{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T05:33:13Z","timestamp":1794375193845,"version":"4.9.0"},"reference-count":35,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,1,30]],"date-time":"2024-01-30T00:00:00Z","timestamp":1706572800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,1,30]],"date-time":"2024-01-30T00:00:00Z","timestamp":1706572800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Autonomic symptom questionnaires are frequently used to assess dysautonomia. It is unknown whether subjective dysautonomia obtained from autonomic questionnaires correlates with objective dysautonomia measured by quantitative autonomic testing. The objective of our study was to determine correlations between subjective and objective measures of dysautonomia. This was a retrospective cross-sectional study conducted at Brigham and Women\u2019s Faulkner Hospital Autonomic Laboratory between 2017 and 2023 evaluating the patients who completed autonomic testing. Analyses included validated autonomic questionnaires [Survey of Autonomic Symptoms (SAS), Composite Autonomic Symptom Score 31 (Compass-31)] and standardized autonomic tests (Valsalva maneuver, deep breathing, sudomotor, and tilt test). The autonomic testing results were graded by a Quantitative scale for grading of cardiovascular reflexes, sudomotor tests and skin biopsies (QASAT), and Composite Autonomic Severity Score (CASS). Autonomic testing, QASAT, CASS, and SAS were obtained in 2627 patients, and Compass-31 in 564 patients. The correlation was strong between subjective instruments (SAS vs. Compass-31, r\u2009=\u20090.74, <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001) and between objective instruments (QASAT vs. CASS, r\u2009=\u20090.81, <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001). There were no correlations between SAS and QASAT nor between Compass-31 and CASS. There continued to be no correlations between subjective and objective instruments for selected diagnoses (post-acute sequelae of COVID-19, n\u2009=\u200961; postural tachycardia syndrome, 211; peripheral autonomic neuropathy, 463; myalgic encephalomyelitis\/chronic fatigue syndrome, 95; preload failure, 120; post-treatment Lyme disease syndrome, 163; hypermobile Ehlers-Danlos syndrome, 213; neurogenic orthostatic hypotension, 86; diabetes type II, 71, mast cell activation syndrome, 172; hereditary alpha tryptasemia, 45). The lack of correlation between subjective and objective instruments highlights the limitations of the commonly used questionnaires with some patients overestimating and some underestimating true autonomic deficit. The diagnosis-independent subjective\u2013objective mismatch further signifies the unmet need for reliable screening surveys. Patients who overestimate the symptom burden may represent a population with idiosyncratic autonomic-like symptomatology, which needs further study. At this time, the use of autonomic questionnaires as a replacement of autonomic testing cannot be recommended.<\/jats:p>","DOI":"10.1038\/s41598-024-52368-x","type":"journal-article","created":{"date-parts":[[2024,1,31]],"date-time":"2024-01-31T08:55:57Z","timestamp":1706691357000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":41,"title":["Mismatch between subjective and objective dysautonomia"],"prefix":"10.1038","volume":"14","author":[{"given":"Peter","family":"Novak","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David M.","family":"Systrom","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sadie P.","family":"Marciano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra","family":"Knief","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Donna","family":"Felsenstein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew P.","family":"Giannetti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew J.","family":"Hamilton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Nicoloro-SantaBarbara","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tara V.","family":"Saco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariana","family":"Castells","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khosro","family":"Farhad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David M.","family":"Pilgrim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William J.","family":"Mullally","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,1,30]]},"reference":[{"key":"52368_CR1","doi-asserted-by":"publisher","first-page":"1207","DOI":"10.1016\/j.jacc.2018.11.059","volume":"73","author":"M Bryarly","year":"2019","unstructured":"Bryarly, M. et al. Postural orthostatic tachycardia syndrome: JACC focus seminar. J. Am. Coll. Cardiol. 73, 1207\u20131228. https:\/\/doi.org\/10.1016\/j.jacc.2018.11.059 (2019).","journal-title":"J. Am. Coll. Cardiol."},{"key":"52368_CR2","doi-asserted-by":"publisher","first-page":"1196","DOI":"10.1016\/j.mayocp.2012.10.013","volume":"87","author":"DM Sletten","year":"2012","unstructured":"Sletten, D. M. et al. COMPASS 31: A refined and abbreviated composite autonomic symptom score. Mayo Clin. Proc. 87, 1196\u20131201. https:\/\/doi.org\/10.1016\/j.mayocp.2012.10.013 (2012).","journal-title":"Mayo Clin. Proc."},{"key":"52368_CR3","doi-asserted-by":"publisher","first-page":"1099","DOI":"10.1212\/WNL.0b013e3182120147","volume":"76","author":"L Zilliox","year":"2011","unstructured":"Zilliox, L. et al. Assessing autonomic dysfunction in early diabetic neuropathy: The survey of autonomic symptoms. Neurology 76, 1099\u20131105. https:\/\/doi.org\/10.1212\/WNL.0b013e3182120147 (2011).","journal-title":"Neurology"},{"key":"52368_CR4","doi-asserted-by":"publisher","first-page":"5706","DOI":"10.1038\/s41598-017-05668-4","volume":"7","author":"H Lee","year":"2017","unstructured":"Lee, H., Low, P. A. & Kim, H. A. Patients with orthostatic intolerance: Relationship to autonomic function tests results and reproducibility of symptoms on tilt. Sci. Rep. 7, 5706. https:\/\/doi.org\/10.1038\/s41598-017-05668-4 (2017).","journal-title":"Sci. Rep."},{"key":"52368_CR5","doi-asserted-by":"publisher","first-page":"574","DOI":"10.1016\/j.amjmed.2008.10.040","volume":"122","author":"SD Arbogast","year":"2009","unstructured":"Arbogast, S. D. et al. Hypotension unawareness in profound orthostatic hypotension. Am. J. Med. 122, 574\u2013580. https:\/\/doi.org\/10.1016\/j.amjmed.2008.10.040 (2009).","journal-title":"Am. J. Med."},{"key":"52368_CR6","doi-asserted-by":"publisher","first-page":"365","DOI":"10.1007\/s10072-021-05764-4","volume":"43","author":"M-J Hilz","year":"2022","unstructured":"Hilz, M.-J., Wang, R. & Singer, W. Validation of the composite autonomic symptom Score 31 in the German language. Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol. 43, 365\u2013371. https:\/\/doi.org\/10.1007\/s10072-021-05764-4 (2022).","journal-title":"Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol."},{"key":"52368_CR7","doi-asserted-by":"publisher","first-page":"2942","DOI":"10.2337\/diacare.27.12.2942","volume":"27","author":"PA Low","year":"2004","unstructured":"Low, P. A. et al. Autonomic symptoms and diabetic neuropathy: A population-based study. Diabetes Care 27, 2942\u20132947. https:\/\/doi.org\/10.2337\/diacare.27.12.2942 (2004).","journal-title":"Diabetes Care"},{"key":"52368_CR8","doi-asserted-by":"publisher","first-page":"748","DOI":"10.1016\/S0025-6196(12)60631-4","volume":"68","author":"PA Low","year":"1993","unstructured":"Low, P. A. Composite autonomic scoring scale for laboratory quantification of generalized autonomic failure. Mayo Clin. Proc. 68, 748\u2013752 (1993).","journal-title":"Mayo Clin. Proc."},{"key":"52368_CR9","doi-asserted-by":"publisher","first-page":"523","DOI":"10.1212\/wnl.52.3.523","volume":"52","author":"GA Suarez","year":"1999","unstructured":"Suarez, G. A. et al. The Autonomic Symptom Profile: A new instrument to assess autonomic symptoms. Neurology 52, 523\u2013528. https:\/\/doi.org\/10.1212\/wnl.52.3.523 (1999).","journal-title":"Neurology"},{"key":"52368_CR10","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1002\/mus.27048","volume":"63","author":"D Kaur","year":"2021","unstructured":"Kaur, D., Tiwana, H., Stino, A. & Sandroni, P. Autonomic neuropathies. Muscle Nerve 63, 10\u201321. https:\/\/doi.org\/10.1002\/mus.27048 (2021).","journal-title":"Muscle Nerve"},{"key":"52368_CR11","doi-asserted-by":"publisher","first-page":"823","DOI":"10.1007\/s11910-022-01240-4","volume":"22","author":"G Lamotte","year":"2022","unstructured":"Lamotte, G. & Sandroni, P. Updates on the diagnosis and treatment of peripheral autonomic neuropathies. Curr. Neurol. Neurosci. Rep. 22, 823\u2013837. https:\/\/doi.org\/10.1007\/s11910-022-01240-4 (2022).","journal-title":"Curr. Neurol. Neurosci. Rep."},{"key":"52368_CR12","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1016\/j.amjmed.2018.09.027","volume":"132","author":"P Novak","year":"2019","unstructured":"Novak, P. Autonomic disorders. Am. J. Med. 132, 420\u2013436. https:\/\/doi.org\/10.1016\/j.amjmed.2018.09.027 (2019).","journal-title":"Am. J. Med."},{"key":"52368_CR13","doi-asserted-by":"publisher","first-page":"102828","DOI":"10.1016\/j.autneu.2021.102828","volume":"235","author":"S Vernino","year":"2021","unstructured":"Vernino, S. et al. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting\u2014Part 1. Auton. Neurosci. Basic Clin. 235, 102828. https:\/\/doi.org\/10.1016\/j.autneu.2021.102828 (2021).","journal-title":"Auton. Neurosci. Basic Clin."},{"key":"52368_CR14","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1093\/ajh\/hpaa131","volume":"34","author":"JF Idiaquez","year":"2020","unstructured":"Idiaquez, J. F., Idiaquez, J., Casar, J. C. & Biaggioni, I. Neurogenic orthostatic hypotension. Lessons from synucleinopathies. Am. J. Hypertens 34, 125\u2013133. https:\/\/doi.org\/10.1093\/ajh\/hpaa131 (2020).","journal-title":"Am. J. Hypertens"},{"key":"52368_CR15","doi-asserted-by":"publisher","DOI":"10.1093\/med\/9780190889227.001.0001","volume-title":"Autonomic Testing","author":"P Novak","year":"2019","unstructured":"Novak, P. Autonomic Testing (Oxford University Press, 2019)."},{"key":"52368_CR16","doi-asserted-by":"publisher","first-page":"273","DOI":"10.3389\/fneur.2020.00273","volume":"11","author":"MG Porubcin","year":"2020","unstructured":"Porubcin, M. G. & Novak, P. Diagnostic accuracy of electrochemical skin conductance in the detection of sudomotor fiber loss. Front. Neurol. 11, 273. https:\/\/doi.org\/10.3389\/fneur.2020.00273 (2020).","journal-title":"Front. Neurol."},{"key":"52368_CR17","doi-asserted-by":"publisher","DOI":"10.4172\/2329-6895.1000226","author":"P Novak","year":"2015","unstructured":"Novak, P. Quantitative scale for grading of cardiovascular autonomic reflex tests and small fibers from skin biopsies (QASAT). J. Neurol. Disord. https:\/\/doi.org\/10.4172\/2329-6895.1000226 (2015).","journal-title":"J. Neurol. Disord."},{"key":"52368_CR18","doi-asserted-by":"publisher","first-page":"2010","DOI":"10.1212\/WNL.0b013e31821e5563","volume":"76","author":"P Novak","year":"2011","unstructured":"Novak, P. Assessment of sympathetic index from the Valsalva maneuver. Neurology 76, 2010\u20132016. https:\/\/doi.org\/10.1212\/WNL.0b013e31821e5563 (2011).","journal-title":"Neurology"},{"key":"52368_CR19","doi-asserted-by":"publisher","first-page":"1470","DOI":"10.1212\/wnl.46.5.1470","volume":"46","author":"The Consensus Committee of the American Autonomic Society and the American Academy of Neurology","year":"1996","unstructured":"The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology 46, 1470. https:\/\/doi.org\/10.1212\/wnl.46.5.1470 (1996).","journal-title":"Neurology"},{"key":"52368_CR20","doi-asserted-by":"publisher","first-page":"240","DOI":"10.1002\/mus.21464","volume":"41","author":"DM Sletten","year":"2010","unstructured":"Sletten, D. M., Weigand, S. D. & Low, P. A. Relationship of Q-sweat to quantitative sudomotor axon reflex test (QSART) volumes. Muscle Nerve 41, 240\u2013246. https:\/\/doi.org\/10.1002\/mus.21464 (2010).","journal-title":"Muscle Nerve"},{"key":"52368_CR21","doi-asserted-by":"publisher","first-page":"529","DOI":"10.1002\/mus.21210","volume":"39","author":"A Peltier","year":"2009","unstructured":"Peltier, A. et al. Reliability of quantitative sudomotor axon reflex testing and quantitative sensory testing in neuropathy of impaired glucose regulation. Muscle Nerve 39, 529\u2013535. https:\/\/doi.org\/10.1002\/mus.21210 (2009).","journal-title":"Muscle Nerve"},{"key":"52368_CR22","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1097\/WNP.0b013e3182873254","volume":"30","author":"MJ Berger","year":"2013","unstructured":"Berger, M. J. & Kimpinski, K. Test-retest reliability of quantitative sudomotor axon reflex testing. J. Clin. Neurophysiol. Off. Publ. Am. Electroencephalogr. Soc. 30, 308\u2013312. https:\/\/doi.org\/10.1097\/WNP.0b013e3182873254 (2013).","journal-title":"J. Clin. Neurophysiol. Off. Publ. Am. Electroencephalogr. Soc."},{"key":"52368_CR23","doi-asserted-by":"publisher","first-page":"4821","DOI":"10.1007\/s10072-022-06007-w","volume":"43","author":"P Novak","year":"2022","unstructured":"Novak, P. Qpack-a Python package for QASAT-quantitative scale for grading cerebral blood flow, autonomic testing, and skin biopsies. Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol. 43, 4821\u20134828. https:\/\/doi.org\/10.1007\/s10072-022-06007-w (2022).","journal-title":"Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol."},{"key":"52368_CR24","doi-asserted-by":"publisher","DOI":"10.3791\/2502","author":"P Novak","year":"2011","unstructured":"Novak, P. Quantitative autonomic testing. J. Vis. Exp. https:\/\/doi.org\/10.3791\/2502 (2011).","journal-title":"J. Vis. Exp."},{"key":"52368_CR35","doi-asserted-by":"publisher","unstructured":"Patil, I. Visualizations with statistical details: The \u2018ggstatsplot' approach. J. Open Source Softw. 6(61), 3167. https:\/\/doi.org\/10.21105\/joss.03167 (2021).","DOI":"10.21105\/joss.03167"},{"key":"52368_CR25","doi-asserted-by":"publisher","first-page":"e0204419","DOI":"10.1371\/journal.pone.0204419","volume":"13","author":"P Novak","year":"2018","unstructured":"Novak, P. Hypocapnic cerebral hypoperfusion: A biomarker of orthostatic intolerance. PLoS ONE 13, e0204419. https:\/\/doi.org\/10.1371\/journal.pone.0204419 (2018).","journal-title":"PLoS ONE"},{"key":"52368_CR26","doi-asserted-by":"publisher","first-page":"22","DOI":"10.3389\/fnagi.2016.00022","volume":"8","author":"P Novak","year":"2016","unstructured":"Novak, P. Orthostatic cerebral hypoperfusion syndrome. Front. Aging Neurosci. 8, 22. https:\/\/doi.org\/10.3389\/fnagi.2016.00022 (2016).","journal-title":"Front. Aging Neurosci."},{"key":"52368_CR27","doi-asserted-by":"publisher","first-page":"744","DOI":"10.1177\/1362361320985658","volume":"25","author":"EC Taylor","year":"2021","unstructured":"Taylor, E. C. et al. Autonomic dysfunction in autism: The roles of anxiety, depression, and stress. Autism Int. J. Res. Pract. 25, 744\u2013752. https:\/\/doi.org\/10.1177\/1362361320985658 (2021).","journal-title":"Autism Int. J. Res. Pract."},{"key":"52368_CR28","doi-asserted-by":"publisher","first-page":"e01194","DOI":"10.1016\/j.heliyon.2019.e01194","volume":"5","author":"N Okawa","year":"2019","unstructured":"Okawa, N. et al. Application of autonomic nervous function evaluation to job stress screening. Heliyon 5, e01194. https:\/\/doi.org\/10.1016\/j.heliyon.2019.e01194 (2019).","journal-title":"Heliyon"},{"key":"52368_CR29","doi-asserted-by":"publisher","first-page":"100384","DOI":"10.1016\/j.ynstr.2021.100384","volume":"15","author":"AV Seligowski","year":"2021","unstructured":"Seligowski, A. V. et al. A prospective examination of sex differences in posttraumatic autonomic functioning. Neurobiol. Stress 15, 100384. https:\/\/doi.org\/10.1016\/j.ynstr.2021.100384 (2021).","journal-title":"Neurobiol. Stress"},{"key":"52368_CR30","doi-asserted-by":"publisher","first-page":"102889","DOI":"10.1016\/j.autneu.2021.102889","volume":"236","author":"DS Goldstein","year":"2021","unstructured":"Goldstein, D. S. Stress and the \u201cextended\u201d autonomic system. Auton. Neurosci. Basic Clin. 236, 102889. https:\/\/doi.org\/10.1016\/j.autneu.2021.102889 (2021).","journal-title":"Auton. Neurosci. Basic Clin."},{"key":"52368_CR31","doi-asserted-by":"publisher","first-page":"1667","DOI":"10.1007\/s10072-021-05806-x","volume":"43","author":"M de Tommaso","year":"2022","unstructured":"de Tommaso, M., Vecchio, E. & Nolano, M. The puzzle of fibromyalgia between central sensitization syndrome and small fiber neuropathy: A narrative review on neurophysiological and morphological evidence. Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol. 43, 1667\u20131684. https:\/\/doi.org\/10.1007\/s10072-021-05806-x (2022).","journal-title":"Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol."},{"issue":"21","key":"52368_CR32","doi-asserted-by":"publisher","first-page":"01155","DOI":"10.1016\/j.anai.2021.10.006","volume":"S1081\u20131206","author":"P Novak","year":"2021","unstructured":"Novak, P. et al. Mast cell disorders are associated with decreased cerebral blood flow and small fiber neuropathy. Ann. Allergy Asthma Immunol. Off. Publ. Am. Coll. Allergy Asthma Immunol. S1081\u20131206(21), 01155\u201301158. https:\/\/doi.org\/10.1016\/j.anai.2021.10.006 (2021).","journal-title":"Ann. Allergy Asthma Immunol. Off. Publ. Am. Coll. Allergy Asthma Immunol."},{"key":"52368_CR33","doi-asserted-by":"publisher","first-page":"79","DOI":"10.1007\/s10286-011-0146-2","volume":"22","author":"H Kaufmann","year":"2012","unstructured":"Kaufmann, H. et al. The Orthostatic Hypotension Questionnaire (OHQ): Validation of a novel symptom assessment scale. Clin. Auton. Res. Off. J. Clin. Auton. Res. Soc. 22, 79\u201390. https:\/\/doi.org\/10.1007\/s10286-011-0146-2 (2012).","journal-title":"Clin. Auton. Res. Off. J. Clin. Auton. Res. Soc."},{"key":"52368_CR34","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1111\/joim.13566","volume":"293","author":"JM Spahic","year":"2023","unstructured":"Spahic, J. M. et al. Malm\u00f6 POTS symptom score: Assessing symptom burden in postural orthostatic tachycardia syndrome. J. Intern. Med. 293, 91\u201399. https:\/\/doi.org\/10.1111\/joim.13566 (2023).","journal-title":"J. Intern. Med."}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-52368-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-52368-x","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-52368-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,1,31]],"date-time":"2024-01-31T09:00:56Z","timestamp":1706691656000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-52368-x"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,1,30]]},"references-count":35,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["52368"],"URL":"https:\/\/doi.org\/10.1038\/s41598-024-52368-x","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,1,30]]},"assertion":[{"value":"8 August 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 January 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 January 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Dr. Novak is advisor\/independent contractor for Dysimmune Diseases Foundation. He received royalties from Oxford University Press. Dr. Novak owns or owned stocks or stock options of Pfizer, Moderna, Editas Medicine and Novavax. The remaining authors have no competing interests as defined by Nature Research, or other interests that might be perceived to influence the results and\/or discussion reported in this paper.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"2513"}}