{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T22:39:24Z","timestamp":1788215964095,"version":"build-2803163510"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,6,20]],"date-time":"2024-06-20T00:00:00Z","timestamp":1718841600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,6,20]],"date-time":"2024-06-20T00:00:00Z","timestamp":1718841600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100014584","name":"Universit\u00e4tsmedizin der Johannes Gutenberg-Universit\u00e4t Mainz","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100014584","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Langenbecks Arch Surg"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Emergencies and emergency surgeries are a central part of everyday surgical care in Germany. However, it is unclear how emergency surgery is practically trained in clinics on a daily basis and what training concept is underlying. Therefore, the aim of this survey study was to capture the status quo of emergency surgical training of German general and visceral surgeons.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>The members of the German Society for General and Visceral Surgery were surveyed online (<jats:italic>n<\/jats:italic>\u2009=\u20095281). The questionnaire included demographic data and expertise in surgery and assistance in emergency surgery regarding common emergency surgical operations. In addition, further training measures in emergency surgery and their support by employers were queried.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Only complete questionnaires (<jats:italic>n<\/jats:italic>\u2009=\u2009184, response rate 3.5%) were included in the analysis. Most participants were in training (<jats:italic>n<\/jats:italic>\u2009=\u200969; 38%), followed by senior physicians (<jats:italic>n<\/jats:italic>\u2009=\u200952; 29%), specialists (<jats:italic>n<\/jats:italic>\u2009=\u200931; 17%) and chief physicians (<jats:italic>n<\/jats:italic>\u2009=\u200930; 17%). 64% of the participants were employed at university hospitals or maximum care hospitals. Regarding further training opportunities, in-clinic shock room training was most frequently used. Outside of their own clinic, the ATLS course was most frequently mentioned. Operations for cholecystitis and appendicitis as well as emergency stoma procedures are the most common emergency procedures. There was a strong difference in the frequency of operated cases depending on the level of training. For operations to treat acute abdominal traumas (hemostasis of liver and spleen, packing) as well as outside of visceral surgery, only low competence was reported. Over 90% of survey participants consider emergency surgery to be an indispensable core competence. Neither in the old (76%) nor in the new training regulations (47%) is emergency surgery adequately represented according to the participants\u2019 assessment. There was a significantly lower prevalence of the \u201csub-steps concept\u201d in emergency surgery at 38% compared to elective surgery (44%). Important elements of imparting skills in emergency surgery are simulation and courses as well as operative sub-steps, according to the majority of survey participants.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>The results show that general and visceral surgeons in Germany are introduced to emergency surgery too little structured during further training and at specialist level. The survey participants had, as expected, hardly any experience in emergency surgery outside of visceral surgery but surprisingly also little experience in visceral surgical trauma care. There is a need to discuss the future organization of emergency surgical training. Adequate simulation structures and extracurricular courses could contribute to an improvement in this respect.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1007\/s00423-024-03360-6","type":"journal-article","created":{"date-parts":[[2024,6,20]],"date-time":"2024-06-20T10:06:18Z","timestamp":1718877978000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Status quo of operative training in emergency surgery in Germany \u2013 results of a survey"],"prefix":"10.1007","volume":"409","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9834-9662","authenticated-orcid":false,"given":"N.","family":"Wachter","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6479-6456","authenticated-orcid":false,"given":"C.","family":"G\u00fcsgen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C.","family":"Geis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0187-9750","authenticated-orcid":false,"given":"L.S.","family":"Penzkofer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4878-265X","authenticated-orcid":false,"given":"K.","family":"Oldhafer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9998-6735","authenticated-orcid":false,"given":"A.G.","family":"Willms","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3219-501X","authenticated-orcid":false,"given":"Tobias","family":"Huber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,6,20]]},"reference":[{"key":"3360_CR1","unstructured":"Bundes\u00e4rztekammer (2018) (Muster-)Weiterbildungsordnung 2018: In der Fassung vom 25.06.2022. https:\/\/www.bundesaerztekammer.de\/fileadmin\/user_upload\/BAEK\/Themen\/Aus-Fort-Weiterbildung\/Weiterbildung\/20220625_MWBO-2018.pdf. Accessed 29 Jun 2023"},{"key":"3360_CR2","doi-asserted-by":"publisher","first-page":"262","DOI":"10.1111\/ans.15628","volume":"90","author":"N Kinnear","year":"2020","unstructured":"Kinnear N, Tran M, Han J et al (2020) Does emergency general surgery model affect staff satisfaction, training and working hours? ANZ J Surg 90:262\u2013267. https:\/\/doi.org\/10.1111\/ans.15628","journal-title":"ANZ J Surg"},{"key":"3360_CR3","doi-asserted-by":"publisher","first-page":"462","DOI":"10.1016\/j.amjsurg.2019.09.038","volume":"219","author":"S Lee","year":"2020","unstructured":"Lee S, Buck JR, Ledgerwood AM et al (2020) Nonoperative Management (NOM) of most liver injuries impairs the mastery of intraoperative hemostasis. Am J Surg 219:462\u2013464. https:\/\/doi.org\/10.1016\/j.amjsurg.2019.09.038","journal-title":"Am J Surg"},{"key":"3360_CR4","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1016\/j.yasu.2007.05.009","volume":"41","author":"FW Endorf","year":"2007","unstructured":"Endorf FW, Jurkovich GJ (2007) Should the trauma surgeon do the emergency surgery? Adv Surg 41:155\u2013163. https:\/\/doi.org\/10.1016\/j.yasu.2007.05.009","journal-title":"Adv Surg"},{"key":"3360_CR5","doi-asserted-by":"publisher","first-page":"1044","DOI":"10.1007\/s00104-020-01170-2","volume":"91","author":"C G\u00fcsgen","year":"2020","unstructured":"G\u00fcsgen C, Anger F, Hauer T et al (2020) Fortbildung Von Allgemein- Und Viszeralchirurgen in Der Lebensrettenden Notfallchirurgie: Ergebnisse Einer Umfrage Unter Operationskursteilnehmern (Advanced training of general and visceral surgeons in life-saving emergency surgery: results of a survey among participants of a surgery course). Chirurg 91:1044\u20131052. https:\/\/doi.org\/10.1007\/s00104-020-01170-2","journal-title":"Chirurg"},{"key":"3360_CR6","doi-asserted-by":"publisher","first-page":"553","DOI":"10.1016\/j.jss.2013.02.005","volume":"183","author":"MW Bowyer","year":"2013","unstructured":"Bowyer MW, Kuhls DA, Haskin D et al (2013) Advanced Surgical skills for exposure in trauma (ASSET): the first 25 courses. J Surg Res 183:553\u2013558. https:\/\/doi.org\/10.1016\/j.jss.2013.02.005","journal-title":"J Surg Res"},{"key":"3360_CR7","doi-asserted-by":"publisher","first-page":"832","DOI":"10.1016\/j.jsurg.2018.10.004","volume":"76","author":"CF Mackenzie","year":"2019","unstructured":"Mackenzie CF, Tisherman SA, Shackelford S et al (2019) Efficacy of trauma surgery technical skills training courses. J Surg Educ 76:832\u2013843. https:\/\/doi.org\/10.1016\/j.jsurg.2018.10.004","journal-title":"J Surg Educ"},{"key":"3360_CR8","unstructured":"Bundes\u00e4rztekammer (2021) Arztestatistik zum 31. Dezember 2021. www.bundesaerztekammer.de\/fileadmin\/user_upload\/BAEK\/Ueber_uns\/Statistik\/2021\/2021_Statistik.pdf. Accessed 28 Jun 2023"},{"key":"3360_CR9","unstructured":"Pohlemann T (2023) Chirurgische Versorgung in Kriegszeiten: Editorial. Passion Chirurgie 13"},{"key":"3360_CR10","unstructured":"Hauer T, Huschitt N (2023) Einsatzchirurgie Im Wandel: Neue Herausforderungen f\u00fcr den Sanit\u00e4tsdienst Der Bundeswehr Aus Chirurgischer Sicht. Passion Chirurgie 13"},{"key":"3360_CR11","unstructured":"Pohlemann T (2023) Aus der Nische f\u00fcr Spezialisten zur realen Bedrohung: Penetrierendes Trauma und Kriegsverletzungen. Passion Chirurgie 13"},{"key":"3360_CR12","doi-asserted-by":"publisher","first-page":"2117","DOI":"10.1056\/NEJMsa035205","volume":"349","author":"JD Birkmeyer","year":"2003","unstructured":"Birkmeyer JD, Stukel TA, Siewers AE et al (2003) Surgeon volume and operative mortality in the United States. N Engl J Med 349:2117\u20132127. https:\/\/doi.org\/10.1056\/NEJMsa035205","journal-title":"N Engl J Med"},{"key":"3360_CR13","doi-asserted-by":"publisher","first-page":"666","DOI":"10.1016\/j.jamcollsurg.2017.08.009","volume":"225","author":"A Mehta","year":"2017","unstructured":"Mehta A, Efron DT, Canner JK et al (2017) Effect of Surgeon and Hospital volume on emergency general surgery outcomes. J Am Coll Surg 225:666\u2013675e2. https:\/\/doi.org\/10.1016\/j.jamcollsurg.2017.08.009","journal-title":"J Am Coll Surg"},{"key":"3360_CR14","volume-title":"Outliers: the story of success","author":"M Gladwell","year":"2009","unstructured":"Gladwell M (2009) Outliers: the story of success. Penguin Books, London"},{"key":"3360_CR15","doi-asserted-by":"publisher","first-page":"290","DOI":"10.1055\/s-0042-102966","volume":"141","author":"S Axt","year":"2016","unstructured":"Axt S, Johannink J, Storz P et al (2016) Chirurgische Weiterbildung an deutschen Kliniken - Wunsch und Realit\u00e4t (Surgical Training in Germany: Desire and reality). Zentralblatt f\u00fcr Chirurgie 141:290\u2013296. https:\/\/doi.org\/10.1055\/s-0042-102966","journal-title":"Zentralblatt f\u00fcr Chirurgie"},{"key":"3360_CR16","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1007\/s10353-016-0423-3","volume":"48","author":"J Johannink","year":"2016","unstructured":"Johannink J, Braun M, Gr\u00f6ne J et al (2016) What is needed for surgical training? Eur Surg 48:143\u2013148. https:\/\/doi.org\/10.1007\/s10353-016-0423-3","journal-title":"Eur Surg"},{"key":"3360_CR17","doi-asserted-by":"publisher","first-page":"2501","DOI":"10.1007\/s00268-020-05539-6","volume":"44","author":"T Huber","year":"2020","unstructured":"Huber T, Richardsen I, Klinger C et al (2020) See (n)one, do (n)one, teach (n)one: reality of Surgical Resident Training in Germany. World J Surg 44:2501\u20132510. https:\/\/doi.org\/10.1007\/s00268-020-05539-6","journal-title":"World J Surg"},{"key":"3360_CR18","doi-asserted-by":"publisher","first-page":"1215","DOI":"10.1016\/j.jsurg.2023.06.026","volume":"80","author":"T Huber","year":"2023","unstructured":"Huber T, Boedecker C, Borchardt T et al (2023) Education Team Time Out in Oncologic visceral surgery optimizes Surgical Resident Training and Team Communication: results of a prospective trial. J Surg Educ 80:1215\u20131220. https:\/\/doi.org\/10.1016\/j.jsurg.2023.06.026","journal-title":"J Surg Educ"},{"key":"3360_CR19","doi-asserted-by":"publisher","first-page":"E208","DOI":"10.1503\/cjs.005919","volume":"63","author":"K Guidolin","year":"2020","unstructured":"Guidolin K, Yan H, Quereshy F (2020) The teaching time-out: a novel framework for surgical education. Can J Surg 63:E208\u2013E210. https:\/\/doi.org\/10.1503\/cjs.005919","journal-title":"Can J Surg"},{"key":"3360_CR20","doi-asserted-by":"publisher","first-page":"e172","DOI":"10.1016\/j.jsurg.2020.08.004","volume":"77","author":"HA Lillemoe","year":"2020","unstructured":"Lillemoe HA, Lynch KA, Schuller MC et al (2020) Beyond the Surgical Time-Out: A National needs Assessment of Preoperative Communication in US General surgery Residency Programs. J Surg Educ 77:e172\u2013e182. https:\/\/doi.org\/10.1016\/j.jsurg.2020.08.004","journal-title":"J Surg Educ"},{"key":"3360_CR21","first-page":"84","volume":"53","author":"CG Ball","year":"2010","unstructured":"Ball CG, Hameed SM, Brenneman FD (2010) Acute care surgery: a new strategy for the general surgery patients left behind. Can J Surg 53:84\u201385","journal-title":"Can J Surg"},{"key":"3360_CR22","doi-asserted-by":"publisher","first-page":"342","DOI":"10.1111\/codi.14474","volume":"21","author":"NRA Symons","year":"2019","unstructured":"Symons NRA, McArthur D, Miller A et al (2019) Emergency general surgeons, subspeciality surgeons and the future management of emergency surgery: results of a national survey. Colorectal Dis 21:342\u2013348. https:\/\/doi.org\/10.1111\/codi.14474","journal-title":"Colorectal Dis"},{"key":"3360_CR23","unstructured":"UEMS Section of Surgery (2024) Emergency Surgery Curriculum. https:\/\/uemssurg.org\/surgicalspecialties\/emergency-surgery\/curriculum\/. Accessed 12 May 2024"},{"key":"3360_CR24","unstructured":"UEMS Section of Surgery (2024) Emergency Surgery Fellows. https:\/\/uemssurg.org\/surgicalspecialties\/emergency-surgery\/fellows\/. Accessed 06 May 2024"},{"key":"3360_CR25","doi-asserted-by":"publisher","unstructured":"Santry HP, Madore JC, Collins CE et al (2015) Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals. J Trauma Acute Care Surg 78 :60\u2009\u2013\u20097; discussion 67\u2009\u2013\u20098. https:\/\/doi.org\/10.1097\/TA.0000000000000492","DOI":"10.1097\/TA.0000000000000492"},{"key":"3360_CR26","doi-asserted-by":"publisher","first-page":"809","DOI":"10.1016\/j.surg.2013.12.012","volume":"155","author":"HP Santry","year":"2014","unstructured":"Santry HP, Pringle PL, Collins CE et al (2014) A qualitative analysis of acute care surgery in the United States: it\u2019s more than just a competent surgeon with a sharp knife and a willing attitude. Surgery 155:809\u2013825. https:\/\/doi.org\/10.1016\/j.surg.2013.12.012","journal-title":"Surgery"},{"key":"3360_CR27","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1111\/j.1742-6723.2011.01489.x","volume":"23","author":"C Hobgood","year":"2011","unstructured":"Hobgood C, Anantharaman V, Bandiera G et al (2011) International Federation for Emergency Medicine Model Curriculum for Emergency Medicine specialists. Emerg Med Australas 23:541\u2013553. https:\/\/doi.org\/10.1111\/j.1742-6723.2011.01489.x","journal-title":"Emerg Med Australas"},{"key":"3360_CR28","doi-asserted-by":"publisher","first-page":"766","DOI":"10.1136\/emj.2009.087775","volume":"27","author":"C Hobgood","year":"2010","unstructured":"Hobgood C, Anantharaman V, Bandiera G et al (2010) International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine. Emerg Med J 27:766\u2013769. https:\/\/doi.org\/10.1136\/emj.2009.087775","journal-title":"Emerg Med J"},{"key":"3360_CR29","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1007\/s00113-019-00735-z","volume":"123","author":"A Franke","year":"2020","unstructured":"Franke A, Bieler D, Paffrath T et al (2020) ATLS\u00ae Und TDSC\u00ae: how it fits together: Ein Behandlungskonzept f\u00fcr MANV und TerrorMANV, lebensbedrohliche oder besondere Lagen (ATLS\u00ae and TDSC\u00ae: how it fits together: a treatment concept for mass casualty and terrorist-related mass casualty situations, life-threatening and special scenarios). Unfallchirurg 123:453\u2013463. https:\/\/doi.org\/10.1007\/s00113-019-00735-z","journal-title":"Unfallchirurg"},{"key":"3360_CR30","unstructured":"Regierungskommission f\u00fcr eine moderne und bedarfsgerechte Krankenhausversorgung (2022) Zweite Stellungnahme und Empfehlung der Regierungskommission f\u00fcr eine moderne und bedarfsgerechte Krankenhausversorgung: Tagesbehandlung im Krankenhaus zur kurzfristigen Entlastung der Krankenh\u00e4user und des Gesundheitswesens. https:\/\/www.bundesgesundheitsministerium.de\/fileadmin\/Dateien\/3_Downloads\/K\/Krankenhausreform\/BMG_REGKOM_Bericht_II_2022.pdf. Accessed 12 Oct 2023"},{"key":"3360_CR31","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1016\/j.ijsu.2016.03.034","volume":"29","author":"M Alaker","year":"2016","unstructured":"Alaker M, Wynn GR, Arulampalam T (2016) Virtual reality training in laparoscopic surgery: a systematic review & meta-analysis. Int J Surg 29:85\u201394. https:\/\/doi.org\/10.1016\/j.ijsu.2016.03.034","journal-title":"Int J Surg"},{"key":"3360_CR32","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1055\/s-0042-116327","volume":"142","author":"T Huber","year":"2017","unstructured":"Huber T, Kirschniak A, Johannink J (2017) Umfrage Zum Training laparoskopischer Fertigkeiten in Deutschland (Survey of Training in laparoscopic skills in Germany). Zentralbl Chir 142:67\u201371. https:\/\/doi.org\/10.1055\/s-0042-116327","journal-title":"Zentralbl Chir"},{"key":"3360_CR33","volume-title":"Operative techniques and recent advances in Acute Care and emergency surgery","year":"2019","unstructured":"Aseni P, de Carlis L, Mazzola A et al (eds) (2019) Operative techniques and recent advances in Acute Care and emergency surgery. Springer International Publishing, Cham"},{"key":"3360_CR34","doi-asserted-by":"publisher","first-page":"1040","DOI":"10.1007\/s00104-020-01332-2","volume":"92","author":"S Brunner","year":"2021","unstructured":"Brunner S, Kr\u00f6plin J, Meyer H-J et al (2021) Einsatz Chirurgischer Simulatoren in Der Weiterbildung \u2013 Eine Deutschlandweite Analyse (Use of surgical simulators in further education-A nationwide analysis in Germany). Chirurg 92:1040\u20131049. https:\/\/doi.org\/10.1007\/s00104-020-01332-2","journal-title":"Chirurg"},{"key":"3360_CR35","doi-asserted-by":"publisher","first-page":"183","DOI":"10.1007\/s12262-021-03080-x","volume":"84","author":"HT Jackson","year":"2022","unstructured":"Jackson HT, Vaziri K, Bass BL (2022) Surgical Education and Training in the US: a collaborative effort to deliver the Next Generation of surgeons. Indian J Surg 84:183\u2013192. https:\/\/doi.org\/10.1007\/s12262-021-03080-x","journal-title":"Indian J Surg"},{"key":"3360_CR36","doi-asserted-by":"publisher","first-page":"268","DOI":"10.1007\/s00113-022-01272-y","volume":"126","author":"G Grimaldi","year":"2023","unstructured":"Grimaldi G (2023) Simulationstrainings in Der Weiterbildung f\u00fcr mehr patientensicherheit: Haben simulations- und Skill-Trainings Einfluss Auf die Patientensicherheit in Deutschland? (simulations in continuing education for more patient safety: do simulation and skills training influence patient safety in Germany?). Unfallchirurgie (Heidelb) 126:268\u2013273. https:\/\/doi.org\/10.1007\/s00113-022-01272-y","journal-title":"Unfallchirurgie (Heidelb)"}],"container-title":["Langenbeck's Archives of Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00423-024-03360-6.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00423-024-03360-6\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00423-024-03360-6.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,6,20]],"date-time":"2024-06-20T10:09:23Z","timestamp":1718878163000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00423-024-03360-6"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,6,20]]},"references-count":36,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["3360"],"URL":"https:\/\/doi.org\/10.1007\/s00423-024-03360-6","relation":{},"ISSN":["1435-2451"],"issn-type":[{"value":"1435-2451","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,6,20]]},"assertion":[{"value":"28 December 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 May 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 June 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"193"}}