{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T04:26:39Z","timestamp":1787199999413,"version":"build-2736575974"},"reference-count":52,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:00:00Z","timestamp":1787011200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University of Oradea"},{"id":[{"id":"https:\/\/ror.org\/00wzhv093","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pediatr. Rep.","Pediatric Reports"],"abstract":"<jats:p>Background: Acute appendicitis is a leading pediatric surgical emergency. Timely diagnosis remains challenging, particularly in young children with atypical presentations. Clinical evaluation alone yields variable diagnostic performance, prompting the use of risk stratification tools. Objective: To evaluate and compare the Alvarado score against alternative clinical scoring systems, laboratory biomarkers, and imaging modalities in pediatric acute appendicitis. Methods: A narrative literature review with structured selection elements was conducted across PubMed, Scopus, and Web of Science for studies published between 2016 and 2026. Results: The Alvarado score demonstrates moderate diagnostic accuracy in children, with good sensitivity but limited specificity (57\u201376%) at standard cut-offs (\u22657). Pediatric-specific scores like the Pediatric Appendicitis Score (PAS) offer higher sensitivity, while the Appendicitis Inflammatory Response (AIR) score provides superior specificity and better identifies complicated appendicitis (including gangrene, phlegmon, and perforation). Continuous risk models, notably the Pediatric Appendicitis Risk Calculator (pARC), outperform fixed additive scores in pediatric cohorts. Combining clinical scores with C-reactive protein, neutrophil-to-lymphocyte ratio, and selective ultrasonography enhances diagnostic precision. Computed tomography reserved for equivocal cases further optimizes diagnostic yield. Conclusion: The Alvarado score should not be used as a standalone tool. A structured, stepwise multimodal approach integrating clinical scores (such as pARC or PAS), inflammatory biomarkers, and selective imaging optimizes diagnostic accuracy and supports timely surgical decision-making in children.<\/jats:p>","DOI":"10.3390\/pediatric18040115","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T16:12:11Z","timestamp":1787069531000},"page":"115","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Comparison of the Alvarado Score with Alternative Diagnostic Tools in Pediatric Acute Appendicitis: A Literature Review"],"prefix":"10.3390","volume":"18","author":[{"given":"Paul","family":"Tchouala Tchakoute","sequence":"first","affiliation":[{"name":"Doctoral School of Biomedical Sciences, University of Oradea, 410073 Oradea, Romania"},{"name":"Department of Pediatric Surgery and Orthopedics, Bihor County Emergency Clinical Hospital, 410469 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2463-8100","authenticated-orcid":false,"given":"Alin","family":"Iuhas","sequence":"additional","affiliation":[{"name":"Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3097-707X","authenticated-orcid":false,"given":"Vlad-Ionu\u021b","family":"Nechita","sequence":"additional","affiliation":[{"name":"Department of Fundamental Sciences, Discipline of Medical Informatics, Research Methodology and Data Analysis, Faculty of Nursing and Health Sciences (FAMSS), \u201cIuliu Ha\u021bieganu\u201d University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrei Vasile","family":"Pa\u0219cal\u0103u","sequence":"additional","affiliation":[{"name":"Department of Morphological Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania"},{"name":"Department of Pathology, Bihor County Emergency Clinical Hospital, 410469 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-2638-2021","authenticated-orcid":false,"given":"Buzdugan Mihaela","family":"\u0218tefania","sequence":"additional","affiliation":[{"name":"Doctoral School of Biomedical Sciences, University of Oradea, 410073 Oradea, Romania"},{"name":"Department of Premedical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2638-9056","authenticated-orcid":false,"given":"Ion Cosmin","family":"Puia","sequence":"additional","affiliation":[{"name":"Doctoral School of Biomedical Sciences, University of Oradea, 410073 Oradea, Romania"},{"name":"Department of Surgery, \u201cOctavian Fodor\u201d Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania"},{"name":"Department of Surgery, \u201cIuliu Ha\u021bieganu\u201d University of Medicine and Pharmacy, 400162 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e164","DOI":"10.1016\/j.surge.2024.04.013","article-title":"A Comparison of the Accuracy of Tzanakis and Alvarado Score in the Diagnosis of Acute Appendicitis: A Systematic Review and Meta-Analysis","volume":"22","author":"Awan","year":"2024","journal-title":"Surgeon"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Kandabas, M.O., Ergin, M., Ozensoy, H.S., Guru, S., Celik, M.N., Donmez, M., and Parlak, S. (2026). Comparison of the Diagnostic Values of MASS, RIPASA, AIR, and AAS Scores in Adult Patients Presenting to the Emergency Department with Suspected Appendicitis. BMC Emerg. Med., 26.","DOI":"10.1186\/s12873-026-01545-4"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"363","DOI":"10.2147\/OAEM.S323960","article-title":"Predictive Factors to Diagnose Appendicitis in Children in the Emergency Department","volume":"13","author":"Dadeh","year":"2021","journal-title":"Open Access Emerg. Med."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"El Haissoufi, K., Hadi, E.H., Habib, S., Aissaoui, H., Atassi, M., Ammor, A., and Benhaddou, H. (2024). Appendicitis in Children: Does Age Really Matter?. Afr. J. Paediatr. Surg.","DOI":"10.4103\/ajps.ajps_99_23"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.pedneo.2023.03.011","article-title":"Diagnostic Performance of the Classic Symptom \u201cAbdominal Pain before Vomiting\u201d for Pediatric Acute Appendicitis","volume":"65","author":"Kitaoka","year":"2024","journal-title":"Pediatr. Neonatol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1278","DOI":"10.1016\/S0140-6736(15)00275-5","article-title":"Acute Appendicitis: Modern Understanding of Pathogenesis, Diagnosis, and Management","volume":"386","author":"Bhangu","year":"2015","journal-title":"Lancet"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1136\/bmj.38940.664363.AE","article-title":"Acute Appendicitis","volume":"333","author":"Humes","year":"2006","journal-title":"BMJ"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1001\/jama.298.4.438","article-title":"Does This Child Have Appendicitis?","volume":"298","author":"Bundy","year":"2007","journal-title":"JAMA"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1055\/s-0041-1722860","article-title":"Diagnostic Value of Clinical Prediction Scores for Acute Appendicitis in Children Younger than 4 Years","volume":"32","author":"Rassi","year":"2022","journal-title":"Eur. J. Pediatr. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1886","DOI":"10.1016\/j.jpedsurg.2023.02.060","article-title":"The Value of the Alvarado Score for the Diagnosis of Acute Appendicitis in Children: A Systematic Review and Meta-Analysis","volume":"58","author":"Bai","year":"2023","journal-title":"J. Pediatr. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/s43159-021-00074-y","article-title":"Predictive Values of Alvarado Score, Serum C-Reactive Protein, and White Blood Cell Count in the Diagnosis of Acute Appendicitis: A Prospective Study","volume":"17","author":"Talabi","year":"2021","journal-title":"Ann. Pediatr. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1016\/S0196-0644(86)80993-3","article-title":"A Practical Score for the Early Diagnosis of Acute Appendicitis","volume":"15","author":"Alvarado","year":"1986","journal-title":"Ann. Emerg. Med."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Ohle, R., O\u2019Reilly, F., O\u2019Brien, K.K., Fahey, T., and Dimitrov, B.D. (2011). The Alvarado Score for Predicting Acute Appendicitis: A Systematic Review. BMC Med., 9.","DOI":"10.1186\/1741-7015-9-139"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1002\/bjs.4464","article-title":"Meta-Analysis of the Clinical and Laboratory Diagnosis of Appendicitis","volume":"91","author":"Andersson","year":"2004","journal-title":"Br. J. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1053\/jpsu.2002.32893","article-title":"Pediatric Appendicitis Score","volume":"37","author":"Samuel","year":"2002","journal-title":"J. Pediatr. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1695","DOI":"10.1007\/s00268-008-9649-y","article-title":"The Appendicitis Inflammatory Response Score: A Tool for the Diagnosis of Acute Appendicitis That Outperforms the Alvarado Score","volume":"32","author":"Andersson","year":"2008","journal-title":"World J. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1151","DOI":"10.1007\/s00268-005-7853-6","article-title":"A New Approach to Accurate Diagnosis of Acute Appendicitis","volume":"29","author":"Tzanakis","year":"2005","journal-title":"World J. Surg."},{"key":"ref_18","first-page":"220","article-title":"Development of the RIPASA Score: A New Appendicitis Scoring System for the Diagnosis of Acute Appendicitis","volume":"51","author":"Chong","year":"2010","journal-title":"Singap. Med. J."},{"key":"ref_19","first-page":"1","article-title":"Comparative performance of Alvarado scale and the pediatric appendicitis scale in schoolchildren and adolescents","volume":"94","author":"Guirado","year":"2022","journal-title":"Rev. Cuba. Pediatr\u00eda"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1186\/s43159-021-00079-7","article-title":"Comparison of Alvarado Score and Pediatric Appendicitis Score for Clinical Diagnosis of Acute Appendicitis in Children\u2014A Prospective Study","volume":"17","author":"Iftikhar","year":"2021","journal-title":"Ann. Pediatr. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1055\/s-0040-1710534","article-title":"Clinical Prediction Scores for Pediatric Appendicitis","volume":"31","author":"Gudjonsdottir","year":"2021","journal-title":"Eur. J. Pediatr. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"75","DOI":"10.25122\/jml-2020-0031","article-title":"Comparison of the Appendicitis Inflammatory Response and Alvarado Scoring Systems in the Diagnosis of Acute Appendicitis in Children","volume":"14","author":"Vaziri","year":"2021","journal-title":"J. Med. Life"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Pogoreli\u0107, Z., Mihanovi\u0107, J., Nin\u010devi\u0107, S., Luk\u0161i\u0107, B., Elezovi\u0107 Baloevi\u0107, S., and Pola\u0161ek, O. (2021). Validity of Appendicitis Inflammatory Response Score in Distinguishing Perforated from Non-Perforated Appendicitis in Children. Children, 8.","DOI":"10.3390\/children8040309"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1937","DOI":"10.18203\/2349-2902.isj20223152","article-title":"Evaluation of Alvarado Score and Appendicitis Inflammatory Response Score as Diagnostic Tools for Acute Appendicitis","volume":"9","author":"Hassan","year":"2022","journal-title":"Int. Surg. J."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"879","DOI":"10.18203\/2349-2902.isj20210920","article-title":"RIPASA Score or Alvarado Score: Diagnosing Acute Appendicitis","volume":"8","author":"Parmeshwar","year":"2021","journal-title":"Int. Surg. J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e13013","DOI":"10.1016\/j.heliyon.2023.e13013","article-title":"Comparison of Alvarado Score, Appendicitis Inflammatory Response Score (AIR) and Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score in Predicting Acute Appendicitis","volume":"9","author":"Zeb","year":"2023","journal-title":"Heliyon"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"220","DOI":"10.37201\/req\/008.2021","article-title":"Diagnostic Accuracy of Combining C-Reactive Protein and Alvarado Score among 2-to-20-Year-Old Patients with Acute Appendicitis Suspected Presenting to Emergency Departments","volume":"34","author":"Alhames","year":"2021","journal-title":"Rev. Esp. Quimioter."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"22","DOI":"10.4103\/bjhs.bjhs_175_23","article-title":"Neutrophil-to-Lymphocyte Ratio to Improve the Diagnostic Performance of Appendicitis Inflammatory Score and Modified Alvarado Score","volume":"9","author":"Bansal","year":"2024","journal-title":"BLDE Univ. J. Health Sci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1089\/sur.2023.295","article-title":"Predictive Factors of Acute Appendicitis in Children with Non-Visualized Appendix on Ultrasound: A Prospective Cohort Study","volume":"25","author":"Zouari","year":"2024","journal-title":"Surg. Infect."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1089\/sur.2023.370","article-title":"Ultrasound Assessment in Children With Suspected Appendicitis: Time to Revise Diagnostic Criteria: A Prospective Cohort Study","volume":"25","author":"Zouari","year":"2024","journal-title":"Surg. Infect."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"676","DOI":"10.1097\/MS9.0000000000000270","article-title":"Clinical Scores (Alvarado and AIR Scores) versus Imaging (Ultrasound and CT Scan) in the Diagnosis of Equivocal Cases of Acute Appendicitis: A Randomized Controlled Study","volume":"85","author":"Noori","year":"2023","journal-title":"Ann. Med. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1016\/j.jss.2023.06.037","article-title":"The Alvarado Score Is the Most Impactful Diagnostic Tool for Appendicitis: A Bibliometric Analysis","volume":"291","author":"Zeinert","year":"2023","journal-title":"J. Surg. Res."},{"key":"ref_33","first-page":"e107774","article-title":"Is Alvarado Score Helpful for Pediatrician in Diagnosis of Acute Appendicitis? Our Center Experience","volume":"9","author":"Sedigheh","year":"2021","journal-title":"Arch. Pediatr. Infect. Dis."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"891","DOI":"10.5152\/tjg.2022.21865","article-title":"The Utility of Immature Granulocyte Count and Percentage on the Prediction of Acute Appendicitis in the Suspected Acute Appendicitis According to the Alvarado Scoring System: A Retrospective Cohort Study","volume":"33","author":"Bozan","year":"2022","journal-title":"Turk. J. Gastroenterol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1055\/s-0040-1718406","article-title":"Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children","volume":"31","author":"Fuhrer","year":"2021","journal-title":"Eur. J. Pediatr. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"150","DOI":"10.52403\/ijrr.20220619","article-title":"Relationship between High Alvarado Scores and Complicate Acute Appendicitis in Acute Appendicitis Patients That Undergo Appendicectomy Surgery","volume":"9","author":"Candranata","year":"2022","journal-title":"Int. J. Res. Rev."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"hcae070.209","DOI":"10.1093\/qjmed\/hcae070.209","article-title":"Evaluating Pediatric Appendicitis Score and Alvarado Scoring System for Detecting Acute Appendicitis in Pediatric Population","volume":"117","author":"Abdelhamid","year":"2024","journal-title":"QJM Int. J. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2231","DOI":"10.1007\/s00330-015-3639-x","article-title":"Appendiceal Diameter as a Predictor of Appendicitis in Children: Improved Diagnosis with Three Diagnostic Categories Derived from a Logistic Predictive Model","volume":"25","author":"Trout","year":"2015","journal-title":"Eur. Radiol."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"M\u00e1n, E., Szil\u00e1gyi, A., Simonka, Z., R\u00e1rosi, F., Pet\u0151, Z., and L\u00e1z\u00e1r, G. (2023). Validation of the Modified Alvarado Score on Patients Attending A&E Units with Suspected Appendicitis. BMC Emerg. Med., 23.","DOI":"10.1186\/s12873-023-00846-2"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1282","DOI":"10.21608\/ijma.2021.38601.1170","article-title":"Comparative Study between Modified Alvarado Score and Abdominal Ultrasound Diagnostic Value of Acute Appendicitis in Children","volume":"3","author":"Rizk","year":"2021","journal-title":"Int. J. Med. Arts"},{"key":"ref_41","first-page":"e72873","article-title":"Efficacy of the Modified Alvarado Scoring System and Radiologic Studies in Diagnosing Appendicitis in Children: A Retrospective Comparative Study","volume":"16","author":"Mnofala","year":"2024","journal-title":"Cureus"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"109","DOI":"10.54996\/anatolianjem.1058404","article-title":"The Predictive Value of Ultrasound, Alvarado Score, and C-Reactive Protein in Pediatric Appendectomy Outcomes","volume":"5","year":"2022","journal-title":"Anatol. J. Emerg. Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1542\/peds.2005-0094","article-title":"A Clinical Decision Rule to Identify Children at Low Risk for Appendicitis","volume":"116","author":"Kharbanda","year":"2005","journal-title":"Pediatrics"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"e127","DOI":"10.1055\/s-0041-1731446","article-title":"Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis","volume":"7","author":"Jose","year":"2021","journal-title":"Surg. J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1186\/s43159-021-00132-5","article-title":"RIPASA versus Alvarado Score in the Assessment of Suspected Appendicitis in Children: A Prospective Study","volume":"17","author":"Asena","year":"2021","journal-title":"Ann. Pediatr. Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"532","DOI":"10.5152\/TurkArchPediatr.2022.22076","article-title":"Comparison of Appendicitis Scoring Systems in Childhood Appendicitis","volume":"57","author":"Basar","year":"2022","journal-title":"Turk. Arch. Pediatr."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1088","DOI":"10.1542\/peds.110.6.1088","article-title":"Effect of an Imaging Protocol on Clinical Outcomes Among Pediatric Patients with Appendicitis","volume":"110","author":"Taylor","year":"2002","journal-title":"Pediatrics"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1197\/j.aem.2006.08.009","article-title":"Atypical Clinical Features of Pediatric Appendicitis","volume":"14","author":"Becker","year":"2007","journal-title":"Acad. Emerg. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1097\/SLA.0000000000003059","article-title":"Development and Implications of an Evidence-Based and Public Health-Relevant Definition of Complicated Appendicitis in Children","volume":"271","author":"Cameron","year":"2020","journal-title":"Ann. Surg."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/j.acap.2016.11.014","article-title":"A Clinical Score to Predict Appendicitis in Older Male Children","volume":"17","author":"Kharbanda","year":"2017","journal-title":"Acad. Pediatr."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1542\/peds.2011-3375","article-title":"Diagnostic Imaging and Negative Appendectomy Rates in Children: Effects of Age and Gender","volume":"129","author":"Bachur","year":"2012","journal-title":"Pediatrics"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e88","DOI":"10.1542\/peds.2013-2208","article-title":"Prospective Evaluation of a Clinical Pathway for Suspected Appendicitis","volume":"133","author":"Saucier","year":"2014","journal-title":"Pediatrics"}],"container-title":["Pediatric Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2036-7503\/18\/4\/115\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T04:23:07Z","timestamp":1787199787000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2036-7503\/18\/4\/115"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,18]]},"references-count":52,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["pediatric18040115"],"URL":"https:\/\/doi.org\/10.3390\/pediatric18040115","relation":{},"ISSN":["2036-7503"],"issn-type":[{"value":"2036-7503","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,18]]}}}