Surgical Masks ~ CDC, OSHA, New England Journal of Medicine, Surgeon General etc.

People conceive face masks in terms of physical tools to mitigate risk, yet masks are nothing more than symbolic gestures producing a false sense of security. Psychologically, masks provide protection to a person’s perception of future-oriented risk reinforcing fears, increasing anxiety, and instilling potential loss of something valuable in anticipation of a threatening future, just perceived in the present.

The human smile has profound significance for human relations, and there is a significant distinction between wearing a mask and wearing a facial covering. Historically, masks have been associated with playing a role, like in the theatre. In fact, the Latin word persona comes from the Greek word prosepon, which means mask. Wearing a mask is like portraying someone else. Using the term “facial covering,” instead of “mask” it becomes clear the effect is to blot out the human face and the inability to connect through a smile.

Masks are being used to stoke fear and cultivate compliance. However, on a basic and fundamental level, facial coverings are stripping us of our humanity and blotting out the face of God from our sight.

The elites have been caught showing what they really believe. Facial coverings are required for the unquestioning masses, but not for the governing elite.

In the 1919 influenza pandemic, masks were available and dispensed to populations, but they had no impact on the epidemic curve. At the time, it was unknown the influenza organism is nanoscopic and can penetrate the surgical mask barrier. As recently as 2010, the US National Academy of Sciences declared, “in the community setting, face masks are not designed or certified to protect the wearer from exposure to respiratory hazards.”

Dr. Eli Perencevich, a professor of medicine and epidemiology at the University of Iowa’s College of Medicine “The average healthy person does not need to have a mask, and they shouldn’t be wearing masks, masks won’t help people avoid the virus and they may actually increase the risk of getting it. People wear them incorrectly increasing the risk of infection because they’re touching their face more often.”

Homemade masks were created as a fashionable way to keep the wearer from breathing in large particles, like car exhaust, air pollution, and pollen during allergy season. They were not conceived of as a way to protect you from acquiring COVID-19.

I’ve been saying for months, every time I put on one of these masks I get severe headaches lasting hours upon hours as a result of hypo-ventilation i.e. not being able to breathe properly to get oxygen into my lungs.

When we take a breath, we pull air into our lungs which primarily contains nitrogen and oxygen. When we exhale, we breathe out carbon dioxide. … Just like oxygen, carbon dioxide is transferred to blood to be carried to the lungs, where it is removed when we exhale. Statics prove; moderate to high levels of carbon dioxide cause headaches and fatigue, higher concentrations produce nausea, dizziness, vomiting, and loss of consciousness often occurs because excess carbon dioxide uses up space in the air instead of oxygen, creating an environment for asphyxiation. A high concentration of carbon dioxide in a confined space is toxic.

I’ve seen people walking/jogging down the street where there is absolutely no one within a quarter-mile in any direction. It’s dangerous to wear a mask when there is absolutely no possibility of infecting someone or being infected by someone. I’ve even seen people wearing masks in their cars; masks habitually slip over eyes, not to mention passing out from inhaling carbon dioxide, either can cause accidents. People, if you’re forced by the government, please use good common sense when wearing one.

AND to those who haphazardly throw the alleged potentially hazardous medical waste (masks, gloves, hand-wipes, etc.) on the ground; litter ends up in storm drains and bodies of water where wildlife mistake these items for food, and lest we forget the people tasked with picking up your precarious discards. Where is your respect for others and the environment? Public shaming and a minimum $1,000 for a first-time offense, double the fine and jail time for additional offenses!!!

Face masks don’t filter out the particle size of the coronavirus. Any viruses aerosolized in a sneeze or cough will get through the mask. Viruses are about 20400 nm (nanometer) in size (0.00080314961”) and considered organic structures which interact with living organisms. Rather than a living organism, bacteria are larger, about 1000 nm in size (3.937e-5”). They are visible under light microscope. Whereas viruses are infectious particles about 100 times smaller than bacteria and can only be observed by electron microscopy.

A virus is a small infectious agent replicating only inside the living cells of other organisms and only active when inside a host because viruses can’t undergo any chemical reactions of their own outside a host cell, they do not need energy because the host cells take over the needed energy to reproduce the viruses.

It is believed the N95 mask ‘may’ effectively prevent viral spread. These masks, when properly fitted, seal closely to the face and filter out 95% of particles 0.3 microns or larger, however, they’re also difficult to fit correctly. For those reasons, the CDC does not recommend them for general use. [4]

“Even a properly fitted N95 respirator does not completely eliminate the risk of illness or death. The respirator is intended to prevent specific diseases or infections. The respirator is labeled or otherwise represented as filtering surgical smoke or plumes, filtering specific amounts of viruses or bacteria, reducing the amount of and/or killing viruses, bacteria, or fungi, or affecting allergenicity and contains coating technologies unrelated to filtration (e.g., to reduce and or kill microorganisms).” As stated above an organism can be seen only through a microscope. Microorganisms include bacteria, protozoans, and fungi and “can only be observed by electron microscopy”.

CDC

also does not recommend surgical masks. Surgical masks are not regulated, anyone can sell anything and call it a surgical mask. [4] “While a surgical mask may be effective in blocking splashes and large-particle droplets, a face mask, by design, does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures. Surgical masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and face.” These masks don’t seal against the face, even though they include non-woven polypropylene moisture resistant layers, approximately 70% of the outside air moves through the mask and about 30% travels around the sides… 30% plus 70% = 100% ineffective.

Fabric masks (handkerchief/bandanna), lacking non-woven moisture-repelling layers are too porous to trap any germs allowing air in and around the sides, . They impede only about 2% of airflow. Wearing basic fabric masks over a warm, wet mouth breeds infection rather than deters it.

By wearing a mask, the exhaled viruses will not be able to escape and will concentrate in the nasal passages, enter the olfactory nerves and travel into the brain. [3]

The World Health Organization (WHO)

[1] discourages mask use: “The wide use of masks by healthy people in the community setting is not supported by current evidence and carries uncertainties and critical risks. There is currently no evidence that wearing a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including COVID-19.”

There’s been enough research done to be able to confidently say masks wouldn’t be able to stop the spread of infection and they only have a small effect on transmission. We shouldn’t be relying on masks to help us go back to normal. All of this leakage in surgical and fabric masks are why public health officials don’t believe wearing a mask prevents anyone from catching a virus already floating around in the environment because airflow follows the path of least resistance.

Surgeon General Dr. Jerome Adams

urges the public to stop buying face masks “”They are NOT effective in preventing general public from catching #Coronavirus, face masks actually increase your risk of infection if they aren’t worn properly.”

Dr. William Schaffner, a preventive medicine professor at the Vanderbilt University School of Medicine,

“the rush to buy masks is a “psychological thing.” Robert Redfield, director of the Centers for Disease Control and Prevention, “There is no role for these masks in the community.”

New England Journal of Medicine

[6]“We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to Covid-19 as face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.”

[6] “It is clear that masks serve symbolic roles. Expanded masking protocols’ greatest contribution may be to reduce the transmission of anxiety, over and above whatever role they may play in reducing transmission of Covid-19.”

OSHA

[7]Cloth:
“Will not protect the wearer against airborne transmissible infectious agents due to loose fit and lack of seal or inadequate filtration.”

Surgical masks:
“Will not protect the wearer against airborne transmissible infectious agents due to loose fit and lack of seal or inadequate filtration.”

Respirators:
“Require proper training, fit testing, availability of appropriate medical evaluations and monitoring, cleaning, and oversight by a knowledgeable staff member.”

*For those trying to find fault in this source, keep in mind the word “intended.” The masks are “intended” to work, but they don’t. They cannot use they “will” because it’s a lie. Wording is very important. Pay attention and you won’t have to attack everything so quickly. It will save you and I a lot of time.

The Spanish Flu pandemic of 1918 was much deadlier than the coronavirus pandemic, 50 million people died. Experts reviewing evidence from 1918 concluded flu masks failed to control infection. In 1919, Wilfred Kellogg’s [2] study for the California State Board of Health concluded that mask ordinances “applied forcibly to entire communities” did not decrease cases and deaths, as confirmed by comparisons of cities with widely divergent policies on masking.”

The Woodstock music festival took place in August 1969. The “Hong Kong flu” (H3N2) influenza pandemic lasted between the winter of 1968 and the early months of 1970 and within the 18 months killed an estimated 100,000 people in the U.S. and 1 million worldwide, yet daily life, more or less, proceeded as if it were business as usual. There were no statewide lockdowns or mandatory mask requirements, and large public events, such as the Woodstock music festival, took place as scheduled.

Masks do have one effect: People tend to stay away from those wearing them because “masks and social distancing are the new herd immunity” … By their reasoning: if I’m not wearing a mask, theirs won’t work. … Great scare tactic to continue keeping people socially segregated.

And BTW, the Coronavirus didn’t create a $1.5 trillion student debt crisis, it didn’t make the minimum wage a starvation wage, and it didn’t leave 40% of Americans unable to afford a minor emergency. Trickle-down economics did.

Oh, and FYI, [5] The CDC NOW SAYS CORONAVIRUS ‘DOES NOT SPREAD EASILY’ ON SURFACES. Its guidelines now include a section on ways the virus doesn’t easily spread, including from touching surfaces or objects. Other ways the virus doesn’t easily spread are from animals to people or people to animals. Stephen Hahn, commissioner of the US Food and Drug Administration said “there was no evidence to suggest the virus can spread through food or what it’s wrapped in, and that there was no need to wipe down groceries.”

THE CENTERS FOR DISEASE CONTROL (CDC) RECOMMEND ALCOHOL AT A CONCENTRATION OF 70% FOR USE AS A DISINFECTANT AND ANTIMICROBIAL

Alcohol at this dilution efficiently penetrates the bacterial cell wall, disrupts the molecular confirmation, then destroys (denatures) the proteins and enzymes inside of the cell.

70% undiluted Isopropyl alcohol/rubbing alcohol will kill coronavirus on surfaces in about 30 seconds. Why 70% and not higher? 70% Isopropyl Alcohol (IPA) a better disinfectant than 91% or 99%. 70% is the most effective concentration of isopropyl alcohol for disinfection. Solutions between 60% and 90% alcohol with 10 – 40% purified water, is rapidly antimicrobial against bacteria, fungi, and viruses. Once alcohol concentrations drop below 50%, usefulness for disinfection drops sharply. Notably, higher concentrations of alcohol don’t generate more desirable bactericidal, viricidal, or fungicidal properties.

The presence of (distilled) water is a crucial factor in destroying or inhibiting the growth of pathogenic microorganisms with isopropyl alcohol. Water acts as a catalyst and plays a key role in denaturing the proteins of vegetative cell membranes. 70% IPA solutions penetrate the cell wall more completely which permeates the entire cell, coagulates all proteins, and therefore the microorganism dies. Extra water content slows evaporation, therefore increasing surface contact time and enhancing effectiveness.

Solutions of 91% IPA may kill some bacteria, but require longer contact times for disinfection, and enable spores to lie in a dormant state without being killed. A 50% isopropyl alcohol solution kills Staphylococcus Aureus in less than 10 seconds, yet a 90% solution with a contact time of over two hours is ineffective. Some disinfectants will kill spores with exposures times exceeding 3-12 hours, these are classified as a chemical sterilant.

STERILIZE vs DISINFECT vs SANITIZE
People use the terms sterilize, sanitize, and disinfect interchangeably, however, there’s a legal difference.

STERILIZATION is the process by which all microorganisms are directly killed or are inactivated.
1. The optimal way to sterilize is with an autoclave which is a strong heated container used for chemical reactions and other processes using high pressures and temperatures, e.g. steam sterilization. You’ll find autoclaves in medical facilities and tattoo salons although you can purchase them for home use for around $175.
2. Boiling, by placing glass jars, bottles, and fitting screw-top lids in a large pot filled with cool water, make sure, the bottles and jars are completely submerged and there is no air trapped inside. Bring water to a rolling boil and continue to boil for a FULL 10 minutes. Turn off the heat and leave the bottles and jars submerged in hot water, until you’re ready to fill them.

DISINFECTANTS are products that destroy all organisms in 10 minutes. Disinfecting requires a strong solution to destroy germs rather than simply reduce organisms. Disinfecting a surface will “kill” the microscopic organisms. When you disinfect, the viruses and fungi present on the surface might not be eliminated. According to the EPA’s guidelines, a disinfectant should reduce the level of pathogenic bacteria by 99.999% during a time frame of greater than 5 minutes but less than 10 minutes.

SANITIZERS are agents which destroy 99.999% of bacteria in 30 seconds. It is a chemical process lessening, even killing germs on surfaces to make them safe for contact. Sanitization is the process by which the numbers of microorganisms are substantially reduced so they are no longer harmful; 99.99% of microbes need to be removed from surfaces. With a sanitizer, you can only reduce the number of microbes to a safe level. Sanitizing is meant to reduce, NOT kill, the occurrence and growth of bacteria, viruses, and fungi.

The disinfecting and sanitizing processes can both reduce the microbes to a 99.99 percent level. However, disinfecting is regarded as the superior cleaning process since it can also kill the spores of the microbes.

1. When you disinfect, you use a chemical completely destroying all microbes. The chemical is called a disinfectant.
2. When you sanitize, you use a chemical sanitizer. With a sanitizer, you can only reduce the number of microbes to a safe level.

BLEACH VS. AMMONIA
Both bleach and ammonia products are effective in sanitizing and disinfecting and are inexpensive to boot. Bleach is typically used to disinfect and sanitize fabrics as well as ceramics and dishes, while ammonia effectively cleans hard surfaces such as glass and tile. Remember to never mix bleach and ammonia. The combination releases toxic fumes.

REVIEW OF THE MEDICAL LITERATURE
Key anchor points to the extensive scientific literature establishing that wearing surgical masks and respirators (e.g., “N95”) does not reduce the risk of contracting a verified illness:
https://www.rcreader.com/commentary/masks-dont-work-covid-a-review-of-science-relevant-to-covide-19-social-policy?fbclid=IwAR2C5uGfUS5yapm7zdWts5O2tN3yZlLPeXxdEuWr-U-3AnizJFT4lvuHrvU

Jacobs, J. L. et al. (2009) “Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: A randomized controlled trial,” American Journal of Infection Control, Volume 37, Issue 5, 417 – 419. https://www.ncbi.nlm.nih.gov/pubmed/19216002 N95-masked health-care workers (HCW) were significantly more likely to experience headaches. Face mask use in HCW was not demonstrated to provide benefit in terms of cold symptoms or getting colds.

Cowling, B. et al. (2010) “Face masks to prevent transmission of influenza virus: A systematic review,” Epidemiology and Infection, 138(4), 449-456. https://www.cambridge.org/core/journals/epidemiology-and- infection/article/face-masks-to-prevent-transmission-of-influenza-virus-a-systematic- review/64D368496EBDE0AFCC6639CCC9D8BC05 None of the studies reviewed showed a benefit from wearing a mask, in either HCW or community members in households (H). See summary Tables 1 and 2 therein.

bin-Reza et al. (2012) “The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence,” Influenza and Other Respiratory Viruses 6(4), 257–267. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1750-2659.2011.00307.x “There were 17 eligible studies. None of the studies established a conclusive relationship between mask/respirator use and protection against influenza infection.”

Smith, J.D. et al. (2016) “Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis,” CMAJ Mar 2016 https://www.cmaj.ca/content/188/8/567 “We identified six clinical studies. In the meta-analysis of the clinical studies, we found no significant difference between N95 respirators and surgical masks in associated risk of (a) laboratory-confirmed respiratory infection, (b) influenza-like illness, or (c) reported work-place absenteeism.”

Offeddu, V. et al. (2017) “Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis,” Clinical Infectious Diseases, Volume 65, Issue 11, 1 December 2017, Pages 1934–1942, https://academic.oup.com/cid/article/65/11/1934/4068747

Radonovich, L.J. et al. (2019) “N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial,” JAMA. 2019; 322(9): 824–833. https://jamanetwork.com/journals/jama/fullarticle/2749214 “Among 2862 randomized participants, 2371 completed the study and accounted for 5180 HCW-seasons. … Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza.”

Long, Y. et al. (2020) “Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis,” J Evid Based Med. 2020; 1- 9. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jebm.12381 “A total of six RCTs involving 9,171 participants were included. There were no statistically significant differences in preventing laboratory-confirmed influenza, laboratory-confirmed respiratory viral infections, laboratory-confirmed respiratory infection, and influenza-like illness using N95 respirators and surgical masks. Meta-analysis indicated a protective effect of N95 respirators against laboratory-confirmed bacterial colonization (RR = 0.58, 95% CI 0.43-0.78). The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza.”

THERE ARE NUMEROUS VALID REASONS TO NOT WEAR A MASK IN ADDITION TO THE STATISTIC ABOVE

ADHD
Agoraphobia
Apnea
Anxiety
Asthma
Chronic Sinus Issues
Claustrophobia
Chronic Inflammatory Response Syndrome (CIRS)
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Regional Pain Syndrome (CRPS)
Deaf and Hard of Hearing
Depression /other mental health
Deviated Septum
Down Syndrome
Dysautonomia
Emphysema
Epilepsy
Hyperemesis Gravidarum (HG)
Hyperhidrosis
Hypoxia
Lung Cancer
Lung Disease and other assorted issues
Multiple Sclerosis
Panic Attack / Panic Disorders
Pleurisy
Post-Partum Anxiety (PPA)
Post-Partum Depression (PPD)
Post-Traumatic Stress Disorder (PTSD)
Pulmonary Embolism
Raynaud’s Syndrome
Reflex Neurovascular Disorder/disease
Sensory Processing Disorder
Vertigo

So, the next time you see someone out and about not wearing a mask, please do not HARASS or BULLY them. You do NOT know their situation or their personal physical or mental health struggles.

After reading all the confirmed data above, and if you want to wear a mask, fine, but please do not become a mask bully and make an already difficult situation even worse for those around you with your nasty looks or your rude remarks.

MANDATE VS LAW

A law is passed by the general assembly and signed by the governor. An order and mandate are interchangeable and are made by the executive branch like a governor or DOH secretary with the power given to them by the legislature. It’s not the governor or secretary acting unilaterally,” said Mallinson. “They’ve already been given the authority by a law that’s been passed by the legislature.

The power to issue a mask mandate comes from the power given to her by the legislature under the Disease Prevention and Control Law of 1955. Section 5 of that law discusses control measures and says, Upon the receipt by a local board or department of health or by the department, as the case may be, of a report of a disease which is subject to isolation, quarantine, or any other control measure, the local board or department of health or the department shall carry out the appropriate control measures in such manner and in such place as is provided by rule or regulation. Disease Prevention and Control Law of 1955
https://www.legis.state.pa.us/WU01/LI/LI/US/PDF/1955/0/0500..PDF

The State Department of Health cites PA Code gives authority to take necessary disease control measures to protect the public from spread of an infectious disease. PA Code § 27.60 The Department or local health authority shall direct isolation of a person or an animal with a communicable disease or infection; surveillance, segregation, quarantine or modified quarantine of contacts of a person or an animal with a communicable disease or infection; and any other disease control measure the Department or the local health authority considers to be appropriate for the surveillance of disease, when the disease control measure is necessary to protect the public from the spread of infectious agents. (b) The Department and local health authority will determine the appropriate disease control measure based upon the disease or infection, the patient’s circumstances, the type of facility available and any other available information relating to the patient and the disease or infection. (c) If a local health authority is not an LMRO, it shall consult with and receive approval from the Department prior to taking any disease control measure.

Businesses are required to force customers to wear masks regardless of the data proving masks are ineffective and hazardous to people’s health, and I’ll continue educating those who so willingly relinquish their rights to government because it’s less restrictive than closing their doors for good. Yes, I’ll wear a mask AS I CONTINUE TO LOUDLY PROTEST THEIR EFFECTIVENESS.

HAND SANITIZER WARNING

The U.S. Food and Drug Administration is warning the public to stop using the following hand sanitizer products as they tested positive to contain 81% (v/v) methanol and NO ethyl alcohol. Those who have been exposed to hand sanitizer containing methanol should call 911 and seek immediate care. Substantial methanol exposure can result in nausea, vomiting, headache, blurred vision, permanent blindness, seizures, coma, permanent damage to the nervous system or death. Children accidently ingesting these products and adolescents and adults who drink these products as an alcohol (ethanol) substitute, are most at risk for methanol poisoning. If you have any of these products, the FDA says to dispose of them immediately in appropriate hazardous waste containers. DO NOT flush or pour them down the drain.

1. All-Clean Hand Sanitizer (NDC: 74589-002-01)
2. Esk Biochem Hand Sanitizer (NDC: 74589-007-01)
3. CleanCare NoGerm Advanced Hand Sanitizer 75% Alcohol (NDC: 74589-008-04)
4. Lavar 70 Gel Hand Sanitizer (NDC: 74589-006-01)
5. The Good Gel Antibacterial Gel Hand Sanitizer (NDC: 74589-010-10)
6. CleanCare NoGerm Advanced Hand Sanitizer 80% Alcohol (NDC: 74589-005-03)
7. CleanCare NoGerm Advanced Hand Sanitizer 75% Alcohol (NDC: 74589-009-01)
8. CleanCare NoGerm Advanced Hand Sanitizer 80% Alcohol (NDC: 74589-003-01)
9. Saniderm Advanced Hand Sanitizer (NDC: 74589-001-01)

press

Kristeen Irigoyen-Hernandez
Human Rights Advocate, Researcher/Chronological Archivist and member in good standing with the Constitution First Amendment Press Association (CFAPA.org)

Kristeen Irigoyen-Hernandez aka Lady2Soothe

CITATIONS:
[1] Advice on the Use of Masks in the Context of Covid-19
file:///C:/Users/HP/Downloads/WHO-2019-nCov-IPC_Masks-2020.3-eng.pdf
[2] Influenza, a study of measures adopted for the control of the epidemic,
by Wilfred H. Kellogg.
https://catalog.hathitrust.org/Record/011933637
[3] Face Masks Pose Serious Risks To The Healthy
https://www.citizensforfreespeech.org/blaylock_face_masks_pose_serious_risks_to_the_healthy?utm_campaign=blaylock_report&utm_medium=email&utm_source=cffs&fbclid=IwAR2hf_H7F2yqfnAUAkCWL8l79Z_ahjDmYFQm0C9OL0EliVYOWSeAn8wJsW0
[4] FDA
https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-and-surgical-masks-face-masks
[5] CDC NOW SAYS CORONAVIRUS ‘DOES NOT SPREAD EASILY’ ON SURFACES
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html
[6] New England Journal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMp2006372?query=recirc_mostViewed_railB_article

[7] OSHA:
https://www.ecf-fl.org/resources/2020%20OSHA%20COVID-19%20Face%20Mask%20PPE%20Update%20as%20of%206-10.pdf?fbclid=IwAR2r1NDBTfZ8vS7RNiSRLEvq_xK9iVngm3U2RBDPpQ-Vh_6K-Ow5AC7V6nM

Covid-19 – Navigating the Uncharted
https://www.nejm.org/doi/pdf/10.1056/NEJMe2002387?articleTools=true

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