{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T15:42:40Z","timestamp":1783525360541,"version":"3.55.0"},"reference-count":37,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2023,9,12]],"date-time":"2023-09-12T00:00:00Z","timestamp":1694476800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,9,12]],"date-time":"2023-09-12T00:00:00Z","timestamp":1694476800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100008977","name":"Universit\u00e4t Ulm","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100008977","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Mol Cell Pediatr"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>The SARS-CoV-2 pandemic has caused significant pulmonary morbidity and mortality in the adult population. Children and adolescents typically show milder symptoms; however, a relevant proportion of them report persistent pulmonary symptoms even after mild SARS-CoV-2 infection. Functional respiratory disorders may be relevant differential diagnoses of persistent dyspnea. This study aims at characterizing functional respiratory disorders that may arise after SARS-CoV-2 infection regarding their clinical presentation and pulmonary function tests as well as gaining insights into the clinical course after initiation of appropriate therapy.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This study retrospectively identified all patients referred to an outpatient clinic for pediatric pulmonology with functional respiratory disorders manifesting after proven SARS-CoV-2 infection between January 1, 2022, and October 31, 2022. Clinical history, thorough clinical examination regarding breathing patterns, and pulmonary function tests (PFTs) were taken into consideration to diagnose functional respiratory disorders.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Twenty-five patients (44% female) with mean (m) age\u2009=\u200912.73\u00a0years (SD\u2009\u00b1\u20091.86) who showed distinctive features of functional respiratory disorders after SARS-CoV-2 infection (onset at<jats:italic>m<\/jats:italic>\u2009=\u20094.15 (\u00b1\u20094.24) weeks after infection) were identified. Eleven patients showed thoracic dominant breathing with insufficient ventilation, and 4 patients mainly had symptoms of inducible laryngeal obstruction. The rest (<jats:italic>n<\/jats:italic>\u2009=\u200910) showed overlap of these two etiologies. Most patients had a flattened inspiratory curve on spirometry and slightly elevated residual volume on body plethysmography, but values of PFTs were normal before and after standardized treadmill exercise testing. Patients were educated about the benign nature of the condition and were offered rebreathing training. All patients with follow-up (<jats:italic>n<\/jats:italic>\u2009=\u20095) showed normalization of the breathing pattern within 3\u00a0months.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Functional respiratory disorders are important differential diagnoses in persisting post-SARS-CoV-2 dyspnea in adolescents. A combination of clinical history, detailed examination of breathing patterns, and pulmonary function tests are helpful to correctly diagnose these conditions. Reassurance and rebreathing training are the mainstay of the therapy. The clinical course is favorable.<\/jats:p><\/jats:sec>","DOI":"10.1186\/s40348-023-00165-3","type":"journal-article","created":{"date-parts":[[2023,9,12]],"date-time":"2023-09-12T07:02:12Z","timestamp":1694502132000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Characterization of adolescents with functional respiratory disorders and prior history of SARS-CoV-2"],"prefix":"10.1186","volume":"10","author":[{"given":"Sebastian Felix Nepomuk","family":"Bode","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anja","family":"Schwender","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Monika","family":"Toth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christine","family":"Kaeppler-Schorn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ute","family":"Siebeneich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joachim","family":"Freihorst","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ales","family":"Janda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorit","family":"Fabricius","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,9,12]]},"reference":[{"issue":"6","key":"165_CR1","doi-asserted-by":"publisher","first-page":"e2022056492","DOI":"10.1542\/peds.2022-056492","volume":"149","author":"RC Brewster","year":"2022","unstructured":"Brewster RC, Parsons C, Laird-Gion J, Hilker S, Irwin M, Sommerschield A et al (2022) COVID-19-associated croup in children. Pediatrics 149(6):e2022056492","journal-title":"Pediatrics."},{"issue":"5","key":"165_CR2","doi-asserted-by":"publisher","first-page":"655","DOI":"10.7326\/M20-6976","volume":"174","author":"DP Oran","year":"2021","unstructured":"Oran DP, Topol EJ (2021) The proportion of SARS-CoV-2 infections that are asymptomatic\u202f: a systematic review. Ann Intern Med 174(5):655\u2013662","journal-title":"Ann Intern Med"},{"key":"165_CR3","doi-asserted-by":"publisher","first-page":"894331","DOI":"10.3389\/fped.2022.894331","volume":"10","author":"SFN Bode","year":"2022","unstructured":"Bode SFN, Haendly M, Fabricius D, Mayer B, Zernickel M, Haddad ADM et al (2022) Pulmonary function and persistent clinical symptoms in children and their parents 12 months after mild SARS-CoV-2 infection. Front Pediatr 10:894331","journal-title":"Front Pediatr"},{"key":"165_CR4","doi-asserted-by":"publisher","first-page":"851008","DOI":"10.3389\/fped.2022.851008","volume":"10","author":"L Knoke","year":"2022","unstructured":"Knoke L, Schlegtendal A, Maier C, Eitner L, Lucke T, Brinkmann F (2022) Pulmonary Function and long-term respiratory symptoms in children and adolescents after COVID-19. Front Pediatr 10:851008","journal-title":"Front Pediatr"},{"issue":"5","key":"165_CR5","doi-asserted-by":"publisher","first-page":"1101","DOI":"10.1038\/s41390-020-1065-5","volume":"89","author":"M Di Nardo","year":"2021","unstructured":"Di Nardo M, van Leeuwen G, Loreti A, Barbieri MA, Guner Y, Locatelli F et al (2021) A literature review of 2019 novel coronavirus (SARS-CoV2) infection in neonates and children. Pediatr Res 89(5):1101\u20131108","journal-title":"Pediatr Res"},{"key":"165_CR6","doi-asserted-by":"publisher","first-page":"104245","DOI":"10.1016\/j.ebiom.2022.104245","volume":"84","author":"A Haddad","year":"2022","unstructured":"Haddad A, Janda A, Renk H, Stich M, Frieh P, Kaier K et al (2022) Long COVID symptoms in exposed and infected children, adolescents and their parents one year after SARS-CoV-2 infection: a prospective observational cohort study. EBioMedicine 84:104245","journal-title":"EBioMedicine"},{"issue":"5","key":"165_CR7","doi-asserted-by":"crossref","first-page":"989","DOI":"10.4103\/0028-3886.299165","volume":"68","author":"C Machado","year":"2020","unstructured":"Machado C, DeFina PA, Chinchilla M, Machado Y, Machado Y (2020) Brainstem dysfunction in SARS-COV-2 infection can be a potential cause of respiratory distress. Neurol India 68(5):989\u2013993","journal-title":"Neurol India"},{"issue":"6","key":"165_CR8","doi-asserted-by":"publisher","first-page":"683","DOI":"10.1001\/jamaneurol.2020.1127","volume":"77","author":"L Mao","year":"2020","unstructured":"Mao L, Jin H, Wang M, Hu Y, Chen S, He Q et al (2020) Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan. China JAMA Neurol 77(6):683\u2013690","journal-title":"China JAMA Neurol"},{"issue":"1","key":"165_CR9","doi-asserted-by":"publisher","first-page":"54","DOI":"10.1016\/j.chest.2021.08.010","volume":"161","author":"I Singh","year":"2022","unstructured":"Singh I, Joseph P, Heerdt PM, Cullinan M, Lutchmansingh DD, Gulati M et al (2022) Persistent exertional intolerance after COVID-19: insights from invasive cardiopulmonary exercise testing. Chest 161(1):54\u201363","journal-title":"Chest"},{"issue":"8","key":"165_CR10","doi-asserted-by":"publisher","first-page":"1012","DOI":"10.1164\/rccm.202206-1243OC","volume":"207","author":"B Regmi","year":"2023","unstructured":"Regmi B, Friedrich J, Jorn B, Senol M, Giannoni A, Boentert M et al (2023) Diaphragm muscle weakness might explain exertional dyspnea 15 months after hospitalization for COVID-19. Am J Respir Crit Care Med 207(8):1012\u20131021","journal-title":"Am J Respir Crit Care Med"},{"issue":"23","key":"165_CR11","doi-asserted-by":"publisher","first-page":"2325","DOI":"10.1016\/j.jacc.2022.03.357","volume":"79","author":"SM Jamal","year":"2022","unstructured":"Jamal SM, Landers DB, Hollenberg SM, Turi ZG, Glotzer TV, Tancredi J et al (2022) Prospective evaluation of autonomic dysfunction in post-acute sequela of COVID-19. J Am Coll Cardiol 79(23):2325\u20132330","journal-title":"J Am Coll Cardiol"},{"issue":"11","key":"165_CR12","doi-asserted-by":"publisher","first-page":"e246668","DOI":"10.1136\/bcr-2021-246668","volume":"14","author":"N Dandawate","year":"2021","unstructured":"Dandawate N, Humphreys C, Gordan P, Okin D (2021) Diaphragmatic paralysis in COVID-19: a rare cause of postacute sequelae of COVID-19 dyspnoea. BMJ Case Rep 14(11):e246668","journal-title":"BMJ Case Rep."},{"issue":"2","key":"165_CR13","doi-asserted-by":"publisher","first-page":"211","DOI":"10.1164\/rccm.167.2.211","volume":"167","author":"American Thoracic S","year":"2003","unstructured":"American Thoracic S, American College of Chest P (2003) ATS\/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 167(2):211\u201377","journal-title":"Am J Respir Crit Care Med."},{"issue":"10","key":"165_CR14","doi-asserted-by":"publisher","first-page":"e2236057","DOI":"10.1001\/jamanetworkopen.2022.36057","volume":"5","author":"MS Durstenfeld","year":"2022","unstructured":"Durstenfeld MS, Sun K, Tahir P, Peluso MJ, Deeks SG, Aras MA et al (2022) Use of cardiopulmonary exercise testing to evaluate long COVID-19 symptoms in adults: a systematic review and meta-analysis. JAMA Netw Open 5(10):e2236057","journal-title":"JAMA Netw Open"},{"issue":"2","key":"165_CR15","doi-asserted-by":"publisher","first-page":"2100870","DOI":"10.1183\/13993003.00870-2021","volume":"58","author":"RF Rinaldo","year":"2021","unstructured":"Rinaldo RF, Mondoni M, Parazzini EM, Pitari F, Brambilla E, Luraschi S et al (2021) Deconditioning as main mechanism of impaired exercise response in COVID-19 survivors. Eur Respir J 58(2):2100870","journal-title":"Eur Respir J."},{"issue":"1","key":"165_CR16","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1186\/s12931-022-01977-z","volume":"23","author":"B Ribeiro Baptista","year":"2022","unstructured":"Ribeiro Baptista B, d\u2019Humieres T, Schlemmer F, Bendib I, Justeau G, Al-Assaad L et al (2022) Identification of factors impairing exercise capacity after severe COVID-19 pulmonary infection: a 3-month follow-up of prospective COVulnerability cohort. Respir Res 23(1):68","journal-title":"Respir Res"},{"issue":"10","key":"165_CR17","doi-asserted-by":"publisher","first-page":"2748","DOI":"10.1016\/j.jaip.2022.07.038","volume":"10","author":"N Rabinovitch","year":"2022","unstructured":"Rabinovitch N, Nevid M, Lomas C, Covar R, Levy H, Leung DYM (2022) Reversible peripheral airway obstruction and lung hyperinflation in children presenting with dyspnea and exercise intolerance after COVID-19 infection. J Allergy Clin Immunol Pract 10(10):2748\u20139.\u00a0e1","journal-title":"J Allergy Clin Immunol Pract."},{"issue":"1","key":"165_CR18","doi-asserted-by":"publisher","first-page":"263","DOI":"10.1186\/s12931-022-02173-9","volume":"23","author":"LM Kimmig","year":"2022","unstructured":"Kimmig LM, Rako ZA, Ziegler S, Richter MJ, G SA, Roller F et al (2022) Long-term comprehensive cardiopulmonary phenotyping of COVID-19. Respir Res 23(1):263","journal-title":"Respir Res."},{"issue":"2","key":"165_CR19","doi-asserted-by":"publisher","first-page":"2101578","DOI":"10.1183\/13993003.01578-2021","volume":"58","author":"J Motiejunaite","year":"2021","unstructured":"Motiejunaite J, Balagny P, Arnoult F, Mangin L, Bancal C, Vidal-Petiot E et al (2021) Hyperventilation as one of the mechanisms of persistent dyspnoea in SARS-CoV-2 survivors. Eur Respir J 58(2):2101578","journal-title":"Eur Respir J."},{"issue":"2","key":"165_CR20","doi-asserted-by":"publisher","first-page":"2100996","DOI":"10.1183\/13993003.00996-2021","volume":"58","author":"I Skjorten","year":"2021","unstructured":"Skjorten I, Ankerstjerne OAW, Trebinjac D, Bronstad E, Rasch-Halvorsen O, Einvik G et al (2021) Cardiopulmonary exercise capacity and limitations 3 months after COVID-19 hospitalisation. Eur Respir J 58(2):2100996","journal-title":"Eur Respir J."},{"key":"165_CR21","doi-asserted-by":"publisher","unstructured":"Loew S, Genecand L, Altarelli M, Gex G, Binkova E, Fr\u00e9sard I, Bridevaux P (2022) Eur Respir J 60:1940. https:\/\/doi.org\/10.1183\/13993003.congress-2022.1940","DOI":"10.1183\/13993003.congress-2022.1940"},{"issue":"1","key":"165_CR22","doi-asserted-by":"publisher","first-page":"e001126","DOI":"10.1136\/bmjresp-2021-001126","volume":"9","author":"I Fresard","year":"2022","unstructured":"Fresard I, Genecand L, Altarelli M, Gex G, Vremaroiu P, Vremaroiu-Coman A et al (2022) Dysfunctional breathing diagnosed by cardiopulmonary exercise testing in \u201clong COVID\u201d patients with persistent dyspnoea. BMJ Open Respir Res 9(1):e001126","journal-title":"BMJ Open Respir Res."},{"issue":"5","key":"165_CR23","doi-asserted-by":"publisher","first-page":"637","DOI":"10.1177\/0145445503256318","volume":"27","author":"S Jack","year":"2003","unstructured":"Jack S, Rossiter HB, Warburton CJ, Whipp BJ (2003) Behavioral influences and physiological indices of ventilatory control in subjects with idiopathic hyperventilation. Behav Modif 27(5):637\u2013652","journal-title":"Behav Modif"},{"issue":"1","key":"165_CR24","first-page":"53","volume":"16","author":"N Barker","year":"2015","unstructured":"Barker N, Everard ML (2015) Getting to grips with \u201cdysfunctional breathing.\u201d Paediatr Respir Rev 16(1):53\u201361","journal-title":"Paediatr Respir Rev"},{"issue":"1","key":"165_CR25","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1136\/thoraxjnl-2014-205738","volume":"70","author":"H Johansson","year":"2015","unstructured":"Johansson H, Norlander K, Berglund L, Janson C, Malinovschi A, Nordvall L et al (2015) Prevalence of exercise-induced bronchoconstriction and exercise-induced laryngeal obstruction in a general adolescent population. Thorax 70(1):57\u201363","journal-title":"Thorax"},{"issue":"3","key":"165_CR26","doi-asserted-by":"publisher","first-page":"366","DOI":"10.1016\/S1081-1206(10)60989-1","volume":"94","author":"M Abu-Hasan","year":"2005","unstructured":"Abu-Hasan M, Tannous B, Weinberger M (2005) Exercise-induced dyspnea in children and adolescents: if not asthma then what? Ann Allergy Asthma Immunol 94(3):366\u2013371","journal-title":"Ann Allergy Asthma Immunol"},{"issue":"1","key":"165_CR27","doi-asserted-by":"publisher","first-page":"e20170347","DOI":"10.1590\/1806-3713\/e20170347","volume":"45","author":"LS Vidotto","year":"2019","unstructured":"Vidotto LS, Carvalho CRF, Harvey A, Jones M (2019) Dysfunctional breathing: what do we know? J Bras Pneumol 45(1):e20170347","journal-title":"J Bras Pneumol"},{"key":"165_CR28","doi-asserted-by":"publisher","unstructured":"Bridevaux P, Altarelli M, Genecand L, Loew S, Binkova E, Gex G, Fr\u00e9sard I (2022) Eur Respir J 60:734. https:\/\/doi.org\/10.1183\/13993003.congress-2022.734","DOI":"10.1183\/13993003.congress-2022.734"},{"issue":"2","key":"165_CR29","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1016\/0022-3999(85)90042-X","volume":"29","author":"J van Dixhoorn","year":"1985","unstructured":"van Dixhoorn J, Duivenvoorden HJ (1985) Efficacy of Nijmegen questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res 29(2):199\u2013206","journal-title":"J Psychosom Res"},{"issue":"8","key":"165_CR30","doi-asserted-by":"publisher","first-page":"1118","DOI":"10.1016\/j.arcped.2009.04.013","volume":"16","author":"M Sznajder","year":"2009","unstructured":"Sznajder M, Stheneur C, Baranes T, Fermanian C, Rossignol B, Chevallier B et al (2009) Diagnostic value of the SHAPE questionnaire in recognition of the hyperventilation syndrome in children: a pilot study. Arch Pediatr 16(8):1118\u20131123","journal-title":"Arch Pediatr"},{"key":"165_CR31","unstructured":"Hardonk HJ, Beumer HM (1979) Hyperventilation syndrome. In: Vinken PJ, editor. Handbook of Clinical Neurology. Amsterdam"},{"issue":"10","key":"165_CR32","doi-asserted-by":"publisher","first-page":"2428","DOI":"10.1002\/ppul.26052","volume":"57","author":"C Peiffer","year":"2022","unstructured":"Peiffer C, Pautrat J, Benzouid C, Fuchs-Climent D, Buridans-Travier N, Houdouin V et al (2022) Diagnostic tests and subtypes of dysfunctional breathing in children with unexplained exertional dyspnea. Pediatr Pulmonol 57(10):2428\u20132436","journal-title":"Pediatr Pulmonol"},{"key":"165_CR33","doi-asserted-by":"publisher","first-page":"620955","DOI":"10.3389\/fphys.2020.620955","volume":"11","author":"MF Ionescu","year":"2020","unstructured":"Ionescu MF, Mani-Babu S, Degani-Costa LH, Johnson M, Paramasivan C, Sylvester K et al (2020) Cardiopulmonary exercise testing in the assessment of dysfunctional breathing. Front Physiol 11:620955","journal-title":"Front Physiol"},{"issue":"12","key":"165_CR34","doi-asserted-by":"publisher","first-page":"3027","DOI":"10.1002\/ppul.26129","volume":"57","author":"B Niggemann","year":"2022","unstructured":"Niggemann B, Maas R, Suerbaum C, Spindler T, Kohl A, Koerner-Rettberg C et al (2022) Psychological characteristics of functional respiratory disorders in children and adolescents-pilot study. Pediatr Pulmonol 57(12):3027\u20133034","journal-title":"Pediatr Pulmonol"},{"issue":"2","key":"165_CR35","doi-asserted-by":"publisher","first-page":"110","DOI":"10.1136\/thorax.58.2.110","volume":"58","author":"M Thomas","year":"2003","unstructured":"Thomas M, McKinley RK, Freeman E, Foy C, Prodger P, Price D (2003) Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial. Thorax 58(2):110\u2013115","journal-title":"Thorax"},{"key":"165_CR36","doi-asserted-by":"publisher","unstructured":"Jones M, Harvey A, Marston L, O'Connell NE (2013) Breathing exercises for dysfunctional breathing\/hyperventilation syndrome in adults. Cochrane Database Syst Rev (5):CD009041. https:\/\/doi.org\/10.1002\/14651858.CD009041.pub2","DOI":"10.1002\/14651858.CD009041.pub2"},{"issue":"1","key":"165_CR37","doi-asserted-by":"publisher","first-page":"00274-2022","DOI":"10.1183\/23120541.00274-2022","volume":"9","author":"L Daines","year":"2023","unstructured":"Daines L, Zheng B, Elneima O, Harrison E, Lone NI, Hurst JR et al (2023) Characteristics and risk factors for post-COVID-19 breathlessness after hospitalisation for COVID-19. ERJ Open Res 9(1):00274\u201302022","journal-title":"ERJ Open Res."}],"container-title":["Molecular and Cellular Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40348-023-00165-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s40348-023-00165-3\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40348-023-00165-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,10,27]],"date-time":"2024-10-27T23:01:42Z","timestamp":1730070102000},"score":1,"resource":{"primary":{"URL":"https:\/\/molcellped.springeropen.com\/articles\/10.1186\/s40348-023-00165-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,12]]},"references-count":37,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,12]]}},"alternative-id":["165"],"URL":"https:\/\/doi.org\/10.1186\/s40348-023-00165-3","relation":{},"ISSN":["2194-7791"],"issn-type":[{"value":"2194-7791","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,12]]},"assertion":[{"value":"30 June 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 August 2023","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 September 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":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"10"}}