{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T20:28:48Z","timestamp":1780604928370,"version":"3.54.1"},"reference-count":42,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,6,28]],"date-time":"2021-06-28T00:00:00Z","timestamp":1624838400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,6,28]],"date-time":"2021-06-28T00:00:00Z","timestamp":1624838400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000185","name":"Defense Advanced Research Projects Agency","doi-asserted-by":"publisher","award":["N66001-16-1-4064"],"award-info":[{"award-number":["N66001-16-1-4064"]}],"id":[{"id":"10.13039\/100000185","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000185","name":"Defense Advanced Research Projects Agency","doi-asserted-by":"publisher","award":["N66001-16-1-4064"],"award-info":[{"award-number":["N66001-16-1-4064"]}],"id":[{"id":"10.13039\/100000185","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000185","name":"Defense Advanced Research Projects Agency","doi-asserted-by":"publisher","award":["N66001-16-1-4064"],"award-info":[{"award-number":["N66001-16-1-4064"]}],"id":[{"id":"10.13039\/100000185","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100008065","name":"Georgia Research Alliance","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100008065","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Monitoring pathological mechano-acoustic signals emanating from the lungs is critical for timely and cost-effective healthcare delivery. Adventitious lung sounds including crackles, wheezes, rhonchi, bronchial breath sounds, stridor or pleural rub and abnormal breathing patterns function as essential clinical biomarkers for the early identification, accurate diagnosis and monitoring of pulmonary disorders. Here, we present a wearable sensor module comprising of a hermetically encapsulated, high precision accelerometer contact microphone (ACM) which enables both episodic and longitudinal assessment of lung sounds, breathing patterns and respiratory rates using a single integrated sensor. This enhanced ACM sensor leverages a nano-gap transduction mechanism to achieve high sensitivity to weak high frequency vibrations occurring on the surface of the skin due to underlying lung pathologies. The performance of the ACM sensor was compared to recordings from a state-of-art digital stethoscope, and the efficacy of the developed system is demonstrated by conducting an exploratory research study aimed at recording pathological mechano-acoustic signals from hospitalized patients with a chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, and acute decompensated heart failure. This unobtrusive wearable system can enable both episodic and longitudinal evaluation of lung sounds that allow for the early detection and\/or ongoing monitoring of pulmonary disease.<\/jats:p>","DOI":"10.1038\/s41598-021-92666-2","type":"journal-article","created":{"date-parts":[[2021,6,28]],"date-time":"2021-06-28T10:02:47Z","timestamp":1624874567000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":36,"title":["Detection of pathological mechano-acoustic signatures using precision accelerometer contact microphones in patients with pulmonary disorders"],"prefix":"10.1038","volume":"11","author":[{"given":"Pranav","family":"Gupta","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haoran","family":"Wen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo","family":"Di Francesco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Farrokh","family":"Ayazi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,6,28]]},"reference":[{"key":"92666_CR1","unstructured":"European Respiratory Society. The Global Impact of Respiratory Disease- Second Edition. Forum of International Respiratory Societies. (2017)."},{"key":"92666_CR2","doi-asserted-by":"publisher","DOI":"10.1038\/s41579-020-00459-7","author":"B Hu","year":"2020","unstructured":"Hu, B., Guo, H., Zhou, P. & Shi, Z. L. Characteristics of SARS-CoV-2 and COVID-19. Nat. Rev. Microbiol. https:\/\/doi.org\/10.1038\/s41579-020-00459-7 (2020).","journal-title":"Nat. Rev. Microbiol."},{"key":"92666_CR3","unstructured":"Strategy, G., The, F. O. R., Of, P., Obstructive, C. & Disease, P. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016. Gold Guidlines (2016)."},{"key":"92666_CR4","doi-asserted-by":"publisher","DOI":"10.1038\/nrdp.2015.76","author":"PJ Barnes","year":"2015","unstructured":"Barnes, P. J. et al. Chronic obstructive pulmonary disease. Nat. Rev. Dis. Prim. https:\/\/doi.org\/10.1038\/nrdp.2015.76 (2015).","journal-title":"Nat. Rev. Dis. Prim."},{"key":"92666_CR5","doi-asserted-by":"publisher","first-page":"283rv3","DOI":"10.1126\/scitranslmed.aaa3487","volume":"7","author":"SR Steinhubl","year":"2015","unstructured":"Steinhubl, S. R., Muse, E. D. & Topol, E. J. The emerging field of mobile health. Sci. Transl. Med. 7, 283rv3-283rv3 (2015).","journal-title":"Sci. Transl. Med."},{"key":"92666_CR6","doi-asserted-by":"publisher","first-page":"e1601185","DOI":"10.1126\/sciadv.1601185","volume":"2","author":"Y Liu","year":"2016","unstructured":"Liu, Y. et al. Epidermal mechano-acoustic sensing electronics for cardiovascular diagnostics and human-machine interfaces. Sci. Adv. 2, e1601185 (2016).","journal-title":"Sci. Adv."},{"key":"92666_CR7","doi-asserted-by":"publisher","first-page":"429","DOI":"10.2217\/pme-2018-0044","volume":"15","author":"J Dunn","year":"2018","unstructured":"Dunn, J., Runge, R. & Snyder, M. Wearables and the medical revolution. Per. Med. 15, 429\u2013448 (2018).","journal-title":"Per. Med."},{"key":"92666_CR8","doi-asserted-by":"publisher","first-page":"389","DOI":"10.1038\/s41587-019-0045-y","volume":"37","author":"J Kim","year":"2019","unstructured":"Kim, J., Campbell, A. S., de \u00c1vila, B.E.-F. & Wang, J. Wearable biosensors for healthcare monitoring. Nat. Biotechnol. 37, 389\u2013406 (2019).","journal-title":"Nat. Biotechnol."},{"key":"92666_CR9","doi-asserted-by":"publisher","first-page":"144","DOI":"10.1016\/j.tcm.2017.08.003","volume":"28","author":"JM Pevnick","year":"2018","unstructured":"Pevnick, J. M., Birkeland, K., Zimmer, R., Elad, Y. & Kedan, I. Wearable technology for cardiology: An update and framework for the future. Trends Cardiovasc. Med. 28, 144\u2013150 (2018).","journal-title":"Trends Cardiovasc. Med."},{"key":"92666_CR10","doi-asserted-by":"publisher","first-page":"158","DOI":"10.4103\/1817-1737.160831","volume":"10","author":"M Sarkar","year":"2015","unstructured":"Sarkar, M., Madabhavi, I., Niranjan, N. & Dogra, M. Auscultation of the respiratory system. Ann. Thorac. Med. 10, 158\u2013168 (2015).","journal-title":"Ann. Thorac. Med."},{"key":"92666_CR11","doi-asserted-by":"publisher","first-page":"744","DOI":"10.1056\/NEJMra1302901","volume":"370","author":"A Bohadana","year":"2014","unstructured":"Bohadana, A., Izbicki, G. & Kraman, S. S. Fundamentals of lung auscultation. N. Engl. J. Med. 370, 744\u2013751 (2014).","journal-title":"N. Engl. J. Med."},{"key":"92666_CR12","doi-asserted-by":"publisher","DOI":"10.1016\/C2009-0-42449-8","author":"S McGee","year":"2012","unstructured":"McGee, S. Evidence-based physical diagnosis. Evidence-Based Physical Diagnosis https:\/\/doi.org\/10.1016\/C2009-0-42449-8 (2012).","journal-title":"Evidence-Based Physical Diagnosis"},{"key":"92666_CR13","unstructured":"Hansen-Honeycutt, J., Chapman, E. B., Nasypany, A., Baker, R. T. & May, J. A Clinical Guide to the Assessment and Treatment of Breathing Pattern Disorders in the Physically Active: Part 2, A Case Series. Int. J. Sports Phys. Ther. (2016)."},{"key":"92666_CR14","doi-asserted-by":"publisher","DOI":"10.1136\/thx.39.4.264","author":"JJ Gilmartin","year":"1984","unstructured":"Gilmartin, J. J. & Gibson, G. J. Abnormalities of chest wall motion in patients with chronic airflow obstruction. Thorax https:\/\/doi.org\/10.1136\/thx.39.4.264 (1984).","journal-title":"Thorax"},{"key":"92666_CR15","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1038\/nrcardio.2010.51","volume":"7","author":"G de Couto","year":"2010","unstructured":"de Couto, G., Ouzounian, M. & Liu, P. P. Early detection of myocardial dysfunction and heart failure. Nat. Rev. Cardiol. 7, 334 (2010).","journal-title":"Nat. Rev. Cardiol."},{"key":"92666_CR16","doi-asserted-by":"publisher","first-page":"17058","DOI":"10.1038\/nrdp.2017.58","volume":"3","author":"MW Bloom","year":"2017","unstructured":"Bloom, M. W. et al. Heart failure with reduced ejection fraction. Nat. Rev. Dis. Prim. 3, 17058 (2017).","journal-title":"Nat. Rev. Dis. Prim."},{"key":"92666_CR17","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-019-44145-y","author":"TP Htun","year":"2019","unstructured":"Htun, T. P., Sun, Y., Chua, H. L. & Pang, J. Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review. Sci. Rep. https:\/\/doi.org\/10.1038\/s41598-019-44145-y (2019).","journal-title":"Sci. Rep."},{"key":"92666_CR18","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.284.6316.626","author":"JP McFadden","year":"1982","unstructured":"McFadden, J. P., Price, R., Eastwood, H. D. & Briggs, R. Raised respiratory rate in elderly patients: A valuable physical sign. Br. Med. J. (Clin. Res. Ed) https:\/\/doi.org\/10.1136\/bmj.284.6316.626 (1982).","journal-title":"Br. Med. J. (Clin. Res. Ed)"},{"key":"92666_CR19","doi-asserted-by":"publisher","DOI":"10.3238\/arztebl.2014.0503","author":"R Strau\u00df","year":"2014","unstructured":"Strau\u00df, R. et al. The prognostic significance of respiratory rate in patients with pneumonia: A retrospective analysis of data from 705 928 hospitalized patients in Germany from 2010\u20132012. Dtsch. Arztebl. Int. https:\/\/doi.org\/10.3238\/arztebl.2014.0503 (2014).","journal-title":"Dtsch. Arztebl. Int."},{"key":"92666_CR20","doi-asserted-by":"publisher","DOI":"10.1038\/s41746-019-0083-3","author":"M Chu","year":"2019","unstructured":"Chu, M. et al. Respiration rate and volume measurements using wearable strain sensors. NPJ Digit. Med. https:\/\/doi.org\/10.1038\/s41746-019-0083-3 (2019).","journal-title":"NPJ Digit. Med."},{"key":"92666_CR21","doi-asserted-by":"publisher","DOI":"10.1186\/s12938-015-0056-y","author":"S Leng","year":"2015","unstructured":"Leng, S. et al. The electronic stethoscope. Biomed. Eng. Online https:\/\/doi.org\/10.1186\/s12938-015-0056-y (2015).","journal-title":"Biomed. Eng. Online"},{"key":"92666_CR22","doi-asserted-by":"publisher","DOI":"10.2147\/MDER.S135882","author":"S Swarup","year":"2018","unstructured":"Swarup, S. & Makaryus, A. N. Digital stethoscope: Technology update. Medical Devices: Evidence and Research https:\/\/doi.org\/10.2147\/MDER.S135882 (2018).","journal-title":"Medical Devices: Evidence and Research"},{"key":"92666_CR23","doi-asserted-by":"publisher","DOI":"10.1063\/5.0029108","author":"Z Zhao","year":"2021","unstructured":"Zhao, Z., Feng, X., Chen, X., Dai, L. L. & Xu, Y. A wearable mechano-acoustic sensor based on electrochemical redox reaction for continuous cardiorespiratory monitoring. Appl. Phys. Lett. https:\/\/doi.org\/10.1063\/5.0029108 (2021).","journal-title":"Appl. Phys. Lett."},{"key":"92666_CR24","doi-asserted-by":"publisher","unstructured":"Gupta, P. et al. Precision high-bandwidth out-of-plane accelerometer as contact microphone for body-worn auscultation devices. In: 2018 Solid-State Sensors, Actuators and Microsystems Workshop, Hilton Head 2018 (2018). https:\/\/doi.org\/10.31438\/trf.hh2018.9","DOI":"10.31438\/trf.hh2018.9"},{"key":"92666_CR25","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1038\/s41746-020-0225-7","volume":"3","author":"P Gupta","year":"2020","unstructured":"Gupta, P. et al. Precision wearable accelerometer contact microphones for longitudinal monitoring of mechano-acoustic cardiopulmonary signals. NPJ Digit. Med. 3, 19 (2020).","journal-title":"NPJ Digit. Med."},{"key":"92666_CR26","unstructured":"Chaudhry, R. & Bordoni, B. Anatomy, Thorax, Lungs. StatPearls (2019)."},{"key":"92666_CR27","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-319-71824-8","author":"KN Priftis","year":"2018","unstructured":"Priftis, K. N., Hadjileontiadis, L. J. & Everard, M. L. Breath sounds from basic science to clinical practice. Breath Sounds From Basic Science to Clinical Practice https:\/\/doi.org\/10.1007\/978-3-319-71824-8 (2018).","journal-title":"Breath Sounds From Basic Science to Clinical Practice"},{"key":"92666_CR28","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0177926","author":"RXA Pramono","year":"2017","unstructured":"Pramono, R. X. A., Bowyer, S. & Rodriguez-Villegas, E. Automatic adventitious respiratory sound analysis: A systematic review. PLoS ONE https:\/\/doi.org\/10.1371\/journal.pone.0177926 (2017).","journal-title":"PLoS ONE"},{"key":"92666_CR29","doi-asserted-by":"publisher","DOI":"10.4137\/ccrpm.s530","author":"S Reichert","year":"2008","unstructured":"Reichert, S., Gass, R., Brandt, C. & Andr\u00e8s, E. Analysis of respiratory sounds: State of the art. Clin. Med. Circ. Respirat. Pulm. Med. https:\/\/doi.org\/10.4137\/ccrpm.s530 (2008).","journal-title":"Clin. Med. Circ. Respirat. Pulm. Med."},{"key":"92666_CR30","doi-asserted-by":"publisher","DOI":"10.1111\/j.1553-2712.2011.01255.x","author":"Z Wang","year":"2012","unstructured":"Wang, Z. & Xiong, Y. X. Lung sound patterns help to distinguish congestive heart failure, chronic obstructive pulmonary disease, and asthma exacerbations. Acad. Emerg. Med. https:\/\/doi.org\/10.1111\/j.1553-2712.2011.01255.x (2012).","journal-title":"Acad. Emerg. Med."},{"key":"92666_CR31","doi-asserted-by":"publisher","DOI":"10.1378\/chest.73.3.333","author":"GR Epler","year":"1978","unstructured":"Epler, G. R., Carrington, C. B. & Gaensler, E. A. Crackles (rales) in the interstitial pulmonary diseases. Chest https:\/\/doi.org\/10.1378\/chest.73.3.333 (1978).","journal-title":"Chest"},{"key":"92666_CR32","doi-asserted-by":"publisher","DOI":"10.1056\/nejm197804272981703","author":"GR Epler","year":"1978","unstructured":"Epler, G. R., McLoud, T. C., Gaensler, E. A., Mikus, J. P. & Carrington, C. B. Normal chest roentgenograms in chronic diffuse infiltrative lung disease. N. Engl. J. Med. https:\/\/doi.org\/10.1056\/nejm197804272981703 (1978).","journal-title":"N. Engl. J. Med."},{"key":"92666_CR33","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1997.03550170070035","author":"J Wardrope","year":"1999","unstructured":"Wardrope, J. & Potts, M. Does this patient have community-acquired pneumonia?. J. Accid. Emerg. Med. https:\/\/doi.org\/10.1001\/jama.1997.03550170070035 (1999).","journal-title":"J. Accid. Emerg. Med."},{"key":"92666_CR34","doi-asserted-by":"publisher","first-page":"368","DOI":"10.1038\/nrcardio.2016.25","volume":"13","author":"B Ziaeian","year":"2016","unstructured":"Ziaeian, B. & Fonarow, G. C. Epidemiology and aetiology of heart failure. Nat. Rev. Cardiol. 13, 368 (2016).","journal-title":"Nat. Rev. Cardiol."},{"key":"92666_CR35","doi-asserted-by":"publisher","DOI":"10.1590\/S1807-59322005000400012","author":"G Lorenzi-Filho","year":"2005","unstructured":"Lorenzi-Filho, G., Genta, P. R., Figueiredo, A. C. & Inoue, D. Cheyne-Stokes respiration in patients with congestive heart failure: Causes and consequences. Clinics (Sao Paulo) https:\/\/doi.org\/10.1590\/S1807-59322005000400012 (2005).","journal-title":"Clinics (Sao Paulo)"},{"key":"92666_CR36","doi-asserted-by":"publisher","DOI":"10.3390\/s21041393","author":"UZ George","year":"2021","unstructured":"George, U. Z., Moon, K. S. & Lee, S. Q. Extraction and analysis of respiratory motion using a comprehensive wearable health monitoring system. Sensors (Switzerland) https:\/\/doi.org\/10.3390\/s21041393 (2021).","journal-title":"Sensors (Switzerland)"},{"key":"92666_CR37","doi-asserted-by":"publisher","DOI":"10.1109\/MEMS46641.2020.9056160","author":"H Liu","year":"2020","unstructured":"Liu, H., Liu, S., Shkel, A. A., Tang, Y. & Kim, E. S. Multi-band MEMS resonant microphone array for continuous lung-sound monitoring and classification. Proceedings of the IEEE International Conference on Micro Electro Mechanical Systems (MEMS) https:\/\/doi.org\/10.1109\/MEMS46641.2020.9056160 (2020).","journal-title":"Proceedings of the IEEE International Conference on Micro Electro Mechanical Systems (MEMS)"},{"key":"92666_CR38","doi-asserted-by":"publisher","DOI":"10.3390\/s17010171","author":"SH Li","year":"2017","unstructured":"Li, S. H., Lin, B. S., Tsai, C. H., Yang, C. T. & Lin, B. S. Design of wearable breathing sound monitoring system for real-time wheeze detection. Sensors (Switzerland) https:\/\/doi.org\/10.3390\/s17010171 (2017).","journal-title":"Sensors (Switzerland)"},{"key":"92666_CR39","doi-asserted-by":"publisher","DOI":"10.1109\/TBME.2016.2600945","author":"AQ Javaid","year":"2017","unstructured":"Javaid, A. Q. et al. Quantifying and reducing motion artifacts in wearable seismocardiogram measurements during walking to assess left ventricular health. IEEE Trans. Biomed. Eng. https:\/\/doi.org\/10.1109\/TBME.2016.2600945 (2017).","journal-title":"IEEE Trans. Biomed. Eng."},{"key":"92666_CR40","doi-asserted-by":"publisher","DOI":"10.1109\/iembs.2005.1617037","author":"MT Pourazad","year":"2005","unstructured":"Pourazad, M. T., Moussavi, Z., Farahmand, F. & Ward, R. K. Heart sounds separation from lung sounds using independent component analysis. In: Annual International Conference of the IEEE Engineering in Medicine and Biology - Proceedings https:\/\/doi.org\/10.1109\/iembs.2005.1617037 (2005).","journal-title":"Annual International Conference of the IEEE Engineering in Medicine and Biology - Proceedings"},{"key":"92666_CR41","doi-asserted-by":"publisher","unstructured":"Wen, H. et al. Wafer-level-packaged HARPSS+ MEMS platform: Integration of robust timing and inertial measurement units (TIMU) on a single chip. In: 2018 IEEE\/ION position, location and navigation symposium (PLANS) 261\u2013266 (2018). https:\/\/doi.org\/10.1109\/PLANS.2018.8373389","DOI":"10.1109\/PLANS.2018.8373389"},{"key":"92666_CR42","doi-asserted-by":"publisher","DOI":"10.1109\/MEMSYS.2018.8346494","author":"H Wen","year":"2018","unstructured":"Wen, H. et al. A high-performance single-chip timing and inertial measurement unit with robust mode-matched gyroscopes. In: Proceedings of the IEEE International Conference on Micro Electro Mechanical Systems (MEMS) https:\/\/doi.org\/10.1109\/MEMSYS.2018.8346494 (2018).","journal-title":"Proceedings of the IEEE International Conference on Micro Electro Mechanical Systems (MEMS)"}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-92666-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-92666-2","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-92666-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,3]],"date-time":"2022-12-03T10:26:39Z","timestamp":1670063199000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-92666-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,28]]},"references-count":42,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["92666"],"URL":"https:\/\/doi.org\/10.1038\/s41598-021-92666-2","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,28]]},"assertion":[{"value":"12 March 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"11 June 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 June 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"P.G., and F.A. are the inventors of the technology being studied and the purpose of this project is to explore its commercialization. The terms of arrangement have been reviewed and approved by Georgia Tech in accordance with its conflict-of-interest policies. L.D.F. and H.W. declare no competing interests.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"13427"}}