|Year : 2021 | Volume
| Issue : 4 | Page : 154-162
Surgical and endoscopic treatment of pulmonary tuberculosis: A report from russia
Sergei V Jargin
Department of Pathology, Peoples' Friendship University of Russia, Moscow, Russia
|Date of Submission||22-May-2021|
|Date of Decision||27-Jun-2021|
|Date of Acceptance||14-Oct-2021|
|Date of Web Publication||11-Jan-2022|
Sergei V Jargin
Department of Pathology, Peoples' Friendship University of Russia, Moscow
Source of Support: None, Conflict of Interest: None
Introduction: This article is a narrative review of Russian-language publications on surgical and endoscopic methods applied for tuberculosis in comparison with the international literature. Methods: Search of the international literature was performed predominantly using PubMed. Russian-language professional publications were searched for in the internet and the electronic library of eLIBRARY.ru. Results: After the introduction of efficient drug therapy in the 1950–1960s, surgical treatment of tuberculosis has been partly abandoned in many parts of the world. The role of surgery remains controversial. Priority of the former Soviet Union in this field was pointed out. Besides, the use of bronchoscopy in tuberculosis is briefly overviewed as well as the treatment of patients with alcoholism. Clinical recommendations are not the goal of this paper. The message is that patients should not undergo surgery and other invasive procedures without evidence-based indications. The patients must be objectively informed about potential benefits and risks to be able to make an independent decision according to the principle of informed consent. Conclusion: The factors contributing to the persistence of suboptimal practices included the authoritative management style, disregard for the rules of scientific polemics and insufficient use of foreign literature. Thanks to the Internet, the foreign literature is used increasingly today. However, some papers containing questionable recommendations have remained without due commentaries, so that persistence of suboptimal practices or reversion to them is not excluded.
Keywords: Bronchoscopy, lung resection, surgery, tuberculosis
|How to cite this article:|
Jargin SV. Surgical and endoscopic treatment of pulmonary tuberculosis: A report from russia. Hamdan Med J 2021;14:154-62
| Introduction|| |
After the introduction of efficient drug therapy in the 1950–1960s, the surgical treatment of tuberculosis (Tb) has been partly abandoned in many parts of the world. The role of surgery remains controversial., The priority of the former Soviet Union (SU) in this field was pointed out., The rapid development of Tb surgery took place in 1947–1960 and thereafter. The Tb surgery has been applied not only in large centres but also in numerous peripheral hospitals., This development has been associated with the names of Lev Bogush (1905–1994) and Mikhail Perelman (1924–2013).,,,, According to Bogush, 'surgery must occupy the leading position in the integral Tb treatment instead of being a last resort for cases of ineffective drug therapy'. He claimed that even severe respiratory insufficiency is not a contraindication for lung resection. Perelman became director of the Institute for Phthisiopulmonology at the I. M. Sechenov Moscow Medical Academy in 1998 and in the following year's editor-in-chief of the 'Tuberkulez i Bolezni Legkikh' (tuberculosis and lung diseases), the leading Russian specialist journal. It was time when the World Health Organization (WHO) promoted the directly observed treatment, short-course (DOTS) programme in Russia. Perelman called this WHO programme absurd, insisting that surgery must be applied in the Tb treatment more often. In this connection, the aim of this review is to point out that patients should not undergo surgery and other invasive procedures to comply with doctrines without bonafide clinical indications.
| Methods|| |
This article is a narrative review of Russian-language publications on surgical and endoscopic methods applied for tuberculosis in the former SU in comparison with the international literature. The search of international literature was performed using PubMed. Russian-language professional publications were searched in the Internet, in libraries and the electronic database eLIBRARY.RU. The data from the literature have been reviewed and synthesized on the basis of the author's observations since 1980.
| Surgical Treatment|| |
From 1973 through 1987, 285,000 patients with pulmonary Tb were operated on in the former SU, in 1987 – 26,000, whereas 85% of the operations were lung resections. In the period 1986–1988, 17,000–18,000 operations for pulmonary Tb were performed in the Russian Soviet Republic (part of the former SU) yearly only in specialised phthisiological hospitals. The incidence of Tb in 1986 and 1988 was, respectively, 43.8 and 40.8 per 100,000 inhabitants. Taking into account the population of Russia, ≥29 surgeries for every 100 newly diagnosed Tb cases were performed in those years. In 2003, 10,479 surgeries (9 per 100 new cases) were performed, which was considered 'extremely insufficient'. This calculation is approximate, since the data from various sources slightly differ. In any case, the decrease in surgical activity was significant [Figure 1] taking into account the reported increase in Tb incidence from 34.0 in 1991 up to 90.4 per 100,000 in 2000. By analogy with other diseases, an artefact can be behind the 'huge variation in Russian mortality' and incidence of certain conditions, e.g., understatement of Tb morbidity during the Soviet time. In 2006, 12,286 operations were carried out for pulmonary Tb including 9300 (75.7%) lobectomies and other resections as well as 399 (3.2%) pneumonectomies.
|Figure 1: The ratio number of surgeries/newly diagnosed tuberculosis cases in Russia,,, compared to other countries,,|
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According to another report, the forms of Tb most frequently treated by resections and pneumonectomies were cavitary Tb (52.2%) and tuberculoma (43.9%). The above-named surgeries were performed and recommended also for patients with inactive post-tuberculous fibrosis including cases with sparse symptoms. At the same time, surgeries were performed in active disseminated Tb. In some provinces (Kemerovo, Chelyabinsk and Mordovia), 25%–40% of patients with destructive Tb were operated on. At the time of initial Tb diagnosis, an operation was deemed indicated in 15%–20% of patients; according to another paper by the same authors, indications for surgery were found in 20%–30% of patients at the time of initial diagnosis and/or amongst cases of active Tb. In Yekaterinburg and the surrounding province (2006–2008), indications for surgery were found in 1784 from 4402 (40.5%) patients with pulmonary Tb, whereas 1079 (24.5%) were operated on. The comparatively low surgery rate was explained by the patients' non-compliance and unavailability. According to the last (2020) edition of the Phthisiology textbook, 6.1%–6.7% of Tb patients are currently operated on in Russia; however, 'in some regions that have actively cooperated with the M. I. Perelman Institute for Phthisiopulmonology…, the percentage has been several times higher'. In the international literature, corresponding figures are generally ≤5%.,, Tb surgery may become more topical due to the multidrug resistance. According to a current estimate from Russia, the need for surgery has increased up to 15% over the last 20 years. However, the recent systematic review and meta-analysis concluded that, compared with the chemotherapy alone, the survival benefit of pulmonary resection combined with chemotherapy is not significant, although the quality of data was deemed 'relatively poor'. According to another meta-analysis, partial lung resection, but not pneumonectomy, was associated with the treatment success in multidrug-resistant Tb. It was not excluded, however, that 'healthier' patients were preferentially chosen for surgery, causing a bias. The confounding by indication, as patients most likely to benefit are selected for the treatment, has been a limitation in many studies., Despite the lack of clinical trial data on efficacy of adjunctive surgical therapy, countries of the former SU have continued to perform many surgical interventions, mainly resections.,
Tuberculoma (>2 cm, also in children) has been generally regarded as an indication for surgery., The same experts designated fibrocavitary Tb as an absolute indication for surgery. Tuberculomas >1 cm were routinely operated on,,, which is generally at variance with the international practice.,, Indications per se are beyond the scope of this review. There has been an opinion since the 1950s that potential instability of tuberculoma does not justify thoracic surgery and that asymptomatic patients with an unchanging solid focus do not require treatment. Tuberculoma as an indication for pulmonary resection was seen differently from other forms of Tb where surgical risks could be justified by a poorer prognosis. Nevertheless, tuberculoma was the most frequent indication for lung surgery in Tb patients at the I. M. Sechenov Medical Academy (44.2%), while at other institutions, this percentage has been up to 50%–80%. In particular, tuberculoma was the most frequent indication for surgery in adolescent Tb patients. Children were routinely operated for tuberculomas, non-specific inflammatory, fibrotic lesions and bronchiectasis; more references are in the preceding review. The surgical treatment of tuberculoma was officially recommended also for cases with extensive lesions in remaining pulmonary tissue. Bilateral resections were performed for various forms of Tb including solitary tuberculomas on both sides.,, A study from the above-mentioned Institute for Phthisiopulmonology reported 771 lung surgeries, performed in 700 Tb patients with drug resistance, up to 4 operations pro patient. Post-operative complications were observed in 100 cases (12.9%) and fatal outcomes in 12 (1.5%). Another example from the same institution: Amongst 60 operated Tb patients (16 pneumonectomies, 24 lobectomies and smaller resections), the complication rate was 37%, mortality – 5%; 18.3% were discharged from the hospital with persisting complications.
Resections were performed for tuberculoma, infiltrative and cavitary Tb without preceding medical treatment or within 1 month after the diagnosis, i.e. when medical therapy could have been efficient., One of the arguments in favour of the early surgery was the non-compliance increasing with time, apparently, as the patients collected more knowledge about their disease and advice from other patients. In diabetes mellitus, a surgery was recommended for tuberculoma after 2–5 months of medical therapy. The authors operated also on asymptomatic patients and recorded an overall 15.73% rate of complications. Apparently, complication rates have been sometimes underestimated, e.g., due to a limited follow-up. Lung surgeries for Tb were performed and recommended also for aged patients with comorbidities.,,, Sokolov found indications for surgery in 210 from 289 (72.6%) 50–73-year-old Tb patients and operated 180 (62.2%) of them, 144 operations being lung resections. Amongst the latter 144 patients, 93 (66.4%) had cavitary disease and 43 (30.8%) – tuberculoma. Reactivation of Tb early after the surgery was noted in 8.6%, fistula – 27.2%, atelectasis or incomplete lung re-expansion – 20%, pneumonia – 5.7%, pleural empyema – 3.6% and other complications – 12.9% of cases; 8 (5.7%) patients died after the surgery. In his monograph based on 233 lung resections in Tb patients older than 50 years (mortality 5.4%), the author reasonably concluded that 'it is important that a surgery would not accelerate an unfavorable outcome'. According to another report, tuberculoma was the most common indication, and lobectomy – the most frequent technique in elderly Tb patients, whereas epidemiological considerations, i.e., potential contagiosity, were amongst arguments in favour of the surgical treatment. Statements of this kind can be found also in recent papers, e.g., 'Surgery in patients with tuberculomas is recommended to reduce their infectiousness'. Note that tuberculoma is infrequently contagious. In the author's opinion, potential contagiosity does not justify a thoracic surgery. In any case, patients must be comprehensively informed about potential benefits and risks to be able to make an independent decision according to the principle of informed consent.
Bilateral resections were performed in various Tb forms including solitary tuberculomas on both sides,,,, or tuberculoma and cancer. Indications for a second lung surgery were found in 20%–37% of previously operated cases. The following report is of interest. Out of 1311 Tb patients operated in one institution in the period 1989–2001, 241 developed relapses. After excluding 8 patients with contraindications, indications for second surgery were found in 84 out of 241 (35%) previously operated patients. Post-operative relapses of Tb were regarded as indications for repeated surgeries up to a 'concluding pneumonectomy' and resections of the single lung. For example, repeated resections on both sides with a subsequent pneumonectomy were performed in one patient along with 52 bronchoscopies (Bs). As mentioned above, the lung resection or pneumonectomy was deemed applicable even in cases with severe respiratory insufficiency.,,, Bilateral resections or pneumonectomy plus contralateral 'economic' (sparing) resection was regarded indicated for patients with a Tb lesion on one side and non-specific inflammatory and/or fibrotic lesion on the other side.
It should be noted in conclusion of this section that pulmonary resections and pneumonectomies for Tb were performed also in the former GDR. Indications for surgery were more limited than discussed above; they were ascertained after chemotherapy and stabilisation of the disease. Active contralateral foci were considered to be contraindications. Mainly small case series were reported.,, Of note, amongst 502 surgical cases (81 pneumonectomies, 266 lobectomies and 155 segmental resections), there were only 3 tuberculomas. In 1965, results of a study were published reporting a decline in the vital capacity of the lungs after such operations. A tendency of a decrease in the frequency of resections for Tb was noticed.,, Today, surgical procedures for pulmonary tuberculosis are highly selective.
| The Comorbidity of Tuberculosis and Alcoholism|| |
According to official instructions, indications for surgery were more frequent in alcoholics than in other Tb patients. In the case of alcoholism, the surgical treatment was recommended to be implemented earlier, i.e., after a shorter period of medical therapy. Amongst other things, vocal cord injuries were observed after repeated Bs sometimes performed in conditions of suboptimal procedural quality assurance. It was noticed that vigorous apomorphine-induced vomiting as emetic or aversive therapy of alcohol dependence provoked haemoptysis. The following treatments were applied to alcoholics: prolonged intravenous infusions, sorbent haemoperfusion, pyrotherapy with sulfozine (oil solution of sulphur for intramuscular injections), endoscopic and surgical biopsies of internal organs, sometimes without clear indications also for research.,,,,, Infusions for the purpose of detoxification were generally recommended for patients with alcoholism including moderately severe withdrawal syndrome.,,, The recommended duration of detoxification was 10–12 days. The latter included intravenous drip infusions of solutions: sodium and calcium chloride, magnesium sulphate, glucose, dextran, etc., (7–10 infusions daily). This is at variance with the international literature. Alcohol and its metabolites are eliminated spontaneously while rehydration can be usually achieved per os. Intravenous glucose and magnesium are generally not recommended for patients with alcohol withdrawal syndrome., Excessive infusions of magnesium-containing solutions are associated with adverse effects also in alcoholics. Furthermore, the detoxification of alcoholics included intramuscular injections of 25% magnesium sulphate solution together with 40% glucose, 10% calcium chloride and 30% sodium thiosulphate solutions and subcutaneous infusions of up to 1 L of isotonic saline.,, Some patients considered such treatments as punishments. In conditions of suboptimal procedural quality assurance, repeated infusions and endovascular and endoscopic manipulations can lead to the transmission of viral hepatitis, which was known to occur in some treated alcoholic patients.
| Compulsory Hospitalisation and Treatment|| |
The compulsory treatment was endorsed by regulations; more details and references are in the review. Reportedly, in 1994, about 60% of patients of one of the 'phthisio-narcological' institutions for compulsory treatment escaped while a half of them were brought back by the police (militia). The duration of compulsory treatment in such institutions was around 1 year or longer. In 1974, chronic alcoholism was officially declared to be a ground for compulsory treatment; the regulation was made stricter in 1985, making the forced hospitalisation and treatment of chronic alcoholics independent of antisocial behaviour. This practice has been designated in 1990 as contradictory to human rights. The system of compulsory treatment for Tb was partly dismantled during the 1990s, but some experts recommended its restoration and further development.,
The outpatient treatment of Tb, usual in other countries, was supposed to be hardly applicable in Russia. According to the Governmental Ordinance No. 378 of 16 June 2006, patients with contagious Tb are not allowed to live in one apartment with other people. As said by the Federal Law No. 77 'Prevention of the spread of Tb in Russia' of 18 June 2001 (amended 2013), 'patients with contagious forms of Tb, repeatedly violating the sanitary and anti-epidemic regimen, as well as those deliberately evading examinations for Tb or (emphasis added) the treatment of Tb, are hospitalized into phthisiological institutions for obligatory examination and treatment by court decisions'. It is stipulated by the same Law that the principle of informed consent is not applicable in this connection. A survey conducted across Russian phthisiological institutions found >6000 legal proceedings in the period 2004–2008 whereas 3163 Tb patients were hospitalised after court decisions. For example, in the study from the Kemerovo province, 463 court cases resulted in 421 decisions to compulsorily hospitalise Tb patients. There are administrative and legal mechanisms, e.g., hospitalisation of Tb patients with the help of police and criminal prosecution in the case of non-compliance. Amongst others, the latter pertains to non-contagious Tb in patients released from jail. Compulsory treatments are generally at variance with the international literature and regulations. According to the WMA International Code of Medical Ethics, 'A physician shall respect a competent patient's right to accept or refuse treatment'. It was noted in regard to Tb that neither the statutory exceptions to the principle of consent nor the conditions of 'required care' allow legally binding measures against patients refusing a treatment or isolation. The informed consent for invasive procedures and chemotherapy is of particular importance in conditions where an overtreatment is not excluded.,, The author agrees to the viewpoint that informed consent is grounded in the principle of bodily integrity, thus being not obligatory for non-invasive procedures such as sputum samples collected through expectoration; more discussion is in the reference. Excessively rigorous interpretations of the informed consent are potentially harmful as they put non-invasive tests into one ethical category with invasive manipulations potentially resulting in less responsible attitude to both.
| Bronchoscopy|| |
Bs has been applied in all forms of Tb in adults and children also when Tb was suspected.,,,,,,, It was recommended for young patients with 'hyperergic' (high degree of hypersensitivity) tuberculin tests or within the diagnostic algorithm for suspected Tb in smear-negative cases. After a detection of mycobacteria, an urgent hospitalisation and examination including Bs has been recommended. Primary Tb was regarded as an indication for Bs in children. In the recent (2021) Russian-language handbook of paediatric pulmonology, 'suspected Tb' is listed amongst indications for Bs. Bs was designated as one of the main diagnostic methods in focal non-destructive Tb. In destructive (cavitary) Tb, repeated therapeutic Bs (1–2 weekly during 2–4 months) were recommended by the Ministry of Health. Some researchers used Bs as a second step of the screening for Tb in children. Therapeutic Bs and bronchoscopic monitoring has been applied in pulmonary Tb also with non-specific bronchial lesions.,, An example: 22,469 Bs were performed in 5195 patients from 1994 through 2013 (1123 Bs yearly on average), including 1766 (34%) patients older than 65 years, at a phthisiological hospital in Moscow (705–1225 beds at different times; 368 surgeries performed in 2013)., In particular, some military doctors performed many Bs, e.g., 1478 procedures in 977 young people (19.5 ± 0.1 years old), as well as in other patients diagnosed with community-acquired pneumonia.,,
Bs with questionable indications has been reviewed previously., Indications for Bs are beyond the scope of this review. Undoubtedly, fibre-optic Bs is a useful method in the diagnosis of pulmonary Tb. Outside the former SU, Bs has not been routinely performed in all Tb patients. There is an opinion that in children, Bs is usually unnecessary, although the procedure may be useful in diagnosing endobronchial TB., Bs does not usually improve the sensitivity of microbiological diagnostics compared to gastric aspirates and induced sputum testing,,,,,, although there is another opinion. As endobronchial Tb can mimic cancer, Bs and biopsy plays an important role in the differential diagnosis. In this connection, Bs is complementary to computed tomography (CT), which can assess the bronchial wall involvement and lumen patency. In particular, the multiple detector CT with the imaging technique such as 'virtual Bs' is a diagnostic method for central airway lesions. Reportedly, CT determined the cause of bleeding more often than Bs, whereas both methods were comparably sensitive in identifying the bleeding site. Some experts suggested that CT can replace Bs in certain cases, e.g., as the first-line diagnostic procedure for massive haemoptysis. Replacing Bs with induced sputum testing for mycobacteria removes Bs-related risks including that of nosocomial infection. Of note, endoscopy is amongst the risk factors of infections such as viral hepatitis. Not surprisingly, the incidence of hepatitis B was reported to be five times higher in Tb patients than in the population of Russia. The enhanced frequency of viral hepatitis or its markers in Tb patients including children was reported. Outbreaks of infections occurred after endoscopy.,, Reportedly, mycobacteria were the greatest obstacle to the infection control in Bs units. It has been suggested that Bs may spread infection within the lung, from one patient to another, and – by inducing coughing – cause airborne infections of other people.
| Surfactant Therapy|| |
The surfactant (Sf) therapy of pulmonary diseases (Tb, acute respiratory distress syndrome, pneumonia, etc.), excluding neonatal respiratory distress syndrome (RDS), and Bs as the delivery method, have been discussed previously.,,, Sf-BL from bovine lungs has been developed and registered in Russia. The manufacturing method is described in the patent (partly translated,), where it is stated that Sf-BL contains ~2% of protein. Endobronchial instillations of xenogeneic proteins may cause immune reactions. In older patients, a more pronounced immune response can be expected than in premature infants with RDS. Endobronchial instillations of porcine Sf led to an increase in the eosinophilic inflammation in patients with bronchial asthma. St-BL was used in asthma, bronchitis, pneumonia, chronic obstructive pulmonary diseases and Tb (references are in the review and patent,), as well as in COVID-19, where immune and inflammatory reactions might contribute to the 'cytokine storm' and collagen synthesis. Bs was used as the delivery method of Sf preparations,,,,,,,,,, with bronchial biopsies, while some other studies used inhalations. Both inhalations and Bs have been used in Tb., Sf-BL was recommended by an official letter of the Ministry of Health for the treatment of viral pneumonia. This letter refers to the manufacturer's instruction, where it is stated that the optimal method of the Sf delivery is Bs with an instillation into individual segmental bronchi. No comparable recommendations have been found in the literature. Until recently, Oleg Rosenberg had been director of the manufacturing firm Biosurf (https://biosurf.ru/). No conflicts of interest have been declared in his publications. Misquoting was found in the Rosenberg's papers on Sf., Here follow several examples from the last Russian-language review: 'A number of studies have shown an improvement in oxygenation, a decrease in the time spent on mechanical ventilation and an increase in survival'. In the cited publications, the conclusions are different, e.g., 'This pilot study presents preliminary evidence that Sf might have therapeutic benefit for patients with ARDS'. Furthermore: '… Sf-BL reduces mortality in adults with ARDS 3–4-fold'. There are no such statements in the cited source. 'Deficiency of pulmonary Sf or changes in its composition have been described not only in neonatal RDS, but also in … pulmonary Tb and other diseases'. A Russian-language handbook is cited, where tuberculosis is not mentioned on the indicated pages 167–181. Finally, '… these data can serve as the basis for multicenter randomized clinical studies of the efficacy of CHF5633 for the treatment of ARDS'. In the cited publication, ARDS is not mentioned. We checked some references from other articles by the same author: 'Results of the phase II multicenter randomized clinical trials and pilot studies of the efficacy of natural Sf preparations in the treatment of ARDS showed a significant improvement in oxygenation, decreased mechanical ventilation time and decreased mortality'. One of the cited studies reported that the treatment of asthmatic patients with a porcine Sf preparation resulted in an augmentation of the eosinophilic inflammation after allergen challenge. The authors concluded that the treatment is not suitable to decrease the allergic response in asthmatic patients, which might also pertain to other animal-derived Sf preparations. In another cited publication, the effectiveness of St-therapy in asthmatic children was not confirmed. References about Tb in the article are self-citations., From another article by the same author: 'It is believed that disturbances in the pulmonary Sf system can be the cause of bronchial obstruction, mucosal edema and increased fluid secretion into the bronchial lumen'. The cited publication was not found; an article with a similar title does not contain such statements but the following: 'Although there is no direct proof that surfactant dysfunction in human asthma causes airway obstruction, the above-mentioned and published data from the literature support the concept that poor functioning surfactant contributes to the pathophysiological scenario in asthma'. There are also other incorrect citations. Some studies from Russia have reported that inhalations of Sf improve the effectiveness of the anti-Tb therapy, significantly accelerating healing, dissolution of specific Tb infiltrations and closing of caverns, while Mycobacterium tuberculosis disappeared from sputum at an early date.,,, No similar reports have been found in the international literature. Finally, intravenous injections of stem cells to Tb patients, should be mentioned together with a warning against the use of Bs without proven clinical indications.
| Conclusion|| |
The role of surgery in Tb remains controversial. Clinical recommendations are not the goal of this review. The central message is that patients should not undergo surgeries, bronchoscopies and other invasive procedures merely to comply with instructions and doctrines without sufficient evidence-based indications, potentially fed by motives such as personnel training, e.g., of military surgeons and endoscopists. The approach should be individual based on a consensus expressed in the international literature. The principle of informed consent must be observed – patients objectively informed on potential benefits and risks to be able to make an independent decision. The informed consent began only recently to be mentioned in papers from the former SU reporting research using invasive methods, e.g., bronchoscopic study of childhood asthma, where the consent of parents was regarded to be sufficient. Note that the principle of informed consent or assent is applicable also to adolescents and children., Even today, patients are sometimes requested to sign in advance a form certifying their blanket consent to unnamed diagnostic and therapeutic procedures. The factors contributing to the persistence of suboptimal practices included the authoritative management style, disregard for the rules of scientific polemics, insufficient use and occasional misquoting of the foreign literature and absence of many internationally used handbooks even in central medical libraries. Thanks to the Internet resources, the foreign literature is used increasingly. However, some papers containing questionable recommendations have remained without due commentaries, so that a persistence of suboptimal practices or reversion to them is not excluded. Other invasive procedures applied with questionable indications have been overviewed previously.,,,
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Conflicts of interest
There are no conflicts of interest.
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