{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:59:20Z","timestamp":1787029160964,"version":"build-2736575974"},"reference-count":48,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2020,6,1]],"date-time":"2020-06-01T00:00:00Z","timestamp":1590969600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Systemic sclerosis (SSc) is a connective tissue disease characterized by initial microvascular damage, immune system activation and progressive fibrosis with insufficiency of internal organs. Gastrointestinal (GI) involvement is characterized by atrophy of the smooth muscle and small bowel hypomotility, mainly resulting from an autonomic nerve dysfunction. These modifications significantly affect gut transit and nutrient absorption, thus leading to malnutrition deficit induced by malabsorption. Nutritional deficit induced by malabsorption might also lead to bone alterations. This study aims to evaluate the relationship between malnutrition and bone status. Thirty-six postmenopausal female patients fulfilling the ACR 2013 criteria for SSc underwent dual-energy X-ray absorptiometry scan (DXA) to detect quantitative lumbar spine bone mineral density (BMD) and trabecular bone score (TBS) analysis to detect bone quality. Data from DXA also allow to assess body composition and provide several quantitative parameters, including free fat mass index (FFMI) that identifies the patient with malnutrition (values &lt;15 kg\/m2 in women and 17 kg\/m2 in men), according to the ESPEN criteria. Body mass index (BMI) was calculated for all SSc patients and every patient completed a diary reporting GI symptoms. Two groups of SSc patients with or without diagnosed malnutrition according to FFMI parameter were identified. Malnourished SSc patients showed significantly lower weight (p = 0.01) and BMI (p = 0.001), as well as lower serum levels of hemoglobin (p = 0.009), albumin (p = 0.002), PTH (p = 0.02) and 25OH-vitamin D (p = 0.008). DXA analysis showed significantly lower lumbar L1-L4 T-score (p = 0.009) and BMD values (p = 0.029) in malnourished SSc patients. Consistently, TBS values were significantly lower in malnourished patients (p = 0.008) and correlated with BMD (at any site) and serum albumin levels (p = 0.02). In addition, FFMI positively correlated with bone parameters as well as with symptoms of intestinal impairment in malnourished SSc patients. Finally, GI symptoms significantly correlated with BMD but not with TBS. This pilot study shows that in malnourished SSc patients (2015 ESPEN criteria: FFMI&lt;15 kg\/m2), an altered bone status significantly correlates with GI involvement, in terms of symptoms being mainly due to intestinal involvement together with the presence of selected serum biomarkers of malnutrition.<\/jats:p>","DOI":"10.3390\/nu12061632","type":"journal-article","created":{"date-parts":[[2020,6,2]],"date-time":"2020-06-02T04:09:03Z","timestamp":1591070943000},"page":"1632","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":19,"title":["Nutritional Status and Bone Microarchitecture in a Cohort of Systemic Sclerosis Patients"],"prefix":"10.3390","volume":"12","author":[{"given":"Sabrina","family":"Paolino","sequence":"first","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Greta","family":"Pacini","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlotta","family":"Schenone","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Massimo","family":"Patan\u00e8","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Sulli","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samir Giuseppe","family":"Sukkar","sequence":"additional","affiliation":[{"name":"Clinical Nutrition Unit, IRCCS San Martino Polyclinic, 16132 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adriano","family":"Lercara","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmen","family":"Pizzorni","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4732-0306","authenticated-orcid":false,"given":"Emanuele","family":"Gotelli","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Cattelan","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federica","family":"Goegan","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vanessa","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Ghent University, St. Pietersnieuwstraat 33, 9000 Gent, Belgium"},{"name":"Department of Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium"},{"name":"Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), 9000 Ghent, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5396-0932","authenticated-orcid":false,"given":"Maurizio","family":"Cutolo","sequence":"additional","affiliation":[{"name":"Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University of Genoa, IRCCS San Martino Polyclinic, 16126 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"578","DOI":"10.1038\/nrrheum.2010.104","article-title":"Assessing microvascular changes in systemic sclerosis diagnosis and management","volume":"6","author":"Cutolo","year":"2010","journal-title":"Nat. Rev. Rheumatol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1685","DOI":"10.1016\/S0140-6736(17)30933-9","article-title":"Systemic Sclerosis","volume":"390","author":"Denton","year":"2017","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Jaeger, V.K., Wirz, E.G., Allanore, Y., Rossbach, P., Riemekasten, G., Hachulla, E., Oliver Distler, O., Air\u00f2, P.E., Carreira, P., and Balbir Gurman, A. (2016). Incidences and Risk Factors of Organ Manifestations in the Early Course of Systemic Sclerosis: A Longitudinal EUSTAR Study. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0163894"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1355","DOI":"10.1136\/annrheumdis-2011-200742","article-title":"EUSTAR Co-authors. Update on the profile of the EUSTAR cohort: An analysis of the EULAR Scleroderma Trials and Research group database","volume":"71","author":"Meier","year":"2012","journal-title":"Ann. Rheum. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1586\/egh.13.22","article-title":"Systemic sclerosis and the gut","volume":"7","author":"Butt","year":"2013","journal-title":"Expert Rev. Gastroenterol. Hepatol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1111\/j.1365-2036.2006.02804.x","article-title":"Systematic review: Pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis (scleroderma)","volume":"23","author":"Sallam","year":"2006","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1093\/rheumatology\/kes429","article-title":"Gastrointestinal motility disorder assessment in systemic sclerosis","volume":"52","author":"Savarino","year":"2013","journal-title":"Rheumatology"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1111\/apt.13963","article-title":"Review article: Pathogenesis and clinical manifestations of gastrointestinal involvement In systemic sclerosis","volume":"45","author":"Kumar","year":"2017","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1097\/MCG.0b013e318042d625","article-title":"Gastric and enteric involvement in progressive system sclerosis","volume":"42","author":"Ebert","year":"2008","journal-title":"J. Clin. Gastroenterol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1697","DOI":"10.1136\/gut.2005.086074","article-title":"A case-control study of the pathology of oesophageal disease in systemic sclerosis (scleroderma)","volume":"55","author":"Roberts","year":"2006","journal-title":"Gut"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"834","DOI":"10.1007\/s10620-018-4977-8","article-title":"Intestinal Involvement in Systemic Sclerosis: A Clinical Review","volume":"63","author":"Lazaros","year":"2018","journal-title":"Dig. Dis. Sci."},{"key":"ref_12","first-page":"278","article-title":"Intestinal dysbiosis is common in systemic sclerosis and associated with gastrointestinal and extraintestinal features of disease","volume":"18","author":"Alrawi","year":"2016","journal-title":"Arthrtits Rheum."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"185","DOI":"10.17219\/acem\/33746","article-title":"Osteoporosis in Gastrointestinal Diseases","volume":"25","author":"Szymczak","year":"2016","journal-title":"Adv. Clin. Exp. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1881","DOI":"10.3899\/jrheum.130032","article-title":"Low bone density in systemic sclerosis. A systematic review","volume":"40","author":"Omair","year":"2013","journal-title":"J. Rheumatol."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Atteritano, M., Sorbara, S., Bagnato, G., Miceli, G., Sangari, D., Morgante, S., Visalli, E., and Bagnato, G. (2013). Bone mineral density, bone turnover markers and fractures in patients with systemic sclerosis: A case control study. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0066991"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Adami, G., Fassio, A., Rossini, M., Caimmi, C., Giollo, A., Orsolini, G., Viapiana, O., and Gatti, D. (2019). Osteoporosis in Rheumatic Diseases. Int. J. Mol. Sci., 20.","DOI":"10.3390\/ijms20235867"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2737","DOI":"10.1002\/art.38098","article-title":"2013 classification criteria for systemic sclerosis: An American College of Rheumatology\/European League against Rheumatism collaborative initiative","volume":"65","author":"Khanna","year":"2013","journal-title":"Arthritis Rheum."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e000782","DOI":"10.1136\/rmdopen-2018-000782","article-title":"Systemic Sclerosis: State Of The Art On Clinical Practice Guidelines","volume":"4","author":"Smith","year":"2018","journal-title":"RMD Open"},{"key":"ref_19","first-page":"S42","article-title":"Screening and therapy for malnutrition and related gastro-intestinal disorders in systemic sclerosis: Recommendations of a North American expert panel","volume":"28","author":"Baron","year":"2010","journal-title":"Clin. Exp. Rheumatol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"597","DOI":"10.1016\/S0899-9007(03)00061-3","article-title":"Body composition interpretation. Contributions of the fat-free mass index and the body fat mass index","volume":"19","author":"Kyle","year":"2003","journal-title":"Nutrition"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/j.clnu.2015.03.001","article-title":"Diagnostic criteria for malnutrition\u2014An ESPEN Consensus Statement","volume":"34","author":"Cederholm","year":"2015","journal-title":"Clin. Nutr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1007\/BF01622200","article-title":"Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: Synopsis of a WHO report. WHO Study Group","volume":"4","author":"Kanis","year":"1994","journal-title":"Osteoporos Int."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1002\/jbmr.2176","article-title":"Trabecular bone score: A noninvasive analytical method based upon the DXA image","volume":"29","author":"Silva","year":"2014","journal-title":"J. Bone Miner Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1016\/j.bone.2015.05.016","article-title":"Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice","volume":"78","author":"Harvey","year":"2015","journal-title":"Bone"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1007\/s11657-020-0688-9","article-title":"Vertebral fracture assessment by dual-energy X-ray absorptiometry along with bone mineral density in the evaluation of postmenopausal osteoporosis","volume":"15","author":"Shetty","year":"2020","journal-title":"Arch. Osteoporos."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1770","DOI":"10.1093\/rheumatology\/keq147","article-title":"Assessment of gastrointestinal symptoms in patients with systemic sclerosis in a UK tertiary referral centre","volume":"49","author":"Thoua","year":"2010","journal-title":"Rheumatology"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1007\/s10067-019-04598-y","article-title":"Malnutrition, associated clinical factors, and depression in systemic sclerosis: A cross-sectional study","volume":"39","author":"Turk","year":"2020","journal-title":"Clin. Rheumatol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1007\/s10067-019-04810-z","article-title":"Prevalence of malnutrition in systemic sclerosis patients assessed by different diagnostic tools","volume":"39","author":"Wojteczek","year":"2020","journal-title":"Clin. Rheuamtol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1007\/s00223-016-0119-5","article-title":"Bone Metabolism in a Large Cohort of Patients with Systemic Sclerosis","volume":"99","author":"Caimmi","year":"2016","journal-title":"Calcif. Tissue Int."},{"key":"ref_30","first-page":"S190","article-title":"Disease-related malnutrition in systemic sclerosis: Evidences and implications","volume":"33","author":"Codullo","year":"2015","journal-title":"Clin. Exp. Rheumatol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1941","DOI":"10.3899\/jrheum.170485","article-title":"Progression of Organ Involvement in Systemic Sclerosis Patients with Persistent \u201cLate\u201d Nailfold Capillaroscopic Pattern of Microangiopathy: A Prospective Study","volume":"44","author":"Pizzorni","year":"2017","journal-title":"J. Rheumatol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1093\/rheumatology\/kel203","article-title":"Outcome of small-bowel motor impairment in systemic sclerosis--a prospective manometric 5-yr follow-up","volume":"46","author":"MarieI","year":"2007","journal-title":"Rheumatology"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1111\/odi.12589","article-title":"The autoimmunity-oral microbiome connection","volume":"23","author":"Nikitakis","year":"2017","journal-title":"Oral. Dis."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1007\/s11894-001-0082-8","article-title":"Osteopenia and osteoporosis in gastrointestinal diseases: Diagnosis and treatment","volume":"3","author":"Southerland","year":"2001","journal-title":"Curr. Gastroenterol. Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"609e10","DOI":"10.1093\/ajcn\/75.4.609","article-title":"Protein and calcium: Antagonists or synergists?","volume":"75","author":"Heaney","year":"2002","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"124e34","DOI":"10.1093\/oxfordjournals.aje.a008899","article-title":"Nutrition and subsequent hip fracture risk among a national cohort of white women","volume":"144","author":"Huang","year":"1996","journal-title":"Am. J. Epidemiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1016\/0002-9343(93)90218-E","article-title":"Consensus Development Conference Diagnosis, prophylaxis and treatment of osteoporosis","volume":"94","author":"Peck","year":"1993","journal-title":"Am. J. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1016\/j.jocd.2008.11.006","article-title":"Evaluation of the potential use of trabecular bone score to complement bone mineral density in the diagnosis of osteoporosis: A preliminary spine BMD-matched case-control study","volume":"12","author":"Pothuaud","year":"2009","journal-title":"J. Clin. Densitom."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1548","DOI":"10.1093\/rheumatology\/key130","article-title":"Correlation between bone quality and microvascular damage in systemic sclerosis patients","volume":"57","author":"Ruaro","year":"2018","journal-title":"Rheumatology"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1093\/ajcn\/nqy237","article-title":"Effect of a hypocaloric, nutritionally complete, higher-protein meal planon bone density and quality in older adults with obesity: A randomized trial","volume":"109","author":"Ashley","year":"2019","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Riccio, P., and Rossano, R. (2019). Undigested Food and Gut Microbiota May Cooperate in the Pathogenesis of Neuroinflammatory Diseases: A Matter of Barriers and a Proposal on the Origin of Organ Specificity. Nutrients, 11.","DOI":"10.3390\/nu11112714"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"M212","DOI":"10.1093\/gerona\/56.4.M212","article-title":"Nutritional parameters, body composition, and progression of disability in older disabled residents living in nursing homes","volume":"56","author":"Zuliani","year":"2001","journal-title":"J. Gerontol. A Biol. Sci. Med. Sci."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"678","DOI":"10.1016\/j.semarthrit.2004.08.006","article-title":"Osteoporosis in Scleroderma","volume":"34","author":"Loucks","year":"2005","journal-title":"Semin. Arthritis Rheum."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"G208","DOI":"10.1152\/ajpgi.00398.2007","article-title":"Novel role of the vitamin D receptor in maintaining the integrity of the intestinal mucosal barrier","volume":"294","author":"Kong","year":"2008","journal-title":"Am. J. Physiol. Gastrointest. Liver Physiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1419","DOI":"10.1007\/s10067-010-1478-3","article-title":"Very Low Levels of Vitamin D in Systemic Sclerosis Patients","volume":"29","author":"Caramaschi","year":"2010","journal-title":"Clin. Rheumatol."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Trombetta, A.C., Smith, V., Gotelli, E., Ghio, M., Paolino, S., Pizzorni, C., Vanhaecke, A., Ruaro, B., Sulli, A., and Cutolo, M. (2017). Vitamin D Deficiency and Clinical Correlations in Systemic Sclerosis Patients: A Retrospective Analysis for Possible Future Developments. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0179062"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1016\/j.autrev.2017.03.002","article-title":"European multicentre pilot survey to assess vitamin D status in rheumatoid arthritis patients and early development of a new Patient Reported Outcome questionnaire (D-PRO)","volume":"16","author":"Vojinovic","year":"2017","journal-title":"Autoimmun. Rev."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1177\/0148607114566854","article-title":"Malnutrition and Cachexia in Heart Failure","volume":"40","author":"Rahman","year":"2016","journal-title":"J. Parenter. Enteral. Nutr."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/12\/6\/1632\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:34:38Z","timestamp":1760175278000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/12\/6\/1632"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,1]]},"references-count":48,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2020,6]]}},"alternative-id":["nu12061632"],"URL":"https:\/\/doi.org\/10.3390\/nu12061632","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,6,1]]}}}