{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T14:40:41Z","timestamp":1785422441025,"version":"3.56.0"},"reference-count":55,"publisher":"Global Tracheostomy Collaborative","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"\n Aim<\/jats:title>\n To evaluate the effectiveness of AvTrach\u00ae wearable artificial airway simulators (AWAS) compared to high-fidelity manikins (HFM) in enhancing tracheostomy suctioning competency, managing physiological stress, and improving engagement through dimensions of physical, conceptual, and psychological fidelity.<\/jats:p>\n <\/jats:sec>\n \n Design<\/jats:title>\n A multi-institutional, randomized controlled trial (RCT) was conducted to compare AWAS with HFM training modalities for tracheostomy suctioning among healthcare professionals and students.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Participants (n = 69) from two institutions were randomized into experimental (AWAS) and control (HFM) groups. Competency was assessed using an Objective Structured Clinical Examination tool, and stress responses were measured through salivary cortisol levels. The study encompassed four sessions: recruitment, baseline competency levels and training, simulation, and clinical demonstrations. Quantitative data were analyzed using descriptive statistics, Wilcoxon rank-sum tests, and mixed-effects regression models.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Both groups demonstrated improved competency post-training (p < 0.001). However, the AWAS group achieved higher clinical competency scores (p < 0.001) and exhibited stable cortisol levels during clinical demonstrations, indicating better stress adaptation. Participants in the AWAS group also reported higher engagement, attributed to dynamic feedback and enhanced emotional immersion.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n AWAS training, integrating physical, conceptual, and psychological fidelity, significantly enhances tracheostomy care competency and stress management compared to HFM. This approach supports technical skill development, emotional preparedness, and interprofessional collaboration, essential for high-stakes clinical environments.<\/jats:p>\n <\/jats:sec>","DOI":"10.62905\/001c.132160","type":"journal-article","created":{"date-parts":[[2025,4,17]],"date-time":"2025-04-17T20:51:23Z","timestamp":1744923083000},"source":"Crossref","is-referenced-by-count":1,"title":["Effect of AvTrach\u00ae Wearable Airway Simulator versus High-Fidelity Manikin on Tracheostomy Suctioning Competency and Physiological Stress: A Multi-Institutional Randomized Controlled Trial"],"prefix":"10.62905","volume":"2","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2260-1080","authenticated-orcid":true,"given":"Vinciya","family":"Pandian","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/04p491231","id-type":"ROR","asserted-by":"publisher"}],"name":"Pennsylvania State University","department":["Ross and Carol Nese College of Nursing"]},{"id":[{"id":"https:\/\/ror.org\/04p491231","id-type":"ROR","asserted-by":"publisher"}],"name":"Pennsylvania State University","department":["Department of Otolaryngology Head and Neck Surgery, College of Medicine"]},{"id":[{"id":"https:\/\/ror.org\/04p491231","id-type":"ROR","asserted-by":"publisher"}],"name":"Pennsylvania State University","department":["Center for Immersive Learning and Digital Innovation"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Colandrea","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05dbx6743","id-type":"ROR","asserted-by":"publisher"}],"name":"Department of Veterans Affairs","department":["Department of Otolaryngology Head-Neck Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy","family":"Sullivan","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/00za53h95","id-type":"ROR","asserted-by":"publisher"}],"name":"Johns Hopkins University","department":["School of Nursing"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carol S","family":"Maragos","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05cb1k848","id-type":"ROR","asserted-by":"publisher"}],"name":"Johns Hopkins Hospital","department":["Department of Otolaryngology Head-Neck Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stanola","family":"Stanley","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/04p491231","id-type":"ROR","asserted-by":"publisher"}],"name":"Pennsylvania State University","department":["Center for Immersive Learning and Digital Innovation"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4926-0957","authenticated-orcid":false,"given":"Michael J","family":"Brenner","sequence":"additional","affiliation":[{"name":"University of Michigan Medical School","department":["Department of Otolaryngology \u2013 Head and Neck Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"49560","published-online":{"date-parts":[[2025,4,1]]},"reference":[{"issue":"1","key":"ref1","first-page":"7","article-title":"Improving Tracheostomy Care Delivery: Instituting Clinical Care Pathways and Nursing Education to Improve Patient Outcomes","volume":"34","author":"M. Colandrea","year":"2016","journal-title":"ORL Head Neck Nurs"},{"issue":"6","key":"ref2","doi-asserted-by":"publisher","first-page":"384","DOI":"10.1097\/SIH.0000000000000392","article-title":"Using Didactics and Simulation to Enhance Comfort, Knowledge, and Skills of Nonsurgical Trainees Caring for Patients With Tracheostomy and Laryngectomy","volume":"14","author":"K. A. Davis","year":"2019","journal-title":"Simul Healthc"},{"issue":"3","key":"ref3","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1097\/sih.0000000000000425","article-title":"Participant Perspectives on the Contributions of Physical, Psychological, and Sociological Fidelity to Learning in Interprofessional Mental Health Simulation","volume":"15","author":"L. M. Naismith","year":"2020","journal-title":"Simul Healthc"},{"issue":"2","key":"ref4","doi-asserted-by":"publisher","first-page":"232","DOI":"10.1177\/0194599820917427","article-title":"The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration","volume":"163","author":"R. L. Cherney","year":"2020","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"2","key":"ref5","first-page":"16","article-title":"A Simulated Tracheostomy Tube Change Educational Intervention to Promote Competency Among Novice Healthcare Professionals: A Repeated Measures Study","volume":"1","author":"J. Peter","year":"2024","journal-title":"Tracheostomy"},{"issue":"4","key":"ref6","doi-asserted-by":"publisher","first-page":"220","DOI":"10.1097\/SIH.0000000000000597","article-title":"Assessing Competence With a Task Trainer: Validity Evidence for Novel Tracheostomy Care Skills Assessment Tool","volume":"17","author":"R. S. Poeppelman","year":"2022","journal-title":"Simul Healthc"},{"issue":"2","key":"ref7","doi-asserted-by":"publisher","first-page":"250","DOI":"10.1177\/0194599820923659","article-title":"In Situ Simulation to Assess Pediatric Tracheostomy Care Safety: A Novel Multicenter Quality Improvement Program","volume":"163","author":"S. J. Shah","year":"2020","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"2","key":"ref8","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1136\/bmjstel-2017-000267","article-title":"The role of high-fidelity simulation in designing emergency airway management algorithms: the experience of the UK National Tracheostomy safety project","volume":"5","author":"B. A. McGrath","year":"2019","journal-title":"BMJ Simul Technol Enhanc Learn"},{"issue":"6","key":"ref9","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1097\/00001888-199306000-00002","article-title":"An overview of the uses of standardized patients for teaching and evaluating clinical skills","volume":"68","author":"H. S. Barrows","year":"1993","journal-title":"AAMC. Academic Medicine"},{"issue":"4","key":"ref10","doi-asserted-by":"publisher","first-page":"643","DOI":"10.1016\/j.jtv.2022.07.016","article-title":"Low-fidelity simulation vs. standardized patients in prevention and management of pressure injury education","volume":"31","author":"S. Altun","year":"2022","journal-title":"J Tissue Viability"},{"issue":"1","key":"ref11","doi-asserted-by":"publisher","first-page":"e104","DOI":"10.1016\/j.bja.2020.04.054","article-title":"Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership","volume":"125","author":"M. J. Brenner","year":"2020","journal-title":"Br J Anaesth"},{"issue":"6","key":"ref12","doi-asserted-by":"publisher","first-page":"487","DOI":"10.1080\/01421590802530898","article-title":"A ten-year review of the literature on the use of standardized patients in teaching and learning: 1996-2005","volume":"31","author":"W. May","year":"2009","journal-title":"Med Teach"},{"issue":"5","key":"ref13","doi-asserted-by":"publisher","first-page":"e6","DOI":"10.1016\/j.nedt.2015.01.019","article-title":"The effects of simulation-based learning using standardized patients in nursing students: A meta-analysis","volume":"35","author":"P. J. Oh","year":"2015","journal-title":"Nurse Educ Today"},{"key":"ref14","article-title":"AvTrach Tracheostomy Simulator","author":"Avkin"},{"issue":"1","key":"ref15","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1097\/NNE.0000000000000393","article-title":"Effect of Simulation on Learner Stress as Measured by Cortisol: An Integrative Review","volume":"43","author":"K. McGuire","year":"2018","journal-title":"Nurse Educ"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1186\/s41077-017-0040-7","article-title":"The effects of active (hot-seat) versus observer roles during simulation-based training on stress levels and non-technical performance: a randomized trial","volume":"2","author":"C. L. Bong","year":"2017","journal-title":"Adv Simul (Lond)"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"86","DOI":"10.1100\/tsw.2011.8","article-title":"The effects of high-fidelity simulation on salivary cortisol levels in SRNA students: a pilot study","volume":"11","author":"T. Jones","year":"2011","journal-title":"ScientificWorldJournal"},{"issue":"5","key":"ref18","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph19052980","article-title":"Objective and Subjective Stress Parameters in Response to High and Low-Fidelity Simulation Activities","volume":"19","author":"M. Czekirda","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1186\/1741-7015-8-18","article-title":"CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials","volume":"8","author":"K. F. Schulz","year":"2010","journal-title":"BMC Med"},{"issue":"3","key":"ref20","doi-asserted-by":"publisher","first-page":"458","DOI":"10.1287\/mnsc.9.3.458","article-title":"An experimental application of the Delphi method to the use of experts","volume":"9","author":"N. Dalkey","year":"1963","journal-title":"Management science"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"229","DOI":"10.3389\/fpsyg.2016.00229","article-title":"Subjective Stress, Salivary Cortisol, and Electrophysiological Responses to Psychological Stress","volume":"7","author":"M. Qi","year":"2016","journal-title":"Front Psychol"},{"issue":"15-16","key":"ref22","doi-asserted-by":"publisher","first-page":"4782","DOI":"10.1111\/jocn.16535","article-title":"Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit","volume":"32","author":"D. T. U. Jung","year":"2023","journal-title":"J Clin Nurs"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"e20230279","DOI":"10.1590\/1980-220X-REEUSP-2023-0279en","article-title":"Association between cortisol levels and performance in clinical simulation: a systematic review","volume":"58","author":"J. G. Teixeira","year":"2024","journal-title":"Rev Esc Enferm USP"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"100031","DOI":"10.1016\/j.cpnec.2021.100031","article-title":"Emotional intelligence, cortisol and alpha-amylase response to highly stressful hyper-realistic surgical simulation of a mass casualty event scenario","volume":"5","author":"I. Zapata","year":"2021","journal-title":"Compr Psychoneuroendocrinol"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1016\/j.ecns.2020.02.001","article-title":"Beyond Technology: A Scoping Review of Features that Promote Fidelity and Authenticity in Simulation-Based Health Professional Education","volume":"42","author":"P. Lavoie","year":"2020","journal-title":"Clinical Simulation in Nursing"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"1220632","DOI":"10.3389\/fmed.2023.1220632","article-title":"Evaluation of tracheostomy suctioning procedure among nursing and respiratory therapy students: wearable manikin vs. standard manikin","volume":"10","author":"K. Lumowa","year":"2023","journal-title":"Front Med (Lausanne)"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1016\/j.ecns.2021.08.009","article-title":"Healthcare Simulation Standards of Best PracticeTM Simulation Design","volume":"58","author":"P. I. Watts","year":"2021","journal-title":"Clinical Simulation in Nursing"},{"issue":"1S","key":"ref28","doi-asserted-by":"publisher","DOI":"10.1097\/SIH.0000000000000762","article-title":"Effects of Simulation Fidelity on Health Care Providers on Team Training\u2014A Systematic Review","volume":"19","author":"S. Mitchell","year":"2024","journal-title":"Simulation in Healthcare"},{"issue":"5","key":"ref29","doi-asserted-by":"publisher","first-page":"e1237","DOI":"10.1002\/hsr2.1237","article-title":"Interprofessional simulation as an enhancement of psychological fidelity: A focus group study of medical and nursing students","volume":"6","author":"B. Burford","year":"2023","journal-title":"Health Sci Rep"},{"issue":"11","key":"ref30","doi-asserted-by":"publisher","first-page":"1179","DOI":"10.1111\/medu.13432","article-title":"How to enhance psychological fidelity in simulation-based medical education","volume":"51","author":"\u00c1. Blask\u00f3","year":"2017","journal-title":"Med Educ"},{"issue":"1","key":"ref31","doi-asserted-by":"publisher","first-page":"811","DOI":"10.1186\/s12909-022-03903-9","article-title":"Autonomic stress response of physiotherapy student in the different scenarios of an objective structured clinical examination","volume":"22","author":"B. Mart\u00ednez-Pascual","year":"2022","journal-title":"BMC Med Educ"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"9506583","DOI":"10.1155\/2022\/9506583","article-title":"Cortisol Awakening Response and Stress in Female Nurses on Monthly Shift Rotations: A Longitudinal Study","volume":"2022","author":"Y. H. Lin","year":"2022","journal-title":"Biomed Res Int"},{"issue":"1","key":"ref33","doi-asserted-by":"publisher","first-page":"e119","DOI":"10.1016\/j.bja.2020.04.064","article-title":"Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals","volume":"125","author":"B. A. McGrath","year":"2020","journal-title":"Br J Anaesth"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"e20220078","DOI":"10.1590\/1980-220X-REEUSP-2022-0078en","article-title":"Psychological stress factors and salivary cortisol in nursing students throughout their training","volume":"56","author":"S. S. Mendes","year":"2022","journal-title":"Rev Esc Enferm USP"},{"issue":"5","key":"ref35","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1097\/sih.0000000000000511","article-title":"Association of Medical Students' Stress and Coping Skills With Simulation Performance","volume":"16","author":"N. E. Anton","year":"2021","journal-title":"Simul Healthc"},{"issue":"1","key":"ref36","doi-asserted-by":"publisher","first-page":"198","DOI":"10.1097\/aln.0000000000003287","article-title":"Stress Management Training Improves Overall Performance during Critical Simulated Situations: A Prospective Randomized Controlled Trial","volume":"133","author":"F. Sigwalt","year":"2020","journal-title":"Anesthesiology"},{"issue":"1","key":"ref37","doi-asserted-by":"publisher","first-page":"296","DOI":"10.1186\/s12909-020-02202-5","article-title":"Stress, anxiety, self-efficacy, and the meanings that physical therapy students attribute to their experience with an objective structured clinical examination","volume":"20","author":"\u00c9. M. R. Ferreira","year":"2020","journal-title":"BMC Med Educ"},{"issue":"10","key":"ref38","doi-asserted-by":"publisher","first-page":"e0293509","DOI":"10.1371\/journal.pone.0293509","article-title":"Nursing students' perceived anxiety and heart rate variability in mock skill competency assessment","volume":"18","author":"C. L. Wong","year":"2023","journal-title":"PLoS One"},{"issue":"4","key":"ref39","doi-asserted-by":"publisher","first-page":"474","DOI":"10.34197\/ats-scholar.2022-0042OC","article-title":"The Influence of Stress on Student Performance during Simulation-based Learning: A Pilot Randomized Trial","volume":"4","author":"R. Cavaleri","year":"2023","journal-title":"ATS Sch"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1016\/j.ecns.2023.101428","article-title":"Development and Evaluation of a Wearable Simulator System","author":"C. S. Bradley","year":"2023","journal-title":"Clin Simul Nurs"},{"issue":"2","key":"ref41","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1007\/s40271-017-0277-1","article-title":"A Systematic Review of Patient and Caregiver Experiences with a Tracheostomy","volume":"11","author":"I. Nakarada-Kordic","year":"2018","journal-title":"Patient"},{"issue":"2","key":"ref42","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1007\/s40271-017-0283-3","article-title":"The Primacy of Patient-Centered Outcomes in Tracheostomy Care","volume":"11","author":"E. Ward","year":"2018","journal-title":"Patient"},{"issue":"9-10","key":"ref43","doi-asserted-by":"publisher","first-page":"2056","DOI":"10.1111\/jocn.16269","article-title":"Cultivating learning in vitro: A meta-ethnography of learning experiences of nursing students regarding high-fidelity simulation","volume":"32","author":"S. Fernandez-Basanta","year":"2023","journal-title":"J Clin Nurs"},{"issue":"5","key":"ref44","doi-asserted-by":"publisher","first-page":"984","DOI":"10.1177\/0194599820961990","article-title":"Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review","volume":"164","author":"K. D. Meister","year":"2021","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"11-12","key":"ref45","doi-asserted-by":"publisher","first-page":"2757","DOI":"10.1111\/jocn.16377","article-title":"Professional competence development through interprofessional simulation-based learning assists perioperative nurses in postgraduation acute clinical practice situations: A qualitative study","volume":"32","author":"H. K. A. Kaldheim","year":"2023","journal-title":"J Clin Nurs"},{"issue":"6","key":"ref46","doi-asserted-by":"publisher","first-page":"2357","DOI":"10.1111\/jocn.17074","article-title":"The future of anatomy education: Simulation-based and AI-based learning","volume":"33","author":"M. A. Mazhar","year":"2024","journal-title":"J Clin Nurs"},{"issue":"17-18","key":"ref47","doi-asserted-by":"publisher","first-page":"5668","DOI":"10.1111\/jocn.16681","article-title":"Influence of simulation design on stress, anxiety and self-confidence of nursing students: Systematic review with meta-analysis","volume":"32","author":"G. Oliveira Silva","year":"2023","journal-title":"J Clin Nurs"},{"issue":"7","key":"ref48","doi-asserted-by":"publisher","first-page":"717","DOI":"10.1016\/S2213-2600(20)30230-7","article-title":"Tracheostomy in the COVID-19 era: global and multidisciplinary guidance","volume":"8","author":"B. A. McGrath","year":"2020","journal-title":"Lancet Respir Med"},{"issue":"3","key":"ref49","doi-asserted-by":"publisher","first-page":"262","DOI":"10.1177\/0003489420941542","article-title":"Multidisciplinary Tracheostomy Quality Improvement in the COVID-19 Pandemic: Building a Global Learning Community","volume":"130","author":"C. Swords","year":"2021","journal-title":"Ann Otol Rhinol Laryngol"},{"issue":"3","key":"ref50","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1111\/jocn.17016","article-title":"Exploring intensive care nurses' perception of simulation-based learning: A systematic review and meta-synthesis","volume":"33","author":"I. Weismantel","year":"2024","journal-title":"J Clin Nurs"},{"issue":"19-20","key":"ref51","doi-asserted-by":"publisher","first-page":"6967","DOI":"10.1111\/jocn.16815","article-title":"Effectiveness of interprofessional tracheostomy teams: A systematic review","volume":"32","author":"A. Ninan","year":"2023","journal-title":"J Clin Nurs"},{"issue":"6","key":"ref52","doi-asserted-by":"publisher","first-page":"499","DOI":"10.4037\/ajcc2022659","article-title":"Prevention of Tracheostomy-Related Pressure Injury: A Systematic Review and Meta-analysis","volume":"31","author":"C. H. Moser","year":"2022","journal-title":"Am J Crit Care"},{"key":"ref53","doi-asserted-by":"publisher","first-page":"103720","DOI":"10.1016\/j.iccn.2024.103720","article-title":"Global predictors of tracheostomy-related pressure injury in the COVID-19 era: A study of secondary data","author":"C. H. Moser","year":"2024","journal-title":"Intensive Crit Care Nurs"},{"issue":"2","key":"ref54","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1001\/jamaoto.2015.3050","article-title":"Inpatient Nursing and Parental Comfort in Managing Pediatric Tracheostomy Care and Emergencies","volume":"142","author":"C. V. Pritchett","year":"2016","journal-title":"JAMA Otolaryngol Head Neck Surg"},{"issue":"7","key":"ref55","doi-asserted-by":"publisher","first-page":"696","DOI":"10.1002\/ppul.23355","article-title":"Improving knowledge, technical skills, and confidence among pediatric health care providers in the management of chronic tracheostomy using a simulation model","volume":"51","author":"A. Agarwal","year":"2016","journal-title":"Pediatr Pulmonol"}],"container-title":["Tracheostomy: Official Journal of the Global Tracheostomy Collaborative"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/trachjournal.scholasticahq.com\/article\/132160-effect-of-avtrach-wearable-airway-simulator-versus-high-fidelity-manikin-on-tracheostomy-suctioning-competency-and-physiological-stress-a-multi-inst","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,24]],"date-time":"2026-01-24T05:49:50Z","timestamp":1769233790000},"score":1,"resource":{"primary":{"URL":"https:\/\/trachjournal.scholasticahq.com\/article\/132160-effect-of-avtrach-wearable-airway-simulator-versus-high-fidelity-manikin-on-tracheostomy-suctioning-competency-and-physiological-stress-a-multi-inst"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,1]]},"references-count":55,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025]]}},"URL":"https:\/\/doi.org\/10.62905\/001c.132160","relation":{},"ISSN":["2997-2531"],"issn-type":[{"value":"2997-2531","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,4,1]]}}}