{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T09:53:49Z","timestamp":1780480429979,"version":"3.54.1"},"reference-count":41,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,10,15]],"date-time":"2019-10-15T00:00:00Z","timestamp":1571097600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,10,15]],"date-time":"2019-10-15T00:00:00Z","timestamp":1571097600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Emerg Med"],"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n              <jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Recreational use of prescription drugs is widespread. We describe acute poisonings related to the recreational use of prescription drugs.<\/jats:p>\n              <\/jats:sec>\n              <jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Retrospective observational study. We retrospectively registered all patients presenting from October 2013 through March 2015 at a primary care emergency outpatient clinic in Oslo, Norway, with an acute poisoning related to recreational drug use. We registered demographic data, toxic agents taken, clinical course and treatment. From this data set we extracted the 819\/2218 (36.9%) cases involving one or more prescription drugs.<\/jats:p>\n              <\/jats:sec>\n              <jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Among the 819 included cases, 190 (23.2%) were female. Median age was 37\u2009years. The drugs most commonly involved were benzodiazepines in 696 (85.0%) cases, methadone in 60 (7.3%), buprenorphine in 53 (6.5%), other opioids in 56 (6.8%), zopiclone\/zolpidem in 26 (3.2%), and methylphenidate in 11 (1.3%). Prescription drugs were combined with other toxic agents in 659 (80.5%) cases; heroin in 351 (42.9%), ethanol in 232 (28.3%), amphetamine in 141 (17.2%), cannabis in 70 (8.5%), gamma-hydroxybutyrate (GHB) in 34 (4.2%), cocaine in 29 (3.5%), and other illegal drugs in 46 (5.6%). The patient was given naloxone in 133 (16.2%) cases, sedation in 15 (1.8%), and flumazenil in 3 (0.4%). In 157 (19.2%) cases, the patient was sent on to hospital.<\/jats:p>\n              <\/jats:sec>\n              <jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>One in three acute poisonings related to recreational drug use involved prescription drugs. Benzodiazepines were by far the most common class of drugs. Prescription drugs had mostly been taken in combination with illegal drugs or ethanol.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12873-019-0271-0","type":"journal-article","created":{"date-parts":[[2019,10,15]],"date-time":"2019-10-15T17:30:03Z","timestamp":1571160603000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Acute poisoning related to the recreational use of prescription drugs: an observational study from Oslo, Norway"],"prefix":"10.1186","volume":"19","author":[{"given":"Marit M\u00e6hle","family":"Grimsrud","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mette","family":"Brekke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victoria Lykke","family":"Syse","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1213-392X","authenticated-orcid":false,"given":"Odd Martin","family":"Vallersnes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2019,10,15]]},"reference":[{"key":"271_CR1","doi-asserted-by":"publisher","first-page":"559","DOI":"10.1146\/annurev-publhealth-031914-122957","volume":"36","author":"A Kolodny","year":"2015","unstructured":"Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559\u201374.","journal-title":"Annu Rev Public Health"},{"key":"271_CR2","volume-title":"European drug report 2015: trends and developments","author":"European monitoring centre for drugs and drug addiction (EMCDDA)","year":"2015","unstructured":"European monitoring centre for drugs and drug addiction (EMCDDA). European drug report 2015: trends and developments. Lisbon: EMCDDA; 2015."},{"key":"271_CR3","volume-title":"The drug situation in Norway 2014: annual report to the European monitoring Centre for Drugs and Drug Addiction \u2013 EMCDDA","year":"2015","unstructured":"Hordvin O, Skretting A, editors. The drug situation in Norway 2014: annual report to the European monitoring Centre for Drugs and Drug Addiction \u2013 EMCDDA. Oslo: SIRUS Norwegian Institute for Alcohol and Drug Research; 2015."},{"key":"271_CR4","doi-asserted-by":"publisher","first-page":"260","DOI":"10.1542\/pir.18-8-260","volume":"18","author":"SM Coupey","year":"1997","unstructured":"Coupey SM. Barbiturates. Pediatr Rev. 1997;18:260\u20134.","journal-title":"Pediatr Rev"},{"key":"271_CR5","doi-asserted-by":"publisher","first-page":"483","DOI":"10.1111\/j.0954-6820.1987.tb01284.x","volume":"221","author":"O Ekeberg","year":"1987","unstructured":"Ekeberg O, Jacobsen D, Flaaten B, Mack A. Effect of regulatory withdrawal of drugs and prescription recommendations on the pattern of self-poisonings in Oslo. Acta Med Scand. 1987;221:483\u20137.","journal-title":"Acta Med Scand"},{"key":"271_CR6","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1097\/chi.0b013e31815a56f1","volume":"47","author":"TE Wilens","year":"2008","unstructured":"Wilens TE, Adler LA, Adams J, Sgambati S, Rotrosen J, Sawtelle R, et al. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47:21\u201331.","journal-title":"J Am Acad Child Adolesc Psychiatry"},{"key":"271_CR7","doi-asserted-by":"publisher","first-page":"403","DOI":"10.1007\/s40265-017-0700-x","volume":"77","author":"KE Evoy","year":"2017","unstructured":"Evoy KE, Morrison MD, Saklad SR. Abuse and misuse of pregabalin and gabapentin. Drugs. 2017;77:403\u201326.","journal-title":"Drugs"},{"key":"271_CR8","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1007\/s40263-015-0303-6","volume":"30","author":"O Schjerning","year":"2016","unstructured":"Schjerning O, Rosenzweig M, Pottegard A, Damkier P, Nielsen J. Abuse potential of pregabalin: a systematic review. CNS Drugs. 2016;30:9\u201325.","journal-title":"CNS Drugs"},{"key":"271_CR9","doi-asserted-by":"publisher","first-page":"243","DOI":"10.5811\/westjem.2016.10.32322","volume":"18","author":"L Klein","year":"2017","unstructured":"Klein L, Bangh S, Cole JB. Intentional recreational abuse of quetiapine compared to other second-generation antipsychotics. West J Emerg Med. 2017;18:243\u201350.","journal-title":"West J Emerg Med"},{"key":"271_CR10","doi-asserted-by":"publisher","first-page":"1343","DOI":"10.1002\/j.1532-2149.2014.496.x","volume":"18","author":"CS Zin","year":"2014","unstructured":"Zin CS, Chen LC, Knaggs RD. Changes in trends and pattern of strong opioid prescribing in primary care. Eur J Pain. 2014;18:1343\u201351.","journal-title":"Eur J Pain"},{"key":"271_CR11","unstructured":"Folkehelseinstituttet. Narkotikautl\u00f8ste d\u00f8dsfall 2017. In: Norwegian Institute of Public Health. \n                    https:\/\/www.fhi.no\/nyheter\/2018\/nakotikautloste-dodsfall-2017\/\n                    \n                  . Accessed 18 Apr 2019."},{"key":"271_CR12","doi-asserted-by":"publisher","first-page":"1005","DOI":"10.3109\/15563650.2014.976792","volume":"52","author":"F Heyerdahl","year":"2014","unstructured":"Heyerdahl F, Hovda KE, Giraudon I, Yates C, Dines AM, Sedefov R, et al. Current European data collection on emergency department presentations with acute recreational drug toxicity: gaps and national variations. Clin Toxicol. 2014;52:1005\u201312.","journal-title":"Clin Toxicol"},{"key":"271_CR13","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1080\/15563650701438268","volume":"46","author":"J Kristinsson","year":"2008","unstructured":"Kristinsson J, Palsson R, Gudjonsdottir GA, Blondal M, Gudmundsson S, Snook CP. Acute poisonings in Iceland: a prospective nationwide study. Clin Toxicol. 2008;46:126\u201332.","journal-title":"Clin Toxicol"},{"key":"271_CR14","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1757-7241-20-1","volume":"20","author":"C Lund","year":"2012","unstructured":"Lund C, Vallersnes OM, Jacobsen D, Ekeberg O, Hovda KE. Outpatient treatment of acute poisonings in Oslo: poisoning pattern, factors associated with hospitalization, and mortality. Scand J Trauma Resusc Emerg Med. 2012;20:1.","journal-title":"Scand J Trauma Resusc Emerg Med"},{"key":"271_CR15","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1186\/s12873-015-0045-2","volume":"15","author":"OM Vallersnes","year":"2015","unstructured":"Vallersnes OM, Jacobsen D, Ekeberg O, Brekke M. Patients presenting with acute poisoning to an outpatient emergency clinic: a one-year observational study in Oslo, Norway. BMC Emerg Med. 2015;15:18.","journal-title":"BMC Emerg Med"},{"key":"271_CR16","doi-asserted-by":"publisher","first-page":"858","DOI":"10.1186\/1471-2458-12-858","volume":"12","author":"C Lund","year":"2012","unstructured":"Lund C, Teige B, Drottning P, Stiksrud B, Rui TO, Lyngra M, et al. A one-year observational study of all hospitalized and fatal acute poisonings in Oslo: epidemiology, intention and follow-up. BMC Public Health. 2012;12:858.","journal-title":"BMC Public Health"},{"key":"271_CR17","doi-asserted-by":"publisher","first-page":"120","DOI":"10.3109\/15563650.2011.649092","volume":"50","author":"C Duineveld","year":"2012","unstructured":"Duineveld C, Vroegop M, Schouren L, Hoedemaekers A, Schouten J, Moret-Hartman M, et al. Acute intoxications: differences in management between six Dutch hospitals. Clin Toxicol. 2012;50:120\u20138.","journal-title":"Clin Toxicol"},{"key":"271_CR18","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1097\/00063110-200306000-00006","volume":"10","author":"G Burillo-Putze","year":"2003","unstructured":"Burillo-Putze G, Munne P, Duenas A, Pinillos MA, Naveiro JM, Cobo J, et al. National multicentre study of acute intoxication in emergency departments of Spain. Eur J Emerg Med. 2003;10:101\u20134.","journal-title":"Eur J Emerg Med"},{"key":"271_CR19","doi-asserted-by":"publisher","first-page":"893","DOI":"10.3109\/15563650.2015.1088157","volume":"53","author":"AM Dines","year":"2015","unstructured":"Dines AM, Wood DM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, et al. Acute recreational drug and new psychoactive substance toxicity in Europe: 12 months data collection from the European drug emergencies network (euro-DEN). Clin Toxicol. 2015;53:893\u2013900.","journal-title":"Clin Toxicol"},{"key":"271_CR20","volume-title":"Rusmidler i Norge 2014","author":"A Skretting","year":"2015","unstructured":"Skretting A, Bye EK, Ved\u00f8y TF, Lund KE. Rusmidler i Norge 2014. Oslo: SIRUS Norwegian Institute for Alcohol and Drug Research; 2015."},{"key":"271_CR21","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1007\/s00228-018-2550-1","volume":"75","author":"C Lyphout","year":"2019","unstructured":"Lyphout C, Yates C, Margolin ZR, Dargan PI, Dines AM, Heyerdahl F, et al. Presentations to the emergency department with non-medical use of benzodiazepines and Z-drugs: profiling and relation to sales data. Eur J Clin Pharmacol. 2019;75:77\u201385.","journal-title":"Eur J Clin Pharmacol"},{"key":"271_CR22","doi-asserted-by":"publisher","first-page":"288","DOI":"10.1186\/s12889-015-1615-7","volume":"15","author":"I Rossow","year":"2015","unstructured":"Rossow I, Bramness JG. The total sale of prescription drugs with an abuse potential predicts the number of excessive users: a national prescription database study. BMC Public Health. 2015;15:288.","journal-title":"BMC Public Health"},{"key":"271_CR23","doi-asserted-by":"publisher","first-page":"239","DOI":"10.3109\/15563650.2014.898771","volume":"52","author":"DM Wood","year":"2014","unstructured":"Wood DM, Heyerdahl F, Yates CB, Dines AM, Giraudon I, Hovda KE, et al. The European drug emergencies network (euro-DEN). Clin Toxicol. 2014;52:239\u201341.","journal-title":"Clin Toxicol"},{"key":"271_CR24","unstructured":"Statistics Norway. Table 01222. In: Statistikkbanken Statistics Norway \n                    https:\/\/www.ssb.no\/en\/statbank\/table\/01222\n                    \n                  . Accessed 5 Nov 2018."},{"key":"271_CR25","doi-asserted-by":"publisher","first-page":"76","DOI":"10.1186\/s13049-016-0268-6","volume":"24","author":"OM Vallersnes","year":"2016","unstructured":"Vallersnes OM, Jacobsen D, Ekeberg O, Brekke M. Outpatient treatment of acute poisoning by substances of abuse: a prospective observational cohort study. Scand J Trauma Resusc Emerg Med. 2016;24:76.","journal-title":"Scand J Trauma Resusc Emerg Med."},{"key":"271_CR26","doi-asserted-by":"publisher","first-page":"636","DOI":"10.1080\/15563650.2017.1312002","volume":"55","author":"OM Vallersnes","year":"2017","unstructured":"Vallersnes OM, Persett PS, Oiestad EL, Karinen R, Heyerdahl F, Hovda KE. Underestimated impact of novel psychoactive substances: laboratory confirmation of recreational drug toxicity in Oslo. Norway Clin Toxicol. 2017;55:636\u201344.","journal-title":"Norway Clin Toxicol"},{"key":"271_CR27","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1177\/0960327107087800","volume":"27","author":"F Heyerdahl","year":"2008","unstructured":"Heyerdahl F, Hovda KE, Bjornaas MA, Brors O, Ekeberg O, Jacobsen D. Clinical assessment compared to laboratory screening in acutely poisoned patients. Hum Exp Toxicol. 2008;27:73\u20139.","journal-title":"Hum Exp Toxicol"},{"key":"271_CR28","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1016\/j.drugalcdep.2012.07.004","volume":"125","author":"JD Jones","year":"2012","unstructured":"Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125:8\u201318.","journal-title":"Drug Alcohol Depend"},{"key":"271_CR29","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.drugalcdep.2015.01.040","volume":"150","author":"JR Richards","year":"2015","unstructured":"Richards JR, Albertson TE, Derlet RW, Lange RA, Olson KR, Horowitz BZ. Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review. Drug Alcohol Depend. 2015;150:1\u201313.","journal-title":"Drug Alcohol Depend"},{"key":"271_CR30","doi-asserted-by":"publisher","first-page":"345","DOI":"10.3109\/15563650.2016.1142090","volume":"54","author":"JR Richards","year":"2016","unstructured":"Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol. 2016;54:345\u201364.","journal-title":"Clin Toxicol"},{"key":"271_CR31","doi-asserted-by":"publisher","first-page":"961","DOI":"10.1046\/j.1360-0443.1999.9479612.x","volume":"94","author":"JM White","year":"1999","unstructured":"White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. 1999;94:961\u201372.","journal-title":"Addiction"},{"key":"271_CR32","volume-title":"Drug consumption in Norway 2011\u20132015","author":"S Sakshaug","year":"2016","unstructured":"Sakshaug S, Str\u00f8m H, Berg C, Blix HS, Litleskare I, Granum T. Drug consumption in Norway 2011\u20132015. Oslo: Norwegian Institute of Public Health; 2016."},{"key":"271_CR33","volume-title":"The 2013 annual assessment of the Norwegian OMT programme","author":"HBK Waal","year":"2014","unstructured":"Waal HBK, Clausen T, H\u00e5seth A, Lillevold PH. The 2013 annual assessment of the Norwegian OMT programme. Oslo: SERAF \u2013 Norwegian Centre for Addiction Research, University of Oslo; 2014."},{"key":"271_CR34","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1016\/j.jsat.2005.02.007","volume":"28","author":"L Amato","year":"2005","unstructured":"Amato L, Davoli M, Perucci CA, Ferri M, Faggiano F, Mattick RP. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abus Treat. 2005;28:321\u20139.","journal-title":"J Subst Abus Treat"},{"key":"271_CR35","first-page":"CD002209","volume":"3","author":"RP Mattick","year":"2009","unstructured":"Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;3:CD002209.","journal-title":"Cochrane Database Syst Rev"},{"key":"271_CR36","first-page":"CD002207","volume":"2","author":"RP Mattick","year":"2008","unstructured":"Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008;2:CD002207.","journal-title":"Cochrane Database Syst Rev"},{"key":"271_CR37","doi-asserted-by":"publisher","first-page":"j1550","DOI":"10.1136\/bmj.j1550","volume":"357","author":"L Sordo","year":"2017","unstructured":"Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L. Wiessing L, et al mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.","journal-title":"BMJ"},{"key":"271_CR38","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1159\/000439273","volume":"22","author":"E Frauger","year":"2016","unstructured":"Frauger E, Amaslidou D, Spadari M, Allaria-Lapierre V, Braunstein D, Sciortino V, et al. Patterns of methylphenidate use and assessment of its abuse among the general population and individuals with drug dependence. Eur Addict Res. 2016;22:119\u201326.","journal-title":"Eur Addict Res"},{"key":"271_CR39","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1016\/j.forsciint.2016.09.001","volume":"268","author":"E Han","year":"2016","unstructured":"Han E, Kwon NJ, Feng LY, Li JH, Chung H. Illegal use patterns, side effects, and analytical methods of ketamine. Forensic Sci Int. 2016;268:25\u201334.","journal-title":"Forensic Sci Int"},{"key":"271_CR40","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1093\/jat\/bky008","volume":"42","author":"L Radunz","year":"2018","unstructured":"Radunz L, Reuter H, Andresen-Streichert H. Modafinil in forensic and clinical toxicology: case reports, analytics and literature. J Anal Toxicol. 2018;42:353\u20139.","journal-title":"J Anal Toxicol"},{"key":"271_CR41","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1186\/s12873-019-0244-3","volume":"19","author":"VL Syse","year":"2019","unstructured":"Syse VL, Brekke M, Grimsrud MM, Persett PS, Heyerdahl F, Hovda KE, et al. Gender differences in acute recreational drug toxicity: a case series from Oslo, Norway. BMC Emerg Med. 2019;19:29.","journal-title":"BMC Emerg Med"}],"container-title":["BMC Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12873-019-0271-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12873-019-0271-0\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12873-019-0271-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,10,13]],"date-time":"2020-10-13T23:15:52Z","timestamp":1602630952000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcemergmed.biomedcentral.com\/articles\/10.1186\/s12873-019-0271-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,10,15]]},"references-count":41,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2019,12]]}},"alternative-id":["271"],"URL":"https:\/\/doi.org\/10.1186\/s12873-019-0271-0","relation":{},"ISSN":["1471-227X"],"issn-type":[{"value":"1471-227X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,10,15]]},"assertion":[{"value":"13 August 2019","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 September 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 October 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The study was done as a quality improvement study, as per the Norwegian Law on Health Personnel \u00a726. Accordingly, the need for approval from an ethics committee was waived, and it was not necessary to obtain consent to participate from the patients. Data were registered anonymously from electronic medical records. The study was approved by the director of the Department of Emergency General Practice at the City of Oslo Health Agency, and by the Oslo University Hospital Information Security and Privacy Office (ref no 2013\/3706).","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"55"}}