IDSA position on Lyme Disease
Advocacy
To understand what we are up against
please read this IDSA position on Lyme Disease advocacy republished last month.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4489928/
Published in final edited form as:
Lancet Infect Dis. 2011 Sep; 11(9): 713–719.
doi: 10.1016/S1473-3099(11)70034-2
PMCID: PMC4489928
NIHMSID: NIHMS703480
Antiscience and ethical concerns associated with advocacy of Lyme disease
Paul G Auwaerter, MD, Johan S Bakken, MD, PhD, Prof Raymond J Dattwyler, MD, Prof J Stephen Dumler, MD, Prof John J Halperin, MD, Edward McSweegan, MD, Prof Robert B Nadelman, MD, Susan O’Connell, MD, Prof Eugene D Shapiro, MD, Prof Sunil K Sood, MD, Prof Allen C Steere, MD, Prof Arthur Weinstein, MD, and Prof Gary P Wormser, MD
Division of Infectious Diseases, Department of Medicine (P G
Auwaerter MD) and Division of Medical Microbiology, Department of Pathology
(Prof J S Dumler MD), The Johns Hopkins Medical Institutions, Baltimore, MD,
USA; Section of Infectious Diseases, St Luke’s Hospital, Duluth, MN, USA (J S
Bakken MD, PhD); Division of Allergy, Immunology and Rheumatology (Prof R J
Dattwyler MD) and Division of Infectious Diseases (Prof R B Nadelman MD, Prof G
P Wormser MD), Department of Medicine, New York Medical College, Valhalla, NY,
USA; Atlantic Neuroscience Institute, Summit, NJ, USA (Prof J J Halperin MD);
Mount Sinai School of Medicine, New York, NY, USA (Prof J J Halperin); Crofton,
MD, USA (E McSweegan PhD); Lyme Borreliosis Unit, Health Protection Agency Microbiology
Laboratory, Southampton General Hospital, Southampton, UK (S O’Connell MD);
Department of Pediatrics, Department of Epidemiology and Public Health, and
Department of Investigative Medicine, Yale University, New Haven, CT, USA (Prof
E D Shapiro MD); Division of Pediatric Infectious Diseases, Cohen Children’s
Medical Center, Manhasset, NY, USA (Prof S K Sood MD); Division of
Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA (Prof A C Steere MD); and Section of
Rheumatology, Department of Medicine, Washington Hospital Center and Georgetown
University Medical Center, Washington, DC, USA (Prof A Weinstein MD)
Correspondence to: Dr Paul G Auwaerter, Division of
Infectious Diseases, Department of Medicine, The Johns Hopkins Medical
Institutions, Baltimore, MD 21205, USA, Email: moc.liamg@retreawuagpCopyright notice and Disclaimer
See other articles in PMC that cite the published article.
Abstract
Advocacy for Lyme disease has become an increasingly important part of an antiscience movement that denies both the viral cause of AIDS and the benefits of vaccines and that supports unproven (sometimes dangerous) alternative medical treatments. Some activists portray Lyme disease, a geographically limited tick-borne infection, as a disease that is insidious, ubiquitous, difficult to diagnose, and almost incurable; they also propose that the disease causes mainly non-specific symptoms that can be treated only with long-term antibiotics and other unorthodox and unvalidated treatments. Similar to other antiscience groups, these advocates have created a pseudoscientific and alternative selection of practitioners, research, and publications and have coordinated public protests, accused opponents of both corruption and conspiracy, and spurred legislative efforts to subvert evidence-based medicine and peer-reviewed science. The relations and actions of some activists, medical practitioners, and commercial bodies involved in Lyme disease advocacy pose a threat to public health.
Introduction
For much of its history, medicine has endured an often
justifiable degree of public scorn and suspicion for its many faults, including
ignorance and ineffectiveness, elitism and exclusivity, unyielding dogma and
fashionable quackery, and a certain laissez-faire commercialism. But the
profession of medicine has evolved, embracing scientific and statistical methods
to establish theories and practices that revolutionised the effectiveness of
medical care in the 20th century. Medicine’s critics, however, have also
evolved. Today, there are diverse groups of activists many of whom share a
common suspicion of modern medicine.In his book, Denying AIDS,1 the psychologist Seth Kalichman wrote of such activists: “They are deeply skeptical of science and untrusting of government and big business. Some are surely misguided and others seem to foolishly believe that they understand everything there was to know…”. He was writing about people who deny the viral cause of AIDS. He could just as easily have been writing about other antiscience movements, including ardent antivaccine activists and those who promote unproven alternative medical therapies.
Aspects of Lyme disease advocacy are an important example of
this antiscience movement. For the purposes of this Personal View, we will
define this antiscience outlook to also include the promotion of pseudoscience
and science that has weak credibility or validity because of fundamental flaws
in its design or poor reproducibility. For two decades, many Lyme disease
activists have portrayed Lyme disease, a tick-borne infection, as an insidious,
ubiquitous, difficult to diagnose, and often incurable disease, which causes mainly
non-specific symptoms such as chronic fatigue, musculoskeletal pain, and
neurocognitive dysfunction that can be treated only through the use of
antibiotics for months or years (panel 1).2
As with other antiscience groups, some Lyme disease activists have created a
parallel universe of pseudoscientific practitioners, research, publications,
and meetings, arranged public protests and made accusations of corruption and
conspiracy, used harassment and occasional death threats, and advocated
legislative efforts to subvert evidence-based medicine and peer-reviewed
science. Politicians, the media, and the public have been left trying to
discern the scientific facts from the pseudoscientific ones, with many
regarding both as equally valid as they try to be fair and balanced. When such
inappropriate and uncritical weighting occurs, public and government officials
unknowingly come to accept or even endorse highly unconventional and sometimes
dangerous theories and therapies.
The infection that launched a thousand protestsLyme disease is a bacterial infection caused by Borrelia burgdorferi sensu lato (which includes B burgdorferi, B afzelii, B garinii, and other species) and transmitted by Ixodes species ticks. The infection is non-fatal, non-communicable from person-to-person, is responsive to antibiotics, and is limited in range both geographically and seasonally. The most common clinical manifestation is a characteristic skin lesion (erythema migrans) that occurs at the site of the tick bite. Within weeks, some untreated patients might develop nervous system abnormalities (eg, meningitis or facial nerve palsy) or cardiac symptoms (eg, heart block); within months, arthritis can develop, most commonly affecting the knee. In addition to these objective clinical manifestations, some patients have several subjective complaints that are usually most prominent early in the infection. These symptoms include fatigue, arthralgia, myalgia, headache, stiff neck, and impaired concentration; symptoms that are common in many infectious and non-infectious disorders.
The Infectious Diseases Society of America (IDSA), a
professional organisation of more than 9000 infectious disease physicians, has
published evidence-based treatment guidelines for the various manifestations of
Lyme disease3
and for many other infectious diseases. On the basis of published,
peer-reviewed studies, the IDSA guidelines recommend antibiotic treatment for
Lyme disease for 10–28 days, depending on the disease manifestation.3
The recommendations are similar to others developed independently by European
societies and expert groups.4
The objective clinical manifestations typically resolve (eg, erythema migrans)
or show improvement (eg, arthritis) during the course of antibiotic treatment.
Additional treatment is usually not needed, but a second course of therapy
might be given in a few cases.3
Panel 1: Concepts* about Lyme disease that are
unsubstantiated or proven to be inaccurate
Epidemiology
Sexually transmitted
Not restricted geographically
Clinical features and outcome
Most patients have only subjective symptoms
Incurable illness when not treated very early
Causes autism, Morgellons disease, multiple sclerosis,
Parkinson’s disease, amyotrophic lateral sclerosis, homicidal behaviour (“Lyme
rage”), immune dysfunction, birth defects, and Alzheimer’s disease
Patients usually have several co-infections, such as from Bartonella,
Babesia, Mycoplasma, Chlamydia, and Anaplasma species
Pathobiology
Borrelia burgdorferi is an intracellular pathogen, forms antibiotic-resistant
cysts, and produces a neurotoxin
Diagnostic testing
Serological testing is of no value in the diagnosis of
extracutaneous manifestations of Lyme disease
IgM testing is appropriate for assessment of patients with
illness of long duration
Serology is less sensitive for detection of Lyme disease in
women than in men
Treatment
Usual doses and durations of antibiotics are insufficient;
open-ended treatment with multiple antibiotics is needed
Combinations of antibiotics are needed to eradicate B
burgdorferi
*Obtained from popular Lyme disease websites, and from
public statements and presentations made by some “Lyme literate medical
doctors” and chronic Lyme disease activists.
The accompanying subjective manifestations, such as fatigue,
are often improved but not completely resolved at the conclusion of antibiotic
treatment. Evidence from clinical trials shows that prolonging the initial
course of antibiotic treatment does not accelerate the rate of resolution of
such symptoms.3,5–7
Four National Institutes of Health (NIH)-sponsored, double-blind, randomised,
placebo-controlled treatment trials have been done to examine whether
persistent (for ≥6 months) subjective symptoms were improved by retreatment
with antibiotics after standard courses of oral or intravenous treatment for
Lyme disease.3,8–10
Data from the two largest studies indicated no benefit from re-treatment with
90 days of additional antibiotic therapy.8
Results from the other two studies reported at most equivocal evidence for
benefit. None of the investigators of the four studies concluded that the
possible and unconfirmed benefits of additional antibiotic treatment outweighed
their risks, which were substantial in the two smaller trials (eg, admission to
hospital for intravenous catheter sepsis).8–10
Consistent with these findings, there was also no microbiological evidence for
persistence of B burgdorferi despite rigorous examination of several body fluid
samples, including culture and molecular diagnostic assays.3,8,10
Nevertheless, many activists believe that patients whose objective
manifestations of Lyme disease have resolved after antibiotic treatment are
still chronically infected with B burgdorferi.
Although unsupported by scientific evidence, a belief system
has emerged for some activists over the past 20 years—that Lyme disease can
cause disabling subjective symptoms even in the absence of objective signs of
disease, that diagnostic tests for extracutaneous manifestations of Lyme
disease are often falsely negative, and that treatment with antibiotics for
months or years is necessary to suppress the symptoms of the disease, which
often recur despite prolonged antibiotic therapy. Consequently, some
individuals with medically unexplained symptoms11
and others with more well defined conditions (panel 1) were diagnosed with, or
themselves attributed their symptoms to, Lyme disease in the absence of
supportive laboratory data. Believing that they were chronically infected,
these individuals formed support groups and sought treatment from “Lyme
literate medical doctors” (LLMDs)—physicians who specialise or claim to be
experts in the diagnosis and treatment of patients with what has been called
chronic Lyme disease.12,13
The overall result is that many patients who receive long-term treatment have
no convincing evidence of ever having had B burgdorferi infection, by history
(sometimes including having never been exposed to ticks, never having been in
an endemic area, and never having had objective clinical findings suggestive of
Lyme disease), physical examination, or laboratory test results.12,13
Even children with autism are thought by some LLMDs to have persistent B
burgdorferi infection as the cause of the disorder.14
By the early 1990s, some activist groups and LLMDs were
accusing university scientists and public health officials of intentionally
under-reporting and under-diagnosing cases of Lyme disease. If medical
insurance companies denied payment for long-term treatment, this refusal was
often blamed on academic physicians being in the pay of insurance companies,
rather than on the absence of credible medical evidence to support either the
diagnosis or a beneficial role for such treatment. Other researchers were accused
of financial conflicts created by patent applications, federal grants, or
funding from pharmaceutical companies.15
The accusations eventually drew the attention of the US Congress.
During a 1993 Senate hearing on Lyme disease, one LLMD accused “a core group of
university-based Lyme disease researchers and physicians…of act[ing]
unscientifically and unethically. They work with government agencies to bias
the agenda of consensus meetings, and have worked to exclude…those with
alternate opinions. They behave this way for reasons of personal or
professional gain, and are involved in obvious conflicts of interest”.16
However, no evidence to substantiate the charges was offered nor was any
requested by the senators serving on the committee. In 2000, activists
persuaded a few congressmen to investigate the federal Lyme disease research
programmes of the Centers for Disease Control and Prevention (CDC) and the NIH.
The General Accounting Office (GAO-01-787R, GAO-01-755)17,18
found no evidence of conflicts of interest, retaliation, physician harassment,
or controlled science.
More recently, Richard Blumenthal, the then Attorney General
of Connecticut in the USA and a long-time supporter of chronic Lyme disease
activism and adviser to the support group Time for Lyme, threatened IDSA with
antitrust litigation after the release of updated Lyme disease treatment
guidelines.19,20
The fact that these practice guidelines, essentially unchanged from the 2000
IDSA guidelines,21
are voluntary measures was ignored. Blumenthal asserted that the authors of the
guidelines were “rife with conflicts of interest”, but declined to identify any
of those conflicts or explain how they might have affected the recommendations.22
His actions were widely denounced by physicians and lawyers alike,23,24
because federal courts had earlier ruled that professional guidelines are a
medical, not a legal, concern. The Blumenthal investigation resulted in the
convening of an independent scientific panel (vetted for potential conflicts of
interest by an ethicist and physician) to review the appropriateness of the
IDSA recommendations. After an extensive review of the scientific evidence, the
new panel unanimously concluded that the Lyme disease guidelines by IDSA were
accurate and appropriate.25
Proven or alleged unethical activities of some LLMDs
Some LLMDs, advocacy organisations for patients, and certain
diagnostic laboratories have interconnections, presenting potential conflicts
of interest for these LLMDs in their multiple roles as advisors, personal
physicians, and recipients of grants from activist organisations. Many of these
physicians are represented by the International Lyme and Associated Diseases
Society (ILADS), located in Maryland, USA. Two of the most vocal
patient-activist organisations are the Lyme Disease Association (LDA) in New Jersey,
and the California Lyme Disease Association (CALDA), USA.
Several physician members of ILADS—including current and
former officers—have been sanctioned by state medical licensing boards or
reprimanded by federal agencies (panel 2).26–33
Other LLMDs have been convicted in state and federal courts raising concerns
about ethics and professional credibility (panel 2).34–41
For example, a doctor in Kansas served a prison sentence for causing the death
of a patient he treated for Lyme disease with injections of bismuth.35
An LLMD in Georgia was charged with allegedly treating patients for Lyme
disease with injections of dinitrophenol, a toxic substance banned from
medicinal consumption in the USA for more than 50 years.36
He was suspended by the state medical board after his indictment in 2005, and
was sentenced to 5 years’ probation for defrauding insurance companies of
US$650 000.36
In 2007, an LLMD in New Jersey was sentenced to 41 months in federal prison for
tax evasion related to his two Lyme disease clinics.39
In Connecticut, a physician and adviser to the Lyme group Turn The Corner
Foundation was reprimanded, fined, and placed on 2 years’ probation for
diagnosing Lyme disease in children without examining them and for improperly
prescribing antibiotics.41
He is appealing the case using funds provided by Lyme activists.
Panel 2: Examples of professional and legal issues of LLMDs
Current or former ILADS officersUniversity employment terminated27
Other LLMDS
Sentenced for selling medical equipment and drug treatments
for a non-existent Lyme disease epidemic34
Imprisonment for causing the death (manslaughter) of a
patient by treating Lyme disease with injections of bismuth35Conviction for conspiracy, mail fraud, wire fraud, and money laundering37
Imprisonment for tax evasion related to two Lyme disease clinics39
Disciplinary action by state medical board for diagnosing and treating patients for Lyme disease without examining them41
ILADs=International Lyme and Associated Diseases Society.
LLMD=Lyme literate medical doctor. NIH=US National Institutes of Health. FDA=US
Food and Drug Administration. Additional information is available at http://www.casewatch.org.
Unvalidated laboratory testing
Despite warnings from the US Food and Drug Administration
and the CDC about the potential unreliability of unvalidated diagnostic tests
for Lyme disease,42
many LLMDs continue to use such assays (panel 3).42–46
Lyme specialty laboratories are favoured by some activists and LLMDs because
their nonstandard testing methods and interpretation criteria often lead to
more positive results than other laboratories that rely on validated methods.47
An owner of one such diagnostic company is an ILADS director and an adviser to
three Lyme organisations. He was one of the authors of the treatment guidelines
by ILADS, although his company affiliation is not disclosed in that document.48
This laboratory was investigated by Medicare; in 2001, the US Federal Office of
the Inspector General placed it on a list of non-compliant laboratories,
resulting in fines totalling $48 000. The laboratory is now compliant.49
In 2009, several residents in Kansas won a $30 million suit against another
Lyme disease specialty laboratory for incorrectly diagnosing these individuals
with Lyme disease.50
By use of an unconventional culture method, a former
president of ILADS reported positive blood cultures for B burgdorferi in more
than 90% of a group of patients who had previously received antibiotic
treatment for Lyme disease.51
His work could not be replicated by others,52
and the novel culture medium was shown to be lethal for Borrelia species.52
Two immunological tests favoured by some LLMDs to indicate the presence of B
burgdorferi infection include a T-cell assay and measurement of the CD57 cell
count; both of these tests are considered to be unreliable.44,46
Ethics of propaganda and persuasion
In 2005, representatives of the LDA in New Jersey, USA, and
CALDA in California, USA, wrote to the Director of the CDC, criticising the
information about Lyme disease on the organisation’s website and its warning
about improper diagnostic tests.42
In December, 2006, a New Jersey congressman complained that it was
“inappropriate for CDC to highlight IDSA’s findings—to the exclusion of
others”.53
Lost in these political discussions was the absence of scientific merit in the
arguments raised by activists. ILADS leaders claim their practice guidelines
are evidence-based and peer-reviewed, but they were not subjected to an
external peer-review process by the journal in which they were published as a
supplement.54
Moreover, the support they cite for their guidelines, consisting mainly of
anecdotes, studies of animal systems of questionable relevance to human
disease, and uncontrolled studies of long-term antibiotic treatment, does not
meet accepted criteria for evidence-based medicine.3,12,48,55–57
The ILADS guidelines were funded by two activist organisations, the LDA in New
Jersey and the Turn The Corner Foundation.48Panel 3: Noted problems with diagnostic tests that are or have been advocated by some LLMDs and chronic Lyme disease activists
Lyme urine antigen test
Unreliable43
CD57 cell count
No specific association with Borrelia burgdorferi infection44
PCR
Variable sensitivity in the plasma, urine, and CSF; no
clinical validation45
Flow cytometry
No clinical validation42
Lymphocyte transformation
Low specificity; no clinical validation46
Immunofluorescence for L-forms of Borrelia
No clinical validation42
Urine reverse western blot
No clinical validation42
Urine dot blot
No clinical validation42
Support groups for Lyme disease originated as information
sources for patients and the public. Many have devolved into partisan
organisations, promoting unproven therapies and the clinical services of their
LLMD advisers. Their leaders lobby for legislation to promote their perception
of chronic Lyme disease and to protect LLMDs from licensing boards, and they
work to raise defence funds for those who face legal complaints. Activists have
organised their own scientific meetings, published their own journal, and
funded research by LLMDs.58,59
All this activity has led to the creation of a cadre of doctors and activists
with their own institutions, research, and conferences, a dedicated pool of
patients, and unorthodox, alternative views of microbiology, immunology, and
pharmacology.
Belief in a chronic, insidious Lyme disease epidemic hidden
from the public by a cabal of public health officials, academic scientists, and
insurance companies has sometimes led to bizarre and dangerous behaviour among
activists. Some have stalked and threatened scientists60
or tried to sue others.61
Employers and deans have received anonymous phone calls alleging misdeeds by
employees and faculty. One activist was confined to a psychiatric ward after
threatening a state’s attorney.62
The latest promotional technique by activists is through the cinema. One well
publicised film, entitled Under Our Skin, was criticised in a previous issue of
The Lancet Infectious Diseases as partisan, manipulative, and prone to
conspiracy63
and by another reviewer as “full of suspicions, assertions, and anecdotes; it’s
low on science and objectivity”.64
Conclusions
Many individuals who represent themselves as Lyme disease
activists and LLMDs hold and promote views of a tick-borne infectious disease
that is inconsistent with credible scientific evidence. Although relatively
small in number, their effect should not be underestimated. Their unorthodox
perspectives and resulting practices have contributed to injury and even deaths
of patients.35,65
Millions of dollars have been spent refuting their claims, and thousands of
hours have been spent responding to false allegations, legal threats,
congressional queries, and other harassments. At a time when unnecessary
health-care expenditures are being scrutinised and widespread bacterial
resistance has been linked to overuse of antibiotics, it is particularly
important that unsubstantiated treatments be avoided.66This situation is not likely to end anytime soon. As with other antiscience groups, many Lyme disease activists are well funded and often connected to influential political and media sources. Treatment of Lyme disease with long-term antibiotics is profitable for LLMDs and can be falsely reassuring to patients, who believe that they have a debilitating chronic infection and thus do not seek diagnosis and treatment for other disorders. There is no deficiency of either new patients or activists. The medical anthropologist Sharon Kaufman wrote that “Information technology has transformed the way trust and knowledge are produced”.67 Most people now find medical information on the internet, and the websites of LLMDs and activists are often viewed as legitimate and reliable sources of information, which they may not be.68,69 Such misplaced trust has also contributed to a similar situation in Europe, with increasing pressure being brought on authorities there to sanction the use of prolonged antibiotic treatment for patients without credible evidence of Lyme disease by groups such as the German Borreliosis Society and Dutch Lyme Association. This ill-founded advocacy is being extended to other, less common, tick-borne infections (and to non-Ixodes tick-transmitted pathogens such as Bartonella).48,70
In conclusion, activists, through public appeal and
political lobbying, have managed to divert attention away from existing
evidence-based medicine in their quest to redefine Lyme disease. There is a
serious concern that they will further endanger the public’s health unless
responsible physicians, scientists, government leaders, and the media firmly
stand up for an evidence-based approach to this infection that is based on
high-quality scientific studies. Many patients who have been labelled as having
chronic Lyme disease arrive at this diagnosis as a consequence of inadequate or
frustrating previous medical care for symptoms that are difficult to define.
Patients who suspect or who have been diagnosed with chronic Lyme disease
should consider seeking a comprehensive assessment from an empathetic
physician. This physician should objectively look at all elements of history,
physical examination, and laboratory data to guide assessment and management
based on the best available clinical evidence.
AcknowledgmentsWe thank Lenise Banwarie and Diana Olson for their assistance. EDS is supported in part by grant K24 RR022477 and Clinical and Translational Science Award (CTSA) grants KL2 RR024138 and UL1 RR024139 from the National Center for Research Resources (NCRR; a component of the NIH) and the NIH Roadmap for Medical Research. The contents of the article are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or the NIH.
Footnotes
ContributorsEMcS prepared the first draft, worked on subsequent drafts, and helped with the literature search. JSB participated in the construction of the paper and reviewed the final draft. PGA, JJH, RBN, SO’C, SKS, ACS, AW, GPW contributed to the writing of the article, and RJD, JSD, EDS contributed to the writing and editing of the paper. JSD, JJH, SO’C, GPW contributed to the literature search, and EDS, ACS, AW, GPW contributed to the data interpretation.
Conflicts of interest
PGA has served as a consultant for Oxford Diagnostics and
has participated in expert testimony in two medicolegal suits about possible
Lyme disease. He has equity interest in Johnson & Johnson, no products of
which are referred to in this article. RJD is part owner of and has stock in
Biopeptides Corporation, no product of which is referred to in this article,
has received payment for providing expert testimony in malpractice cases and
holds patents on vaccine and diagnostic technology with SUNY at Stony Brook
Biopeptides. JSD has received support for travel to meetings from DiaSorin and has
licence of US patent 5,955,359 to Focus Diagnostics; none of these declarations
are directly related to the contents of this article. JJH has served as an
expert witness in several medicolegal cases concerning Lyme disease and has
equity in Abbott, Bristol-Myers Squibb, Johnson & Johnson, and Merck; no
products from these companies are referred to in this article. EMcS was a
former programme officer for Lyme disease at the US NIH. RBN has served as an
expert witness in malpractice litigation involving Lyme disease. EDS is a board
member of the American Lyme Disease Foundation, for which no compensation is
received. He has reviewed medical records for the Metropolitan Life Insurance
Company and has provided medicolegal testimony. GPW is a board member of the
American Lyme Disease Foundation for which no compensation is received, has
served as an expert witness in malpractice cases involving Lyme disease, has
research grants from the NIH/Immunetics, BioRad, DiaSorin, and BioMerieux to
study diagnostic tests for Lyme disease, none of which is mentioned in the
manuscript, and has equity in Abbott, a company not known to have any approved
product for Lyme disease. JSB, RJD, JSD, JJH, RBN, EDS, ACS, and GPW have
served on the panel for the 2006 IDSA Lyme disease guidelines. JSB, SO’C, SKS,
ACS, and AW declare that they have no conflicts of interest.References
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