{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T12:59:32Z","timestamp":1779886772355,"version":"3.53.1"},"reference-count":38,"publisher":"Springer Science and Business Media LLC","issue":"6","license":[{"start":{"date-parts":[[2023,4,13]],"date-time":"2023-04-13T00:00:00Z","timestamp":1681344000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,4,13]],"date-time":"2023-04-13T00:00:00Z","timestamp":1681344000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Medizinische Fakult\u00e4t Heidelberg der Universit\u00e4t Heidelberg"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Acta Neurochir"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Purpose<\/jats:title>\n                <jats:p>This study aimed to guide the more efficient management of type 4 and 5 thoracolumbar or lumbar osteoporotic fractures (OF) in patients aged 80 years and older with an acute onset of neurological decline. This aim was achieved by assessing the clinical course and morbidity and mortality rates and identifying potential risk factors for patient mortality<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Electronic medical records were retrieved from a single institution pertaining to the period between September 2005 and December 2020. Data on patient demographics, neurological conditions, surgical characteristics, complications, hospital course, and 90-day mortality were also collected.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Over a 16-year period, 35 patients aged \u226580 years diagnosed with thoracolumbar and lumbar OF were enrolled in the study. The mean Charlson comorbidity index (CCI) was &gt;6, indicating a poor baseline reserve (9.4 \u00b1 1.9), while cardiovascular diseases were the most prevalent among comorbidities. The mean surgical duration was 231.6 \u00b1 89.3 min, with a mean blood loss of 694.4\u00b1 200.3 mL. The in-hospital was 8.6% and 90-day mortality rates at 11.4%. Two patients underwent revision surgery for deep wound infection. Intraoperative and postoperative radiography and computed tomography (CT) imaging revealed correct screw placement. Proper alignment of the thoracolumbar spine was achieved in all the patients. Unique risk factors for mortality included the presence of comorbidities and the occurrence of postoperative complications.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>Emergent instrumentation in patients with acute onset of neurological decline and potentially unstable spines due to thoracolumbar and lumbar OF improved functional outcomes at discharge. Age should not be a determinant of whether to perform surgery.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1007\/s00701-023-05564-z","type":"journal-article","created":{"date-parts":[[2023,4,13]],"date-time":"2023-04-13T09:03:01Z","timestamp":1681376581000},"page":"1407-1416","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Perioperative morbidity and mortality in octogenarians sustaining traumatic osteoporotic type 4 and 5 thoracolumbar and lumbar fractures: a retrospective study with 3 years follow-up"],"prefix":"10.1007","volume":"165","author":[{"given":"Pavlina","family":"Lenga","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gelo","family":"G\u00fclec","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karl","family":"Kiening","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas W.","family":"Unterberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Basem","family":"Ishak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,4,13]]},"reference":[{"key":"5564_CR1","unstructured":"Ageing and health. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/ageing-and-health. Accessed 13 Mar 2022"},{"key":"5564_CR2","volume-title":"WHO analgesic ladder","author":"AA Anekar","year":"2022","unstructured":"Anekar AA, Cascella M (2022) WHO analgesic ladder. StatPearls"},{"issue":"1","key":"5564_CR3","doi-asserted-by":"publisher","first-page":"114","DOI":"10.1097\/00007632-198901000-00024","volume":"14","author":"RA Arciero","year":"1989","unstructured":"Arciero RA, Leung KY, Pierce JH (1989) Spontaneous unstable burst fracture of the thoracolumbar spine in osteoporosis. A report of two cases. Spine 14(1):114\u2013117","journal-title":"Spine"},{"issue":"1087","key":"5564_CR4","doi-asserted-by":"publisher","first-page":"20170739","DOI":"10.1259\/bjr.20170739","volume":"91","author":"A Atinga","year":"2018","unstructured":"Atinga A, Shekkeris A, Fertleman M, Batrick N, Kashef E, Dick E (2018) Trauma in the elderly patient. Br J Radiol 91(1087):20170739","journal-title":"Br J Radiol"},{"issue":"3","key":"5564_CR5","doi-asserted-by":"publisher","first-page":"181","DOI":"10.29252\/beat-060301","volume":"6","author":"A Azarhomayoun","year":"2018","unstructured":"Azarhomayoun A, Aghasi M, Mousavi N, Shokraneh F, Vaccaro AR, Haj Mirzaian A, Derakhshan P, Rahimi-Movaghar V (2018) Mortality rate and predicting factors of traumatic thoracolumbar spinal cord injury; a systematic review and meta-analysis. Bull Emerg Trauma 6(3):181\u2013194","journal-title":"Bull Emerg Trauma"},{"issue":"2 Suppl","key":"5564_CR6","doi-asserted-by":"publisher","first-page":"50S","DOI":"10.1177\/2192568217745823","volume":"8","author":"TR Blattert","year":"2018","unstructured":"Blattert TR, Schnake KJ, Gonschorek O et al (2018) Nonsurgical and surgical management of osteoporotic vertebral body fractures: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Glob Spine J 8(2 Suppl):50S\u201355S","journal-title":"Glob Spine J"},{"issue":"20","key":"5564_CR7","doi-asserted-by":"publisher","first-page":"2253","DOI":"10.1097\/BRS.0b013e31814b2d8e","volume":"32","author":"G Cheh","year":"2007","unstructured":"Cheh G, Bridwell KH, Lenke LG, Buchowski JM, Daubs MD, Kim Y, Baldus C (2007) Adjacent segment disease followinglumbar\/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine 32(20):2253\u20132257","journal-title":"Spine"},{"issue":"2","key":"5564_CR8","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1111\/j.1757-7861.2012.00174.x","volume":"4","author":"L Dai","year":"2012","unstructured":"Dai L (2012) Principles of management of thoracolumbar fractures. Orthop Surg 4(2):67\u201370","journal-title":"Orthop Surg"},{"issue":"2","key":"5564_CR9","first-page":"68","volume":"8","author":"J Davis","year":"2009","unstructured":"Davis J, Dunn RN (2009) Short-segment posterior instrumentation of thoracolumbar fractures as standalone treatment. SA Orthop J 8(2):68\u201374","journal-title":"SA Orthop J"},{"issue":"3","key":"5564_CR10","doi-asserted-by":"publisher","first-page":"221","DOI":"10.1016\/S0895-4356(02)00585-1","volume":"56","author":"V de Groot","year":"2003","unstructured":"de Groot V, Beckerman H, Lankhorst GJ, Bouter LM (2003) How to measure comorbidity. a critical review of available methods. J Clin Epidemiol 56(3):221\u2013229","journal-title":"J Clin Epidemiol"},{"key":"5564_CR11","first-page":"100","volume":"29","author":"R Desai","year":"2016","unstructured":"Desai R, Nayar G, Suresh V, Wang TY, Loriaux D, Martin JR, Gottfried ON (2016) Independent predictors of mortality following spine surgery. J Clin Neurosci Off J Neurosurg Soc Australas 29:100\u2013105","journal-title":"J Clin Neurosci Off J Neurosurg Soc Australas"},{"issue":"6","key":"5564_CR12","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1016\/0895-4356(92)90133-8","volume":"45","author":"RA Deyo","year":"1992","unstructured":"Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45(6):613\u2013619","journal-title":"J Clin Epidemiol"},{"issue":"15","key":"5564_CR13","doi-asserted-by":"publisher","first-page":"1228","DOI":"10.1097\/BRS.0000000000000992","volume":"40","author":"AA Edidin","year":"2015","unstructured":"Edidin AA, Ong KL, Lau E, Kurtz SM (2015) Morbidity and mortality after vertebral fractures: comparison of vertebral augmentation and nonoperative management in the Medicare population. Spine 40(15):1228\u20131241","journal-title":"Spine"},{"issue":"2","key":"5564_CR14","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1177\/2151458514525042","volume":"5","author":"O Emohare","year":"2014","unstructured":"Emohare O, Cagan A, Morgan R, Davis R, Asis M, Switzer J, Polly DW (2014) The Use of computed tomography attenuation to evaluate osteoporosis following acute fractures of the thoracic and lumbar vertebra. Geriatr Orthop Surg Rehabil 5(2):50\u201355","journal-title":"Geriatr Orthop Surg Rehabil"},{"issue":"2","key":"5564_CR15","first-page":"242","volume":"52","author":"MD Grossman","year":"2002","unstructured":"Grossman MD, Miller D, Scaff DW, Arcona S (2002) When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma 52(2):242\u2013246","journal-title":"J Trauma"},{"issue":"1","key":"5564_CR16","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1055\/s-0041-1729466","volume":"6","author":"A Gupta","year":"2022","unstructured":"Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Razi AE, Paulino C, Bono CM, Hershman S (2022) Quantifying the impact of comorbidities on outcomes following surgery for osteoporotic vertebral compression fractures. J Clin Interv Radiol ISVIR 6(1):3\u20139","journal-title":"J Clin Interv Radiol ISVIR"},{"issue":"4","key":"5564_CR17","doi-asserted-by":"publisher","first-page":"895","DOI":"10.1007\/s10143-018-01067-z","volume":"42","author":"B Ishak","year":"2019","unstructured":"Ishak B, Younsi A, Wieckhusen C, Slonczewski P, Unterberg AW, Kiening KL (2019) Accuracy and revision rate of intraoperative computed tomography point-to-point navigation for lateral mass and pedicle screw placement: 11-year single-center experience in 1054 patients. Neurosurg Rev 42(4):895\u2013905","journal-title":"Neurosurg Rev"},{"issue":"5","key":"5564_CR18","doi-asserted-by":"publisher","first-page":"E16","DOI":"10.3171\/FOC.2008.25.11.E16","volume":"25","author":"P Jabbour","year":"2008","unstructured":"Jabbour P, Fehlings M, Vaccaro AR, Harrop JS (2008) Traumatic spine injuries in the geriatric population. Neurosurg Focus 25(5):E16","journal-title":"Neurosurg Focus"},{"issue":"5","key":"5564_CR19","doi-asserted-by":"publisher","first-page":"909","DOI":"10.1111\/jgs.14669","volume":"65","author":"RS Jawa","year":"2017","unstructured":"Jawa RS, Singer AJ, Rutigliano DN, McCormack JE, Huang EC, Shapiro MJ, Fields SD, Morelli BN, Vosswinkel JA (2017) Spinal fractures in older adult patients admitted after low-level falls: 10-year incidence and outcomes. J Am Geriatr Soc 65(5):909\u2013915","journal-title":"J Am Geriatr Soc"},{"key":"5564_CR20","doi-asserted-by":"publisher","unstructured":"Lenga P, Bajwa AA, Schneider T, Iwanaga J, Tubbs RS, Kiening KL, Unterberg AW, Ishak B (2023) High rate of pulmonary cement embolism after cement-augmented pedicle screw fixation: a 12-year single-center study. J Neurol Surg Part Cent Eur Neurosurg. https:\/\/doi.org\/10.1055\/s-0043-1761943","DOI":"10.1055\/s-0043-1761943"},{"key":"5564_CR21","doi-asserted-by":"publisher","first-page":"e643","DOI":"10.1016\/j.wneu.2020.04.056","volume":"139","author":"J-C Liao","year":"2020","unstructured":"Liao J-C (2020) Impact of osteoporosis on different type of short-segment posterior instrumentation for thoracolumbar burst fracture\u2014a finite element analysis. World Neurosurg 139:e643\u2013e651","journal-title":"World Neurosurg"},{"issue":"1","key":"5564_CR22","doi-asserted-by":"publisher","first-page":"262","DOI":"10.1186\/s12891-017-1623-0","volume":"18","author":"J-C Liao","year":"2017","unstructured":"Liao J-C, Chen W-P, Wang H (2017) Treatment of thoracolumbar burst fractures by short-segment pedicle screw fixation using a combination of two additional pedicle screws and vertebroplasty at the level of the fracture: a finite element analysis. BMC Musculoskelet Disord 18(1):262","journal-title":"BMC Musculoskelet Disord"},{"issue":"8","key":"5564_CR23","doi-asserted-by":"publisher","first-page":"3104","DOI":"10.1177\/0300060518772422","volume":"46","author":"C-L Lin","year":"2018","unstructured":"Lin C-L, Chou P-H, Fang J-J, Huang K-Y, Lin R-M (2018) Short-segment decompression and fixation for thoracolumbar osteoporotic fractures with neurological deficits. J Int Med Res 46(8):3104\u20133113","journal-title":"J Int Med Res"},{"issue":"1","key":"5564_CR24","doi-asserted-by":"publisher","first-page":"259","DOI":"10.1186\/s12891-019-2534-z","volume":"20","author":"M Nakahashi","year":"2019","unstructured":"Nakahashi M, Uei H, Tokuhashi Y, Maseda M, Sawada H, Soma H, Miyakata H (2019) Vertebral fracture in elderly female patients after posterior fusion with pedicle screw fixation for degenerative lumbar pathology: a retrospective cohort study. BMC Musculoskelet Disord 20(1):259","journal-title":"BMC Musculoskelet Disord"},{"issue":"3","key":"5564_CR25","doi-asserted-by":"publisher","first-page":"220","DOI":"10.1016\/S0002-9343(02)01190-7","volume":"113","author":"A Papaioannou","year":"2002","unstructured":"Papaioannou A, Watts NB, Kendler DL, Yuen CK, Adachi JD, Ferko N (2002) Diagnosis and management of vertebral fractures in elderly adults. Am J Med 113(3):220\u2013228","journal-title":"Am J Med"},{"issue":"1","key":"5564_CR26","doi-asserted-by":"publisher","first-page":"714","DOI":"10.1186\/s12877-021-02682-0","volume":"21","author":"C Pfeifle","year":"2021","unstructured":"Pfeifle C, Kohut P, Jarvers J-S, Spiegl UJ, Heyde C-E, Osterhoff G (2021) Does time-to-surgery affect mortality in patients with acute osteoporotic vertebral compression fractures? BMC Geriatr 21(1):714","journal-title":"BMC Geriatr"},{"issue":"2 Suppl","key":"5564_CR27","doi-asserted-by":"publisher","first-page":"46S","DOI":"10.1177\/2192568217717972","volume":"8","author":"KJ Schnake","year":"2018","unstructured":"Schnake KJ, Blattert TR, Hahn P et al (2018) Classification of osteoporotic thoracolumbar spine fractures: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Glob Spine J 8(2 Suppl):46S\u201349S","journal-title":"Glob Spine J"},{"issue":"6","key":"5564_CR28","doi-asserted-by":"publisher","first-page":"662","DOI":"10.1055\/a-0620-9170","volume":"156","author":"M Scholz","year":"2018","unstructured":"Scholz M, Schleicher P, Kandziora F et al (2018) Recommendations for diagnosis and treatment of fractures of the ring of axis. Z Orthopadie Unfallchirurgie 156(6):662\u2013671","journal-title":"Z Orthopadie Unfallchirurgie"},{"issue":"5","key":"5564_CR29","doi-asserted-by":"publisher","first-page":"1138","DOI":"10.1007\/s00586-021-07044-3","volume":"31","author":"M Schwendner","year":"2022","unstructured":"Schwendner M, Motov S, Ryang Y-M, Meyer B, Krieg SM (2022) Dorsal instrumentation with and without vertebral body replacement in patients with thoracolumbar osteoporotic fractures shows comparable outcome measures. Eur Spine J 31(5):1138\u20131146","journal-title":"Eur Spine J"},{"issue":"5","key":"5564_CR30","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1097\/BSD.0b013e31802d0bc5","volume":"20","author":"MJ Sokolowski","year":"2007","unstructured":"Sokolowski MJ, Jackson AP, Haak MH, Meyer PR, Sokolowski MS (2007) Acute mortality and complications of cervical spine injuries in the elderly at a single tertiary care center. J Spinal Disord Tech 20(5):352\u2013356","journal-title":"J Spinal Disord Tech"},{"issue":"4","key":"5564_CR31","first-page":"346","volume":"13","author":"B Sporbeck","year":"2015","unstructured":"Sporbeck B, Bechara FG, H\u00e4fner H-M et al (2015) S3-Leitlinie zum Umgang mit Antikoagulation bei Operationen an der Haut. JDDG J Dtsch Dermatol Ges 13(4):346\u2013357","journal-title":"JDDG J Dtsch Dermatol Ges"},{"issue":"4","key":"5564_CR32","doi-asserted-by":"publisher","first-page":"764","DOI":"10.14245\/ns.1836336.168","volume":"16","author":"JY-W Tan","year":"2019","unstructured":"Tan JY-W, Kaliya-Perumal A-K, Oh JY-L (2019) Is spinal surgery safe for elderly patients aged 80 and above? predictors of mortality and morbidity in an Asian population. Neurospine 16(4):764\u2013769","journal-title":"Neurospine"},{"issue":"2","key":"5564_CR33","doi-asserted-by":"publisher","first-page":"347","DOI":"10.1007\/s00264-015-3025-y","volume":"40","author":"Y Tian","year":"2016","unstructured":"Tian Y, Zhu Y, Yin B, Zhang F, Liu B, Chen W, Zhang Y (2016) Age- and gender-specific clinical characteristics of acute adult spine fractures in China. Int Orthop 40(2):347\u2013353","journal-title":"Int Orthop"},{"issue":"23","key":"5564_CR34","doi-asserted-by":"publisher","first-page":"2646","DOI":"10.1097\/01.brs.0000244555.28310.40","volume":"31","author":"S-T Wang","year":"2006","unstructured":"Wang S-T, Ma H-L, Liu C-L, Yu W-K, Chang M-C, Chen T-H (2006) Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study. Spine 31(23):2646\u20132652 discussion 2653","journal-title":"Spine"},{"issue":"9","key":"5564_CR35","doi-asserted-by":"publisher","first-page":"1012","DOI":"10.1097\/00007632-198809000-00008","volume":"13","author":"JN Weinstein","year":"1988","unstructured":"Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S (1988) Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine 13(9):1012\u20131018","journal-title":"Spine"},{"issue":"4","key":"5564_CR36","doi-asserted-by":"publisher","first-page":"E2","DOI":"10.3171\/2015.7.FOCUS15270","volume":"39","author":"EA Winkler","year":"2015","unstructured":"Winkler EA, Yue JK, Birk H, Robinson CK, Manley GT, Dhall SS, Tarapore PE (2015) Perioperative morbidity and mortality after lumbar trauma in the elderly. Neurosurg Focus 39(4):E2","journal-title":"Neurosurg Focus"},{"key":"5564_CR37","doi-asserted-by":"publisher","first-page":"382","DOI":"10.1016\/j.clinimag.2021.08.005","volume":"80","author":"Y Zhu","year":"2021","unstructured":"Zhu Y, Triphuridet N, Yip R, Becker BJ, Wang Y, Yankelevitz DF, Henschke CI (2021) Opportunistic CT screening of osteoporosis on thoracic and lumbar spine: a meta-analysis. Clin Imaging 80:382\u2013390","journal-title":"Clin Imaging"},{"issue":"4","key":"5564_CR38","doi-asserted-by":"publisher","first-page":"704","DOI":"10.14245\/ns.2142418.209","volume":"18","author":"M Zileli","year":"2021","unstructured":"Zileli M, Sharif S, Fornari M (2021) Incidence and epidemiology of thoracolumbar spine fractures: WFNS Spine Committee recommendations. Neurospine 18(4):704\u2013712","journal-title":"Neurospine"}],"container-title":["Acta Neurochirurgica"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00701-023-05564-z.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00701-023-05564-z\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00701-023-05564-z.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,5,29]],"date-time":"2023-05-29T08:06:01Z","timestamp":1685347561000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00701-023-05564-z"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,13]]},"references-count":38,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2023,6]]}},"alternative-id":["5564"],"URL":"https:\/\/doi.org\/10.1007\/s00701-023-05564-z","relation":{},"ISSN":["0942-0940"],"issn-type":[{"value":"0942-0940","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,13]]},"assertion":[{"value":"19 January 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 March 2023","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 April 2023","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was conducted in accordance with the Declaration of Helsinki and approved by the local ethics committee (S-880\/2021).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}},{"value":"The requirement for informed consent was waived because of the retrospective nature of this study.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"No individual person\u2019s data were included in this study","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors have no relevant financial or non-financial interests to disclose.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}