Acupuncture wins BMA approvalBMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7252.11/b (Published 01 July 2000) Cite this as: BMJ 2000;321:11
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EDITOR - In summary, the recent BMA publication on acupuncture states
that there is evidence that this intervention is effective in certain
conditions; also it is popular with general practitioners and patients,
many of whom believe that is should be integrated with other NHS services,
and therefore made freely available. 
Whilst one can have little objection or reservation to the private
provision of acupuncture and other forms of complementary and alternative
medicine (C.A.M.) I remain very concerned with the recommendation that on
the available evidence, the NHS should now be required to shoulder this
additional provision, particularly when it is in serious difficulties in
satisfying the legitimate demands it is already striving to meet.
Briefly, my reasons are as follows.
Firstly, scrutiny of the quoted data, including the admirable review by
professor Ernst , shows that the evidence of its effectiveness in the
great array of disorders in which acupuncture is presently used, is
conspicuous by its absence. Even for low back pain, though the evidence
is supportive, it is not overwhelming. It is of course interesting to
speculate why low back should be different in this way to other painful
disorders, such as neck pain, osteoarthritis, and dental pain where the
quoted evidence is unconvincing. Though acupuncture may be popular with
both GP's and patients alike, this is insufficient reason per se to make
it freely available. For the present therefore its provision should be
limited to patients with low back pain. If not, there is likely to be a
Trojan horse effect, not only for acupuncture, but for the delivery of all
varieties of CAM by the NHS.
Secondly, one must suspect that the enthusiasm for acupuncture and other
forms of CAM in primary care is largely motivated by the opportunity to
sideline 'heart sink' and other chronic complaining patients to another
treatment option where they will be less visible in day to day practice,
and where their deskilling effect is less palpable. Undoubtedly, a
similar effect has been achieved by counselling, now widely provided in
primary care, but for which sound clinical evidence of effectiveness
remains elusive.  Again, it is questionable whether these are adequate
reasons to fund unrestricted acupuncture and CAM from the public purse.
Thirdly, there is no reference in the BMA report to the use of acupuncture
in secondary care, where presumably it would also need to be provided.
Moreover it is noted on the opening page that in 1991 the NHS was already
spending £1 billion per annum on CAM, at a time when it was allegedly cash
starved, and frequently unable to provide a satisfactory emergency
service. Unless some rules of effectiveness are not firmly applied
(hopefully by the National Institute for Clinical Excellence) no matter
how much money is poured into the NHS by this or successive governments,
it will never be enough. The prospect of transferring this present total
public expenditure on acupuncture and CAM to the taxpayer must surely give
pause for thought.
Hon. Consultant Surgeon, University Hospital of Wales
Late Chairman, Chairman, Cardiff Community HNS Trust
1 Acupuncture wins BMA Approval.
BMJ 2000; 321: 11 (1 July)
2 Ernst E (1999). Clinical effectiveness of acupuncture: an overview
of systemic reviews.
In E. Ernst and A. White (Eds.) Acupuncture: a scientific appraisal.
3 Counselling in General Practice. Drug and Therapeutics Bulletin
Vol. 38, No.7 July 2000
Competing interests: No competing interests
Andrew Moore et al have identified, eloquently, a major problem with
the BMA's report on 'acupuncture' - it provides little in the way of
evidence for the efficacy or effectiveness of 'acupuncture'.
'Acupuncture' is widely held, particularly by the billions of people
who use it, by it's practitioners to be one part of a modality (the
modality is "acupuncture and moxibustion", as developed by Traditional
Chinese Medicine). It is very effective at treating a wide variety of
disorders such that the WHO recommended the treatment for about 40
different conditions, from musculoskeletal to neurophysiological, as far
back as 1981.
The problem, which Moore comes close to identifying, is that
'acupuncture' does not really exist as a form of treatment per se;
acupuncture alone is not the modality that has convinced billions of
people of its efficacy - this is a figment of the imagination of, for
example, 'western medical' acupuncturists (such as many GPs and physios).
It is unlikely to achieve results on which the WHO recommendations are
Ironically, those persons well-funded for research into 'acupuncture'
are western trained 'medical acupuncturists'. Using a very limited and
relatively ineffective process they call 'acupuncture' (they stick needles
into people) such 'acupuncturists' realise results which are expectedly
inferior to the TCM-based forms of "acupuncture & moxibustion" from
which most formal trials originate in China. Most systematic reviews and
meta-analyses generated by 'medical acupuncturists' and Western medical
researchers do not account for these Chinese studies as they find great
difficulty understanding the complexities of treatments the trials are
designed around. Hence the published studies in the West tend to be of
poor quality 'acupuncture', which reveal nothing of the great
effectiveness of Traditional 'acupuncture & moxibustion'. To explain
their own lack of understanding and success, said researchers then try to
discredit successful Chinese trials by stating they are not 'gold
standard' (as applied to drug studies) little appreciating that any 'gold
standard' applied to TCM studies must take full account of the way TCM
practices are performed.
The BMA has a dilemma, it needs to display empathy with public
awareness but is strapped with data gained largely from 'medical
acupuncture studies' which show little of value as Moore says.
Moore gives as examples back pain, dental pain, migraine and 'smoking
cessation' studies and uses for reference material reviews and meta-
analyses performed by 'medical acupuncturists'. These can easily be
refuted by questioning the precedents on which the reviewers criticise
those particular studies as well as by referring to others which review
Traditional Chinese techniques.
For example, reviewers who consider 'sham' acupuncture valid for
research purposes - which does not exist in TCM - as a kind of placebo
discredits the reviews, hence all reviews referring to 'sham' acupuncture
studies are already flawed.
The only way to correct the BMA's apparent lack of clarity is for it
to seriously investigate Chinese research, as presented by many noted
academies of learning by their exceptionally gifted scientists, and to
discount the reviews performed by western medical researchers with poor
knowledge of Traditional Chinese Medicine and trials performed by 'western
medical acupuncturist' using ineffective procedures and unrepresentative
(of public perception) 'acupuncture' practices.
Competing interests: No competing interests
The BMA report on acupuncture is regrettable. It
suggests, inter alia, that acupuncture is more effective
than control interventions for back pain, dental pain and
migraine. If only this were the case. Three recent
systematic reviews on acupuncture for these
indications demonstrate the importance of basing
judgements on information of high quality and not on
For back pain , four randomised and blind studies
showed no benefit. Five open studies showed
acupuncture to be highly effective. The BMA conclusion
that acupuncture was effective in back pain was based
on all nine studies together.
For dental pain , sixteen studies were originally
included in a review that concluded that it was effective.
Unfortunately, many of these were not randomised, or
not blind or had major methodological flaws. Only three
small studies remain after removing biased or flawed
studies , and these could not demonstrate any
benefit. None of the studies would be allowed for
registration purposes if this intervention were a new
For migraine , trials showing a significant benefit
from acupuncture were of dubious methodological
quality (inadequately randomised, not blind). The
reviewers themselves are highly circumspect about
ascribing any clinical significance to acupuncture.
The BMA report says that results are inconclusive for
acupuncture in a variety of other conditions. These are
weasel words indeed for anyone who has read either
the reviews or the original papers on which they are
based. Take smoking cessation as an example . The
results of a profoundly negative Cochrane review are
shown in the Table where results at six and 12 months
with acupuncture are compared with placebo
responses with nicotine replacement therapy . No
sign there of acupuncture working.
|Intervention||Patients stopped smoking/Total||Percent
|Acupuncture at 6 months||50/532||14 (11 to 18)|
|Acupuncture at 12 months||75/548||14 (11 to 17)|
|Nicotine inhaler placebo, 6-12 months||44/486||9 (7 to
|Nicotine spray placebo, 6-12 months||52/439||12 (9 to
|Nicotine patch placebo, 6-12 months||322/3772||9 (8 to
|Nicotine gum placebo, 6-12 months||1070/9270||12 (11
The fact is that every time one looks at acupuncture
reviews or trials the problem is the same one of poor
quality leading to bias. We know that bias is a major
problem , and reviews which include poor quality
studies over estimate treatment effects . Trial validity
should also be taken into account , and we need to
acknowledge that original reports can come to the
wrong conclusion from their own data. This was true of
two of 13 studies into acupuncture in chronic neck and
back pain .
For those areas where the BMA report thought there
was evidence of effectiveness of acupuncture, either
there was none, or what quality evidence there was
indicated lack of effectiveness. For those areas where
the BMA thought the results inconclusive, there was
either no useful information or it was conclusive that
acupuncture was ineffective.
Doctors should beware. There is no useful evidence
that shows acupuncture to be helpful. There is
evidence  that it does harm.
Many things that we do can make people feel better
without showing any benefit on a major outcome like
pain. Perhaps the important point is that we should not
deceive ourselves, or people who trust our
recommendations. There is no gold standard evidence
that acupuncture improves pain, or anything else. The
BMA report has drawn media interest like flies to a
dung heap. This is unfortunate because the report is
quite simply wrong.
RA Moore DSc HJ McQuay DM
Consultant Biochemist Professor of Pain Relief
AD Oldman DPhil LE Smith PhD
Research Associate Research Associate
1 Ernst E, White AR. Acupuncture for back pain: A
meta-analysis of randomised controlled trials. Archives
of Internal Medicine 1998 158: 2235-2241.
2 Ernst E, Pittler MH. The effectiveness of acupuncture
in treating acute dental pain. British Dental Journal
3 Smith LA, Oldman AD. Acupuncture and dental pain.
British Dental Journal 1999; 186:158-159
4 Melchart D, Linde K, Fischer P et al. Acupuncture for
recurrent headaches: a systematic review of
randomised controlled trials. Cephalalgia 1999
5 White AR, Rampes H, Ernst E. Acupuncture for
smoking cessation (Cochrane review). In Cochrane
Library issue 1, 2000.
6 Silagy C, Mant D, Fowler G, Lancaster T. Nicotine
therapy for smoking cessation. Cochrane Library 1998
Issue 2 (date of latest amendment 27/5/98)
7 Schulz KF, Chalmers I, Hayes RJ, Altman DG.
Empirical evidence of bias: Dimensions of
methodological quality associated with estimates of
treatment effects in controlled trials. JAMA 1995; 273:
8 Khan KS, Daya S, Jadad AR. The importance of
quality of primary studies in producing unbiased
systematic reviews. Arch Intern Med 1996;156 :661-6.
9 Smith LA, Oldman AD, McQuay HJ, Moore RA.
Teasing apart quality and validity in systematic reviews:
an example from acupuncture trials in chronic neck and
back pain. Pain. 2000 86: 119-132.
10 Ernst E, White A. Life-threatening adverse reactions
after acupuncture? A systematic review. Pain
Competing interests: No competing interests
Kovacs and Gil del Real have made the common, yet fundamental, error
of taking a 'systematic review' as gospel and not bothering to seek data
themselves. If researchers merely read others' reviews and meta-analyses,
without making a determined intelligent effort to check validity by
searching for trials data that may question the review, how do they know
if biased or naive selectivity of material has not led to a conclusion
that is easily refuted?
They state that for of an EXHAUSTIVE search for data for a Cochrane
Collaberation systematic review a native Chinese researcher was employed
to search for clinical trials into low back pain for evaluation, and there
were none'; apart from being an unlikely scenario, considering the
enormous wealth of Chinese research data, that not one study could be
found it's clear they did not bother to look themselves. It took me 10
minutes, looking into my archive of material published in The World
Journal of Acupuncture-Moxibustion, a publication which details many
varied research trials carried out by scientists throughgout Chinese
academia that is sponsored by The World Federation of Acupuncture-
Moxibustion Societies and Institute of Acupuncture-Moxibustion, and the
China Academy of Traditional Chinese Medicine to find 6 studies relating
to acupuncture and related modalities. Imagine what I may find in an hour,
or even by perusing other notable international publications!
Was the 'native Chinese researcher' properly briefed one wonders, or
merely selective of material? Perhaps those controlling the selction
process do not really understand what 'acupuncture' is to Chinese
scientists - it's generally a different animal to that understood, in very
limited fashion, by western medical acupuncturists. Perhaps searching for
'low back pain' precluded identifying native words that translated as
'lumbocrural', 'vertebral hyperosteogeny', 'protrusion of lumbar
intervertebral disc' etc.
My brief 'research' located the following clinical trials for
acupuncture and related modalities:-
1. "Combined treatment of 100 cases of sciatica with acupuncture and
point-injection" by GUO Xuemei and Li Ying, Taiyuan Central Hospital,
Shanxi Province, 030009, China and The Affiliated Hospital of Shanxi
Institue of TCM.
100cases combined treatment and 60 control acupuncture group. Combined
group total effective rate 97%, control 85%.
2. "Point penetration and deep acupuncture therapies for sciatica: an
observation of 108 cases" by CHEN Xingsheng and Marta Grzesiowska,
Affiliated Acupuncture Hospital of Anhui College of TCM, Hefei 230061,
China, and Canadian Student.
108 patients deep acupuncture, and 90 cases filiform needle acupuncture
therapy as control. Treatment group total effecte rate 93.52%, control
3. "Observation of the curative effect of 92 cases with lumbocrural
pain treated by the therapy of needle warming through moxibustion" by CHEN
Xinghua, The First Affiliated Hospital, Guangzhou University of TCM,
Guangzhou 510504, China.
92 cases moxibustion needle acupuncture, 91 cases control with simple
acupuncture; total effective rates being 95.65% and 83.52% respectively.
4. "Clinical observation on the treatment of lumbar vertebra
hyperosteogeny with electro- and hydro-acupuncture" by HUANG wei and RU
Liqiang, Affiliated Xiehe Hospital and department of Mechanism of
Acupuncture Analgesia of Tongji Medical University, Wuhan 430022, China.
5. "Clinical observation of electroacupuncture treatment of 51 cases
of protrusion of lumbar intervertebral disc" by HAN Youdong, JIANG Yiqian
and WANG Xiuying of the Department of Acupuncture and Moxibustion,
Affiliated Hospital of Shandong University of TCM and Pharmacology, Jinan
Total effective rate 96.1%.
6. "Clinical and Experimental studies of ischialgia treated by
acupuncture" by LIU Zhishun of Guang An Men Hospital, China Academy of
TCM, Beijing 100053, China.
Total effective rate 100% (53% cured, 30% markedly improved, 17%
effective, p<0.01). This study also showed that relief from pain
coincided with dramatic drop in 5HT concentration in peripheral blood
plasma (P<0.05) after treatments (175.45+/-66.26) compared to before
I suspect that these inevitable misunderstandings (when experienced
and well-trained practitioners of
acupuncture & moxibustion, adept at understanding TCM application and
theory, are not used in systemtic review processes) will continue to lead
to such inappropriate conclusions, despite the enormous wealth of
scientific research data generated by Chinese medical and non-medical
Couple this with general ease at which researchers can put together
studies based on others' "reviews and analyses" of numerous studies
without doing the hard work - and wide open to abuse - and it is no wonder
our government are struggling to understand why people claim tremendous
benefits from this TCM modality yet their scientists cannot put together a
decent review, using the vast wealth of Chinese data, to support peoples'
true life experiences.
Once experienced non-medical practitioners of this remarkable healing
art are employed in a research capacity, funded by the government, to
remove the veil of mystery from TCM modalities people will begin to enjoy
the scientific truth currently hidden in the west by incompetence and
Competing interests: No competing interests
The BMA report recently referred to in the BMJ1 concludes that
acupuncture should be made more widely available to users of the British
National Health Service, and that general practice physicians should
receive some training in this technique.
The BMA report appears to base
its conclusion on the following: a) the evidence showing that "acupuncture
is more effective than control interventions for back pain, nausea and
vomiting, migraine and dental pain"; b) the fact that 47% of general
practitioners have arranged for their patients to receive acupuncture
treatment; and c) the wish of 46% of those professionals to receive
further training in acupuncture in order to treat their own patients.
The available evidence on the effectiveness of acupuncture in the
treatment of back pain appears to have been misinterpreted. The Cochrane
Collaboration Back Review Group has recently published a major systematic
review of the effectiveness of acupuncture in the treatment of low back
pain2. This review followed a rigorous methodology and an exhaustive
search for information (i.e. a native Chinese researcher participated in
the review in order to evaluate possible clinical trials published in that
language, although there were none).
Its results showed that there was
scientific evidence on the effectiveness of acupuncture for the treatment
of low back pain, but it was inconclusive and could not serve as a basis
for recommending it. This was consistent with the results of systematic
reviews3 done in the past, and with a randomized trial which compared its
effectiveness with that of massage and self-care education4.
Although scientific evidence in this respect has not changed much in the
last nine years, public and physician opinion does appear to have changed,
due to other reasons. The desire to comply with public opinion can lead to
the adoption of decisions that do not have sufficient scientific support.
However, the establishment of a double standard for the approval or
rejection of a treatment technique, bowing to the pressure of public
opinion and not taking into account evidence based recommendations, would
be harmful to the public's health and to the economy of the National
Additionally, in the long term it could also be harmful to
the types of treatment approved with the lower standard, and even to the
credibility of the institutions that recommend its use.
Clinical practice is not always based on scientific evidence and the
search for an efficient use of available resources. The interest of
general practitioners in receiving training in acupuncture could be due to
the publication of scientific studies that demonstrate its effectiveness.
However, since this is not so, at least in the area of back pain, it may
be due to other reasons.
Until just a few decades ago, patients were
convinced of the effectiveness of leeches for the treatment of infectious
diseases, physicians prescribed them, and apothecaries sold them.
Nevertheless, in spite of public demand and medical interest, evidence of
the efficacy, safety and cost-effectiveness of the treatment was also
lacking. This lesson from the past should be kept in mind.
Francisco M. Kovacs, MD, PhD
María Teresa Gil del Real, MPH, PhD
Scientific Department, Kovacs Foundation, Palma de Mallorca, Spain
Members of the Management Committee of the COST B4 Program on
1. Silvert M. News. Acupuncture wins BMA approval. BMJ 2000 (1 July);
2. van Tulder MW, Cherkin DC, Berman B, et al. The effectiveness of
acupuncture in the management of acute and chronic low back pain. A
systematic review within the framework of the Cochrane Collaboration Back
Review Group. Spine 1999; 24(11): 1113-23.
3. Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: A
criteria-based meta-analysis. J Clin Epidemiol 1990;43: 1191-9.
4. Cherkin DC, Eisenberg D, Kaptchuk T, et al. A randomized trial
comparing acupuncture, therapeutic massage and self-care education for
chronic low back pain. Presented at the Fourth International Forum for
Primary Care Research on Low Back Pain. Eilat. Israel. 2000. As yet
Competing interests: No competing interests
Concerns about the BMA Acupuncture Report
Letter to the Editor,
As one of presenters at the 1997 NIH consensus development conference
on acupuncture (Acupuncture 1998)
I read with great interest the recent BMA report on acupuncture (BMA
2000). There are significant
differences between the two reports that raise a number of questions. In
particular I am concerned that a series
of systematic reviews and meta-analyses appear to have been uncritically
accepted and at times misstated in
the BMA report. If there are questions about these publications, it
unfortunately raises questions about the
validity of some of the conclusions in the BMA publication.
In their systematic review of the treatment of stroke Ernst and White
stated that they reviewed all controlled
clinical trials but found none that included a model attempting a placebo
control (Ernst, White 1996). Yet a
placebo controlled study by Naeser was not included in their review
(Naeser et al. 1992), despite being
referenced by other studies that they analysed. Obviously the search
strategy for their review was inadequate.
The inclusion of this study would likely change the conclusions of their
review and the conclusions of the
BMA report, as it showed a positive effect for acupuncture compared to
In their systematic review of acupuncture for back pain (Ernst, White
1998), Ernst and White included a
study that was not about acupuncture (Garvey et al. 1989). The study was
instead an investigation of the
efficacy of trigger point treatment, testing a single injection of
lidocaine or lidocaine and steroid into trigger
points for acute back pain. The control treatment was a single session of
"dry needling" or "vapocoolant
spray with massage". The results favored the vapocoolant spray with
massage and the dry needling and were
"unexpected", since these were the intended (placebo) controls. Other
reviews of pain studies did not include
this study, presumably because it was not considered a study of
acupuncture (e.g. Ezzo, Berman et al. 2000).
This systematic review of back pain by Ernst and White also included a
study by Yue (Yue 1978) that was
excluded from their neck pain systematic review (White, Ernst 1999).
Either this study meets the inclusion
criteria for a systematic review or it does not. Further, the authors
included some studies that tested laser
stimulation rather than acupuncture thereby raising additional questions
about those systematic reviews (Ernst
White 1998, White, Ernst 1999), since there are questions about whether
laser therapy can be reasonably
considered the practice of acupuncture (ter Riet et al. 1990a).
There are many shortcomings in acupuncture trials, not the least of
which is the routine administration of
inadequate acupuncture therapy (Stux, Birch 2000). In their review of
neck pain studies White and Ernst
rejected the adequacy of treatment in a study by Emery and Lythgoe for
ankylosing spondylitis (Emery,
Lythgoe 1986) because "most acupuncturists would consider this an
inadequate treatment" (White, Ernst
1999), yet they scored another study with single treatment sessions such
as the Garvey et al study (Garvey et
al. 1989) as "moderately adequate"! No practicing acupuncturist would
consider needling a single point one
time as an adequate treatment of back pain by acupuncture. Even a standard
text on the use of trigger point
acupuncture states that more than one session needling more than one point
at each is usually necessary
(Baldry 1989). Normally acupuncture involves a course of treatments, and
the needling of considerably more
than one point (Ezzo, Berman et al. 2000, Ezzo, Lao et al. 2000, Stux,
Birch 2000). The fact that the reviews
by Ernst and White do not capture this major methodological shortcoming,
highlights problems with their
reviews that possibly undermine the validity of their conclusions. Their
methodology for assessing adequacy
of treatment seems very confused. Their findings are often not in accord
with the conservative "minimum
adequate treatment" ascertained after extensive literature reviews (Birch
1997, Stux, Birch 2000), and found to
be important in assessing acupuncture studies (Ezzo, Berman et al. 2000,
Ezzo, Lao et al. 2000). Since
significant results or trends towards efficacy were often found despite
inadequate treatment being administered
in the majority of studies, one could logically argue for the possibility
that greater efficacy of acupuncture
would have been found had adequate treatments been administered in
The statement in the BMA report that "systematic reviews of
acupuncture for asthma....have shown no
evidence of an effect" (BMA 2000) appears not to be entirely accurate. In
their systematic review Linde et al.
highlighted the difficulties of analysing the data and concluded "there is
not enough evidence to make
recommendations about the value of acupuncture in asthma treatment" (Linde
et al . 2000), which is not too
dissimilar to earlier conclusions "there is insufficient data to draw
reliable conclusions about the effectiveness
of acupuncture treatment for asthma" (Linde et al. 1996). This is a far
cry from saying that there was "no
evidence of an effect" (BMA 2000). There is clearly evidence but it is
difficult to fully interpret. The BMA
report seems to have misstated the conclusions of the authors who
conducted the systematic review of
acupuncture for asthma.
It is not at all clear why discussion of the efficacy of acupuncture
for addictive substances such as alcohol,
heroin and cocaine was not included in the report. Currently the use of
acupuncture for addictions is one of
the fastest growing areas in the use of acupuncture (Culliton, Kiresuk
1996). While it is true that the results
are often mixed in clinical trials, and major methodological problems can
be found (Brewington et al. 1994,
Culliton, Kiresuk 1996, McLellan et al. 1993, ter Riet et al 1990b), but
which themselves are not unusual
compared to other areas of acupuncture research, acupuncture is considered
a useful tool in the treatment of
these addictions. Recent evidence from Yale Medical School shows clear
efficacy of acupuncture for cocaine
dependence [Avants et al. 2000]. This deserves attention and is notably
absent in the BMA report.
Finally, the US NIH consensus development conference on acupuncture
involved a panel of experts from
diverse backgrounds reading the literature and receiving public
presentations summarizing the literature.
Before they formulated their conclusions about acupuncture, they
critically assessed all reports and
presentations. The panel members were known and there was a public
discussion of the process and
conclusions. It would be very interesting to know what the process was by
which the BMA report was
written and who its authors were. It would seem that a possible bias has
entered through some of these
In conclusion, it is hoped that the above comments can contribute to
a more objective discussion of
acupuncture treatment. While much of the BMA report is very good, showing
an even handed approach in its
analysis, it is not without its problems. Those identified above probably
require separate analyses by other
parties. If in light of these new analyses, different conclusions are
reached, a method of disseminating these
new conclusions will need to be found.
Stephen Birch PhD, LicAc (USA).
Stichting for the Study of Traditional East Asian Medicine, Amsterdam.
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Competing interests: No competing interests