. Gynecol."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Barger, M.K., Dunn, J.T., Bearman, S., DeLain, M., and Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth, 13.","DOI":"10.1186\/1471-2393-13-83"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"806","DOI":"10.1097\/01.AOG.0000259312.36053.02","article-title":"Development of a Nomogram for Prediction of Vaginal Birth After Cesarean Delivery","volume":"109","author":"Grobman","year":"2007","journal-title":"Obstet. Gynecol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"S\u00f8rbye, I.K., Vangen, S., Oneko, O., Sundby, J., and Bergsj\u00f8, P. (2011). Caesarean section among referred and self-referred birthing women: A cohort study from a tertiary hospital, northeastern Tanzania. BMC Pregnancy Childbirth, 11.","DOI":"10.1186\/1471-2393-11-55"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Keag, O.E., Norman, J.E., and Stock, S.J. (2018). Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med., 15.","DOI":"10.1371\/journal.pmed.1002494"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e027807","DOI":"10.1136\/bmjopen-2018-027807","article-title":"Predicting the success of vaginal birth after caesarean delivery: A retrospective cohort study in China","volume":"9","author":"Li","year":"2019","journal-title":"BMJ Open"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"145","DOI":"10.4103\/aam.aam_54_17","article-title":"Outcome of vaginal birth after cesarean section: A retrospective comparative analysis of spontaneous versus induced labor in women with one previous cesarean section","volume":"17","author":"Kiwan","year":"2018","journal-title":"Ann. Afr. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"S84","DOI":"10.1055\/s-0040-1714344","article-title":"Vaginal birth after two previous cesarean sections versus elective repeated cesarean: A retrospective study","volume":"37","author":"Manzoni","year":"2020","journal-title":"Am. J. Perinatol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Zhang, H.-L., Zheng, L.-H., Cheng, L.-C., Liu, Z.-D., Yu, L., Han, Q., Miao, G.-Y., and Yan, J.-Y. (2020). Prediction of vaginal birth after cesarean delivery in Southeast China: A retrospective cohort study. BMC Pregnancy Childbirth, 20.","DOI":"10.1186\/s12884-020-03233-y"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.wombi.2010.04.001","article-title":"A new perspective on VBAC: A retrospective cohort study","volume":"24","author":"Rozen","year":"2011","journal-title":"Women Birth"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1111\/aogs.13059","article-title":"Practice variation of vaginal birth after cesarean and the influence of risk factors at patient level: A retrospective cohort study","volume":"96","author":"Vankan","year":"2017","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_32","first-page":"586","article-title":"Clinical study on vaginal birth after cesarean","volume":"51","author":"He","year":"2016","journal-title":"Zhonghua Fu Chan Ke Za Zhi"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1007\/s00404-020-05454-0","article-title":"Vaginal birth after caesarean section: A multicentre study on prognostic factors and feasibility","volume":"301","author":"Familiari","year":"2020","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1515\/jpm-2020-0222","article-title":"Vaginal birth after cesarean (Vbac): Fear it or dare it? An evaluation of potential risk factors","volume":"49","author":"Lazarou","year":"2021","journal-title":"J. Perinat. Med."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Rusavy, Z., Francova, E., Paymova, L., Ismail, K.M., and Kalis, V. (2019). Timing of cesarean and its impact on labor duration and genital tract trauma at the first subsequent vaginal birth: A retrospective cohort study. BMC Pregnancy Childbirth, 19.","DOI":"10.1186\/s12884-019-2359-7"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"403.e1","DOI":"10.1016\/j.ajog.2016.12.001","article-title":"Vaginal birth after cesarean: Neonatal outcomes and United States birth setting","volume":"216","author":"Tilden","year":"2017","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1002\/uog.23629","article-title":"Vaginal birth after Cesarean section and levator ani avulsion: A case\u2013control study","volume":"58","author":"Paymova","year":"2021","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1111\/birt.12539","article-title":"Perinatal outcomes of planned home birth after cesarean and planned hospital vaginal birth after cesarean at term gestation in British Columbia, Canada: A retrospective population-based cohort study","volume":"48","author":"Bayrampour","year":"2021","journal-title":"Birth"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1016\/j.ijgo.2015.09.031","article-title":"Prediction of vaginal birth after cesarean delivery","volume":"133","author":"Bhide","year":"2016","journal-title":"Int. J. Gynecol. Obstet."},{"key":"ref_40","first-page":"1","article-title":"Rates and Determinants of Successful Vaginal Birth after a Previous Caesarean Section: A Prospective Cohort Study","volume":"4","author":"Eleje","year":"2019","journal-title":"ARC J. Gynecol. Obstet."},{"key":"ref_41","first-page":"369","article-title":"Influencing factors and antenatal assessment of the vaginal birth after cesarean section","volume":"54","author":"Guo","year":"2019","journal-title":"Zhonghua Fu Chan Ke Za Zhi"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1159\/000357757","article-title":"Predicting Vaginal Birth after Cesarean Section: A Cohort Study","volume":"77","author":"Racek","year":"2014","journal-title":"Gynecol. Obstet. Investig."},{"key":"ref_43","first-page":"1","article-title":"Vaginal Birth After a Previous Caesarean Section: Current Trends and Outlook in Ghana","volume":"4","author":"Seffah","year":"2014","journal-title":"J. West Afr. Coll. Surg."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1016\/j.tjog.2022.03.006","article-title":"Vaginal birth after cesarean section: Experience from a regional hospital","volume":"61","author":"Chen","year":"2022","journal-title":"Taiwan. J. Obstet. Gynecol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"2523617","DOI":"10.1080\/07853890.2025.2523617","article-title":"Development and validation of an improved prediction model for vaginal birth after previous cesarean section: A retrospective cohort study of a Chinese population","volume":"57","author":"Liu","year":"2025","journal-title":"Ann. Med."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Zhu, T., Luo, D., Li, Y., and Xiong, L. (2025). Duration of labor stages and pregnancy outcomes in vaginal birth after cesarean: A retrospective comparative analysis. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1643142"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1747","DOI":"10.1007\/s00192-019-03978-x","article-title":"Risk factors for obstetric anal sphincter injuries at vaginal birth after caesarean: A retrospective cohort study","volume":"30","author":"Monga","year":"2019","journal-title":"Int. Urogynecol. J."},{"key":"ref_48","first-page":"75","article-title":"Vaginal Birth after Cesarean Section (VBAC) Success Rate and Predictors of Success in a Tertiary Care Hospital","volume":"11","author":"Masoom","year":"2021","journal-title":"J. Soc. Obstet. Gynaecol. Pak."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"444","DOI":"10.5603\/GP.2019.0076","article-title":"Safety and success rate of vaginal birth after two cesarean sections: Retrospective cohort study","volume":"90","author":"Modzelewski","year":"2019","journal-title":"Ginekol. Pol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"8871","DOI":"10.1038\/s41598-023-36027-1","article-title":"Factors associated with successful vaginal birth after one lower uterine transverse cesarean section delivery","volume":"13","author":"Tesfahun","year":"2023","journal-title":"Sci. Rep."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1515\/jpm-2025-0440","article-title":"Second pregnancy vaginal birth after cesarean- impact of maternal age on outcomes from a retrospective cohort study","volume":"54","author":"Mariyam","year":"2025","journal-title":"J. Perinat. Med."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"894","DOI":"10.3892\/etm.2021.10326","article-title":"Vaginal birth after Cesarean experience in Romania: A retrospective case-series study and online survey","volume":"22","author":"Carauleanu","year":"2021","journal-title":"Exp. Ther. Med."},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Fu, J.-C., Xirasagar, S., Liu, J., and Probst, J.C. (2010). Cesarean and VBAC rates among immigrant vs. native-born women: A retrospective observational study from Taiwan Cesarean delivery and VBAC among immigrant women in Taiwan. BMC Public Health, 10.","DOI":"10.1186\/1471-2458-10-548"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1080\/01443615.2021.1916451","article-title":"Factors associated with the outcome of TOLAC after one previous caesarean section: A retrospective cohort study","volume":"42","author":"Parveen","year":"2022","journal-title":"J. Obstet. Gynaecol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1016\/j.ejogrb.2019.09.015","article-title":"Establishment and validation of a prediction model for vaginal delivery after cesarean and its pregnancy outcomes\u2014Based on a prospective study","volume":"242","author":"Lin","year":"2019","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"e294","DOI":"10.1016\/j.wombi.2021.05.010","article-title":"Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial","volume":"35","author":"Homer","year":"2022","journal-title":"Women Birth"},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Homer, C.S., Besley, K., Bell, J., Davis, D., Adams, J., Porteous, A., and Foureur, M. (2013). Does continuity of care impact decision making in the next birth after a caesarean section (VBAC)? a randomised controlled trial. BMC Pregnancy Childbirth, 13.","DOI":"10.1186\/1471-2393-13-140"},{"key":"ref_58","first-page":"7","article-title":"Nuchal Cord and Its Implications","volume":"14","author":"Kiecka","year":"2022","journal-title":"Pediatr. Rep."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/7\/1286\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T12:21:08Z","timestamp":1783081268000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/7\/1286"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,3]]},"references-count":58,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["medicina62071286"],"URL":"https:\/\/doi.org\/10.3390\/medicina62071286","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,3]]}}}