{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T17:18:39Z","timestamp":1791566319453,"version":"4.3.4"},"reference-count":51,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2025,9,5]],"date-time":"2025-09-05T00:00:00Z","timestamp":1757030400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pharmaceuticals"],"abstract":"<jats:p>Background\/Objectives: Chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2DM) frequently coexist, contributing to worse clinical outcomes and increased risk of exacerbations. While newer glucose-lowering agents have demonstrated cardiovascular and renal benefits, their comparative efficacy on COPD exacerbations remain uncertain. Methods: We systematically searched PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov from inception to June 2025. We included randomised controlled trials (RCTs) and observational studies enrolling adults with COPD and T2DM that reported the risk of COPD exacerbations following initiation of SGLT2is, GLP-1RAs, DPP-4is, or sulfonylureas, with an active comparator group. The primary outcome was a composite of moderate-to-severe COPD exacerbations. Secondary outcomes included the individual components separately. A Bayesian random-effects network meta-analysis was performed to estimate risk ratio (RR) with 95% credible intervals (95% CIs). Results: Nine observational studies were ultimately included. No RCTs were retrieved. Compared to sulfonylureas, initiation of SGLT2is (RR 0.64, 0.59\u20130.69), GLP-1RAs (0.66, 0.60\u20130.71), and DPP-4is (0.79, 0.74\u20130.86) was associated with reduced risk of moderate-to-severe exacerbations. Moreover, SGLT2is (0.80, 0.75\u20130.86) and GLP-1RAs (0.83, 0.77\u20130.88) were more favourable compared to DPP4is. Consistent results were found for secondary outcomes. Sensitivity analyses confirmed the robustness of the findings for the primary outcome. Robustness was not consistently observed across all treatment comparisons for secondary outcomes. Conclusions: Among patients with COPD and T2DM, newer glucose-lowering agents, particularly SGLT2is and GLP-1RAs, were associated with significantly lower risk of moderate-to-severe exacerbations. These findings support the potential respiratory benefits of these agents and warrant confirmation through RCTs.<\/jats:p>","DOI":"10.3390\/ph18091337","type":"journal-article","created":{"date-parts":[[2025,9,5]],"date-time":"2025-09-05T14:53:01Z","timestamp":1757083981000},"page":"1337","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Efficacy of SGLT2 Inhibitors, GLP-1 Receptor Agonists, DPP-4 Inhibitors, and Sulfonylureas on Moderate-to-Severe COPD Exacerbations Among Patients with Type 2 Diabetes: A Systematic Review and Network Meta-Analysis"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3011-7405","authenticated-orcid":false,"given":"Edoardo","family":"Pirera","sequence":"first","affiliation":[{"name":"Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialized Medicine (Promise) G. D\u2019Alessandro, University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4529-3703","authenticated-orcid":false,"given":"Domenico","family":"Di Raimondo","sequence":"additional","affiliation":[{"name":"Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialized Medicine (Promise) G. D\u2019Alessandro, University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4349-3322","authenticated-orcid":false,"given":"Lucio","family":"D\u2019Anna","sequence":"additional","affiliation":[{"name":"Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Rd, London W6 8RF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6440-7318","authenticated-orcid":false,"given":"Antonino","family":"Tuttolomondo","sequence":"additional","affiliation":[{"name":"Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialized Medicine (Promise) G. D\u2019Alessandro, University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,5]]},"reference":[{"key":"ref_1","unstructured":"(2025, April 13). 2025 GOLD Report. Available online: https:\/\/goldcopd.org\/2025-gold-report\/."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Wang, Y., Han, R., Ding, X., Feng, W., Gao, R., and Ma, A. (2025). Chronic Obstructive Pulmonary Disease across Three Decades: Trends, Inequalities, and Projections from the Global Burden of Disease Study 2021. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1564878"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"GBD 2013 Mortality and Causes of Death Collaborators (2015). Global, Regional, and National Age-Sex Specific All-Cause and Cause-Specific Mortality for 240 Causes of Death, 1990\u20132013: A Systematic Analysis for the Global Burden of Disease Study 2013. Lancet, 385, 117\u2013171.","DOI":"10.1016\/S0140-6736(14)61682-2"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1183\/09031936.06.00025805","article-title":"Chronic Obstructive Pulmonary Disease: Current Burden and Future Projections","volume":"27","author":"Lopez","year":"2006","journal-title":"Eur. Respir. J."},{"key":"ref_5","unstructured":"World Health Organization (2025, August 25). Projections of Global Deaths from 2016 to 2060. Available online: https:\/\/colinmathers.com\/2022\/05\/10\/projections-of-global-deaths-from-2016-to-2060\/."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1635","DOI":"10.1007\/s11606-007-0313-2","article-title":"Beyond Comorbidity Counts: How Do Comorbidity Type and Severity Influence Diabetes Patients\u2019 Treatment Priorities and Self-Management?","volume":"22","author":"Kerr","year":"2007","journal-title":"J. Gen. Intern. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1016\/S2213-2600(15)00241-6","article-title":"Risk of Cardiovascular Comorbidity in Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis","volume":"3","author":"Chen","year":"2015","journal-title":"Lancet Respir. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"911","DOI":"10.1164\/rccm.2203022","article-title":"Association between Glycemic State and Lung Function: The Framingham Heart Study","volume":"167","author":"Walter","year":"2003","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1093\/aje\/kwi076","article-title":"Lung Function and Glucose Metabolism: An Analysis of Data from the Third National Health and Nutrition Examination Survey","volume":"161","author":"McKeever","year":"2005","journal-title":"Am. J. Epidemiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1207","DOI":"10.2147\/COPD.S407085","article-title":"All-Cause, Cardiovascular and Respiratory Mortality in People with Type 2 Diabetes and Chronic Obstructive Pulmonary Disease (COPD) in England: A Cohort Study Using the Clinical Practice Research Datalink (CPRD)","volume":"18","author":"Raslan","year":"2023","journal-title":"Int. J. Chronic Obstr. Pulm. Dis."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Di Martino, G., Di Giovanni, P., Cedrone, F., Michela, D., Meo, F., Scampoli, P., Romano, F., and Staniscia, T. (2022). The Impact of COPD on Hospitalized Patients with Diabetes: A Propensity Score Matched Analysis on Discharge Records. Healthcare, 10.","DOI":"10.3390\/healthcare10050885"},{"key":"ref_12","first-page":"CD013650","article-title":"Dipeptidyl Peptidase-4 Inhibitors, Glucagon-like Peptide 1 Receptor Agonists and Sodium-Glucose Co-Transporter-2 Inhibitors for People with Cardiovascular Disease: A Network Meta-Analysis","volume":"10","author":"Kanie","year":"2021","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"315","DOI":"10.2337\/db21-0688","article-title":"Liraglutide Improves Forced Vital Capacity in Individuals with Type 2 Diabetes: Data from the Randomized Crossover LIRALUNG Study","volume":"71","author":"Ciudin","year":"2022","journal-title":"Diabetes"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1515","DOI":"10.1016\/j.jaci.2017.11.043","article-title":"Glucagon-like Peptide 1 Signaling Inhibits Allergen-Induced Lung IL-33 Release and Reduces Group 2 Innate Lymphoid Cell Cytokine Production In Vivo","volume":"142","author":"Toki","year":"2018","journal-title":"J. Allergy Clin. Immunol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e1719","DOI":"10.1210\/clinem\/dgab818","article-title":"Association Between SGLT2 Inhibitors vs DPP-4 Inhibitors and Risk of Pneumonia Among Patients with Type 2 Diabetes","volume":"107","author":"Au","year":"2022","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2067","DOI":"10.1042\/CS20210099","article-title":"Contribution of Dipeptidyl Peptidase 4 to Non-Typeable Haemophilus Influenzae-Induced Lung Inflammation in COPD","volume":"135","author":"Kotnala","year":"2021","journal-title":"Clin. Sci."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2008","DOI":"10.1001\/jama.283.15.2008","article-title":"Meta-Analysis of Observational Studies in Epidemiology: A Proposal for Reporting. Meta-Analysis of Observational Studies in Epidemiology (MOOSE) Group","volume":"283","author":"Stroup","year":"2000","journal-title":"JAMA"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"777","DOI":"10.7326\/M14-2385","article-title":"The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions: Checklist and Explanations","volume":"162","author":"Hutton","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"i4919","DOI":"10.1136\/bmj.i4919","article-title":"ROBINS-I: A Tool for Assessing Risk of Bias in Non-Randomised Studies of Interventions","volume":"355","author":"Sterne","year":"2016","journal-title":"BMJ"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.jclinepi.2010.03.016","article-title":"Graphical Methods and Numerical Summaries for Presenting Results from Multiple-Treatment Meta-Analysis: An Overview and Tutorial","volume":"64","author":"Salanti","year":"2011","journal-title":"J. Clin. Epidemiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"932","DOI":"10.1002\/sim.3767","article-title":"Checking Consistency in Mixed Treatment Comparison Meta-Analysis","volume":"29","author":"Dias","year":"2010","journal-title":"Stat. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1177\/0272989X13487257","article-title":"Evidence Synthesis for Decision Making 6: Embedding Evidence Synthesis in Probabilistic Cost-Effectiveness Analysis","volume":"33","author":"Dias","year":"2013","journal-title":"Med. Decis. Mak."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1093\/ije\/dys041","article-title":"Predicting the Extent of Heterogeneity in Meta-Analysis, Using Empirical Data from the Cochrane Database of Systematic Reviews","volume":"41","author":"Turner","year":"2012","journal-title":"Int. J. Epidemiol."},{"key":"ref_24","unstructured":"(2024, September 14). Cochrane Handbook for Systematic Reviews of Interventions. Available online: https:\/\/training.cochrane.org\/handbook\/current."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1344","DOI":"10.2337\/dc20-1794","article-title":"Glucagon-Like Peptide 1 Receptor Agonists and Chronic Lower Respiratory Disease Exacerbations Among Patients with Type 2 Diabetes","volume":"44","author":"Albogami","year":"2021","journal-title":"Diabetes Care"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e071380","DOI":"10.1136\/bmj-2022-071380","article-title":"Novel Antihyperglycaemic Drugs and Prevention of Chronic Obstructive Pulmonary Disease Exacerbations among Patients with Type 2 Diabetes: Population Based Cohort Study","volume":"379","author":"Pradhan","year":"2022","journal-title":"BMJ"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1088","DOI":"10.1164\/rccm.202303-0491OC","article-title":"Association of GLP-1 Receptor Agonists with Chronic Obstructive Pulmonary Disease Exacerbations among Patients with Type 2 Diabetes","volume":"208","author":"Foer","year":"2023","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e2251177","DOI":"10.1001\/jamanetworkopen.2022.51177","article-title":"Association of Sodium-Glucose Cotransporter 2 Inhibitor vs Dipeptidyl Peptidase-4 Inhibitor Use with Risk of Incident Obstructive Airway Disease and Exacerbation Events Among Patients with Type 2 Diabetes in Hong Kong","volume":"6","author":"Au","year":"2023","journal-title":"JAMA Netw. Open"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"00803","DOI":"10.1183\/23120541.00803-2024","article-title":"Pulmonary Outcomes of Incretin-Based Therapies in COPD Patients Receiving Single-Inhaler Triple Therapy","volume":"11","author":"See","year":"2025","journal-title":"ERJ Open Res."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1017","DOI":"10.1136\/thorax-2023-221040","article-title":"Glucagon-like Peptide-1 Receptor Agonists May Benefit Cardiopulmonary Outcomes in Patients with COPD","volume":"79","author":"Yen","year":"2024","journal-title":"Thorax"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"112122","DOI":"10.1016\/j.diabres.2025.112122","article-title":"Comparison of SGLT2 and DPP4 Inhibitors on Clinical Outcomes in COPD Patients with Diabetes: A Nationwide Cohort Study","volume":"223","author":"Chang","year":"2025","journal-title":"Diabetes Res. Clin. Pract."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Ray, A., Paik, J.M., Wexler, D.J., Sreedhara, S.K., Bykov, K., Feldman, W.B., and Patorno, E. (2025). Glucose-Lowering Medications and Risk of Chronic Obstructive Pulmonary Disease Exacerbations in Patients with Type 2 Diabetes. JAMA Intern. Med., e247811.","DOI":"10.1001\/jamainternmed.2024.7811"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"846","DOI":"10.1513\/AnnalsATS.202407-703OC","article-title":"SGLT-2 Inhibitors and the Risk of Chronic Obstructive Pulmonary Disease Exacerbations and Mortality in Chronic Obstructive Pulmonary Disease Patients","volume":"22","author":"Yen","year":"2025","journal-title":"Ann. Am. Thorac. Soc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1785","DOI":"10.1177\/0962280216669183","article-title":"Optimally Estimating the Sample Mean from the Sample Size, Median, Mid-Range, and\/or Mid-Quartile Range","volume":"27","author":"Luo","year":"2018","journal-title":"Stat. Methods Med. Res."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1111\/cea.14284","article-title":"Glucagon-like Peptide-1 Receptor Agonist Use Is Associated with Lower Serum Periostin","volume":"53","author":"Foer","year":"2023","journal-title":"Clin. Exp. Allergy"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"3433","DOI":"10.1111\/all.14879","article-title":"Glucagon-like Peptide-1 Receptor Agonist Inhibits Aeroallergen-Induced Activation of ILC2 and Neutrophilic Airway Inflammation in Obese Mice","volume":"76","author":"Toki","year":"2021","journal-title":"Allergy"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Joo, H., Park, S.J., Min, K.H., and Rhee, C.K. (2021). Association between Plasma Interleukin-33 Level and Acute Exacerbation of Chronic Obstructive Pulmonary Disease. BMC Pulm. Med., 21.","DOI":"10.1186\/s12890-021-01423-8"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"804","DOI":"10.1165\/rcmb.2015-0311OC","article-title":"Glucagon-Like Peptide 1 Receptor: A Novel Pharmacological Target for Treating Human Bronchial Hyperresponsiveness","volume":"55","author":"Rogliani","year":"2016","journal-title":"Am. J. Respir. Cell Mol. Biol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.rmed.2019.06.015","article-title":"Long-Term Observational Study on the Impact of GLP-1R Agonists on Lung Function in Diabetic Patients","volume":"154","author":"Rogliani","year":"2019","journal-title":"Respir. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"405","DOI":"10.2147\/COPD.S350133","article-title":"Respiratory Effects of Treatment with a Glucagon-Like Peptide-1 Receptor Agonist in Patients Suffering from Obesity and Chronic Obstructive Pulmonary Disease","volume":"17","author":"Hilberg","year":"2022","journal-title":"Int. J. Chron. Obs. Pulmon Dis."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"309","DOI":"10.2337\/db17-0607","article-title":"Mechanisms to Elevate Endogenous GLP-1 Beyond Injectable GLP-1 Analogs and Metabolic Surgery","volume":"67","author":"Briere","year":"2018","journal-title":"Diabetes"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"109631","DOI":"10.1016\/j.mehy.2020.109631","article-title":"Sodium Glucose Cotransporter2 Inhibitor-Possible Treatment for Patients with Diabetes, Pulmonary Disease and CO2 Retention","volume":"139","author":"Brikman","year":"2020","journal-title":"Med. Hypotheses"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1183\/09031936.03.00405703","article-title":"Systemic Effects of Chronic Obstructive Pulmonary Disease","volume":"21","author":"Noguera","year":"2003","journal-title":"Eur. Respir. J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1183\/09031936.00148014","article-title":"Does COPD Stand for \u201cCOmorbidity with Pulmonary Disease\u201d?","volume":"45","author":"Vanfleteren","year":"2015","journal-title":"Eur. Respir. J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.ejim.2025.01.016","article-title":"Risk Trajectory of Cardiovascular Events after an Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis","volume":"135","author":"Pirera","year":"2025","journal-title":"Eur. J. Intern. Med."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"210041","DOI":"10.1183\/16000617.0041-2021","article-title":"Unravelling the Mechanisms Driving Multimorbidity in COPD to Develop Holistic Approaches to Patient-Centred Care","volume":"30","author":"Burke","year":"2021","journal-title":"Eur. Respir. Rev."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"e061807","DOI":"10.1136\/bmjopen-2022-061807","article-title":"Efficacy and Safety of GLP-1 Receptor Agonists versus SGLT-2 Inhibitors in Overweight\/Obese Patients with or without Diabetes Mellitus: A Systematic Review and Network Meta-Analysis","volume":"13","author":"Ma","year":"2023","journal-title":"BMJ Open"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1016\/j.ajcnut.2023.04.017","article-title":"The Weight-Loss Effect of GLP-1RAs Glucagon-Like Peptide-1 Receptor Agonists in Non-Diabetic Individuals with Overweight or Obesity: A Systematic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials","volume":"118","author":"Liu","year":"2023","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"292","DOI":"10.2337\/dc24-1678","article-title":"Efficacy of GLP-1 Receptor Agonists on Weight Loss, BMI, and Waist Circumference for Patients With Obesity or Overweight: A Systematic Review, Meta-Analysis, and Meta-Regression of 47 Randomized Controlled Trials","volume":"48","author":"Wong","year":"2025","journal-title":"Diabetes Care"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e13336","DOI":"10.1111\/obr.13336","article-title":"Sodium-Glucose Co-Transporter 2 Inhibitors on Weight Change and Cardiometabolic Profiles in Individuals with Overweight or Obesity and without Diabetes: A Meta-Analysis","volume":"22","author":"Wong","year":"2021","journal-title":"Obes. Rev."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1002\/jrsm.1054","article-title":"Automating Network Meta-Analysis","volume":"3","author":"Lu","year":"2012","journal-title":"Res. Synth. Methods"}],"container-title":["Pharmaceuticals"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1424-8247\/18\/9\/1337\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:41:02Z","timestamp":1760035262000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1424-8247\/18\/9\/1337"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,5]]},"references-count":51,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9]]}},"alternative-id":["ph18091337"],"URL":"https:\/\/doi.org\/10.3390\/ph18091337","relation":{},"ISSN":["1424-8247"],"issn-type":[{"value":"1424-8247","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,5]]}}}