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COVID-19 After Effects: Concerns for Singers
*Lynn Helding,
†
Thomas L. Carroll,
‡
John Nix,
§
Michael M. Johns,
¶
Wendy D. LeBorgne, and
║
David Meyer, *xLos
Angeles, yBoston, zSan Antonio, {CIncinnati, and ║Winchester, USA
Key Words: COVID-19−SARS-CoV-2−Coronavirus−Singing−Choral performance−Sequelae.
INTRODUCTION
Many discussions about assessing the risk of COVID-19
center around three possible outcomes: (1) avoiding
infection altogether, (2) contracting COVID-19 illness
and recovering, and (3) contracting COVID-19 illness
and dying. Another outcome must be considered: con-
tracting COVID-19 illness, surviving, and living with its
sequelae, or aftereffects.
Research on the aftereffects of COVID-19 is emerging,
but predictions can be made from similar coronaviruses
such as severe acute respiratory syndrome (SARS)
and Middle East respiratory syndrome (MERS). Look-
ing ahead to what COVID-19 aftereffects may portend
for the general population of survivors is one aspect of
the present paper. Yet COVID-19 sequelae hold special,
and potentially devastating, risks for singers. These risks
should be considered by all persons who sing, whether
they are professional performers, professional singing
teachers, or avocational singers, for whom weekly choir
practices are a source of social connection and commu-
nity cohesion.
This paper offers an in-depth discussion of the following:
1. COVID-19 demographic risks
2. Singers and aerosol transmission of SARS-CoV-2
3. Lasting lung damage/respiratory sequelae
4. Laryngeal and nonrespiratory sequelae
4.1. Intubation-related vocal-fold injuries
4.2. Postviral vocal fold paralysis or paresis
4.3. Postviral laryngeal sensory neuropathy
4.4. Chronic fatigue disorders
5. Risk assessment
5.1. COVID-19 screening app
5.2. Online survival calculator
5.3. Risk assessment tool
5.4. Decision assistance tool
1. COVID-19 demographic risks
According to the Centers for Disease Control, persons 65
and older, or persons with chronic lung disease, moderate to
severe asthma, serious heart conditions, immunocomprom-
ising conditions (cancer treatment, smoking, transplant
recipients, immune deficiencies, HIV/AIDS, and long term
use of steroids), obesity, sickle cell disease, type 2 diabetes,
chronic kidney disease, or liver disease are at higher risk
than the rest of the population.
1,2
The number of people
contracting COVID-19 varies with age. In general, younger
people are more likely to contract COVID-19, as they are
more socially active and represent a larger portion of the
workforce than older persons.
3,4
However, the risk of hav-
ing a more severe case of COVID-19 increases with age, par-
ticularly above age 50.
3,5
This contrast between case
numbers by age and complications by age (as seen through
hospitalization rates) is shown in Figure 1. As of this writ-
ing, CDC statistics on case numbers by age have not been
updated since May 30, 2020.
Certain ethnic groups have higher hospitalization rates
than others. Non-Hispanic American Indian or Alaska
Native persons have a hospitalization rate approximately
5.6 times that of non-Hispanic White persons, while non-
Hispanic Black persons and Hispanic or Latino persons
have a hospitalization rate approximately 4.6 times that
of non-Hispanic White persons.
5
It is thought that these
differences in hospitalization rates (which would signify a
more severe case of the disease) are not due to genetic
differences between the groups, but rather health dispar-
ities, such as access to quality care. Women make up a
slightly larger number of the total cases than men,
according to the CDC’s statistics, but men are more
likely to need hospitalization, are more likely to be
admitted to an ICU, and are more likely to die from
COVID-19 (Table 1).
Persons 40−69 years of age should be on guard, as this
age group still has a high percentage of cases and an
increased risk of hospitalization for COVID-19 than youn-
ger people. Many aspiring or active professional performers
are in the 18−44-year age group which has the highest num-
ber of cases. The 40−69-year age range is also one in which
other health complications (due to lifestyle and genetic fac-
tors) are more prevalent than in younger people. High blood
pressure, diabetes, heart disease, kidney problems, and obe-
sity increase the risk for complications requiring hospitaliza-
tion and possibly intensive care. Persons who are from
higher risk ethnic/racial groups who also have other health
conditions need to be especially cautious, as do those indi-
viduals living in states currently experiencing rapid case
growth.
From the *Vocology and Voice Pedagogy University of Southern California,
Thornton School of Music, Los Angeles, CA, USA; yDepartment of Otolaryngology,
Head and Neck Surgery Harvard Medical School, Boston, MA, USA; zVoice and
Voice Pedagogy University of Texas at San Antonio, San Antonio, TX, USA; xUSC
Voice Center Division Director, Laryngology Professor USC Caruso, Department of
Otolaryngology Head and Neck Surgery, Los Angeles, CA, USA; {The Blaine Block
Institute for Voice Analysis and Rehabilitation, The Professional Voice Center of
Greater Cincinnati University of Cincinnati, CIncinnati, OH, USA; and the ║Janette
Ogg Voice Research Center, Shenandoah Conservatory, Winchester, VA, USA.
Address correspondence and reprint requests to David Meyer, MM, DM, Janette
Ogg Voice Research Center, Shenandoah Conservatory, 1460 University Drive, Win-
chester, VA 22601. E-mail: Dmeyer2@su.edu
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.07.032
ARTICLE IN PRESS
2. Singers and aerosol transmission of SARS-CoV-2
SARS-CoV-2 is the virus that causes COVID-19. It can be
transmitted in one of three ways: (1) direct contact, (2) indi-
rect contact, or (3) airborne particles. Direct contact trans-
mission occurs through person-to-person contact via a
handshake or other touching, with subsequent self-transfer
of the virus to the recipient’s mucus membranes. Indirect
contact occurs when viral particles land on objects in the
environment that are commonly touched (the objects are
referred to as “fomites”once the particles touch them, ie
chairs, clothes, or shared objects) and, once acquired by a
susceptible host, are self-transferred to that person’s mucus
membranes.
6
While the Centers for Disease Control continue to list
droplet and close proximity as the primary route of spread
of SARS-CoV-2, more evidence is emerging that airborne
transmission likely accounts for the majority of the spread
of SARS-CoV-2 and occurs when particles of varying size
are transmitted through the air and are inhaled into one’s
upper and lower respiratory tracts.
7,8
Viral load (meaning
how much virus a person is exposed to), how long an indi-
vidual is exposed to a viral load, and an individual’s per-
sonal susceptibility all play a contributory role in SARS-
CoV-2 transmission. One viral particle may be enough to
infect some people who touch a droplet and infect them-
selves, but recent data substantiate what has been suspected
by the scientific community for some time regarding SARS-
CoV-2 transmission: smaller spaces with less ventilation
and higher viral load with more people present lead to
higher infection rates via aerosols.
8,9
Particles transmitted through the air are divided into two
categories, droplets and aerosols. Droplets are the largest
particles transmitted (larger than 5 mm), and there are more
of these particles in a cough or a sneeze than in speech.
FIGURE 1. Case numbers versus complications.
TABLE 1.
Differences by Gender
Gender (All Cases) Cases Per 100K Hospitalization Percentage Admit to ICU Died
Male 401.1 16% 3% 6%
Female 406 12% 2% 5%
Source: Reprinted with permission from ref. 3.
Data from 1,320,488 laboratory confirmed COVID-19 cases reported to the CDC January 22-May 30, 2020.
Men are more likely to be hospitalized, and have slightly higher rates for severe complications (ICU admissions) and death than women.
ARTICLE IN PRESS
2Journal of Voice, Vol. &&, No. &&, 2020
Droplets fall quickly from the air in close proximity to the
host and do not float through the air. Aerosols, particles
smaller than droplets, transmit SARS-CoV-2 over greater
distances and times because they float and can remain sus-
pended in the air for hours. Additionally, the smaller the
particle, the more likely it is to reach the lower respiratory
tract when inhaled
10
; larger droplets are more likely to be
caught in the nasal passages, larger airways and paranasal
sinuses.
11
Although the disease may be acquired through
these structures, small particles, specifically those less than
one micron, carry little virus due to their small size, but float
for hours.
Most concerning are “medium-sized”particles that fall
between 1 and 5 mm.
12
These are produced in higher pro-
portion during speech and singing.
13
They tend to carry a
higher viral load, and, once in the air, their moisture evapo-
rates and turns them into virally concentrated “droplet
nuclei."
14
The medium-sized particles are able to float for
hours, find the lower airways with a higher viral load per
particle, and carry a higher probability than particles of
other sizes or droplets of successfully infecting a susceptible
host. Both small and medium-sized particles are generated
from the alveoli of lungs (smallest air sacs where oxygen
exchange occurs) by way of a “fluid film burst”as the alveoli
open and close during breathing.
15
It has been long estab-
lished that breathing and speaking lead to aerosolization of
particles.
16
Vocal folds also have a fluid film, and their
vibration likely contributes to the generation of medium-
sized particles. This may be why speaking and singing pro-
duce more medium-sized aerosols and why singers might be
at increased risk of transmission. Asadi et al demonstrated
that increased vocal amplitude (loudness) led to increased
aerosolization due to more medium-sized particles being
emitted. In addition, they demonstrated that some people
may be “speech superemitters”who emit particles at rates
an order of magnitude higher than others for yet-to-be-
determined reasons.
13
A recent study using a laser particle
counter demonstrated higher aerosolization rates from sing-
ing as compared to speaking among 8 professional singers.
17
While not true with all viruses (specifically influenza), it
was recently demonstrated that large droplets and medium-
sized particles of SARS-CoV-2 are stopped by a surgical
face mask (article did not specify type of surgical face mask,
but was not N95 etc); however, small particles may still
escape the mask into the air.
18
Surgical face masks thus sig-
nificantly mitigate the risk of disease spread (although by no
means are the sole consideration as discussed earlier). Cloth
masks of various materials also mitigate risk because they
stop droplet and hopefully most medium-sized particle
transmission. However, it is impossible to determine the
ability of cloth masks to stop all medium-sized particles
because of the masks’heterogeneity. In a recent opinion,
Dr. Malcolm Butler stated why having all persons wear a
cloth mask is the next best thing to a vaccine: “When an
infected person wears a mask (and remember that you are
most infectious before you even start to feel sick), the total
volume of virus floating around in the air that we share is
dramatically reduced... the simple act of wearing a mask is
enough to stop the pandemic spread."
12
The virus must find
a susceptible person, infect that person through a respira-
tory, or possibly ocular, mucosal route and then be in
enough concentration to overcome their defenses.
It is important to realize that the person closest to an
infected individual may not be the most at risk. Air move-
ment in a space may blow particles away from a close indi-
vidual and towards another person further away.
19
Room
air turnover and ventilation are key to removing floating
aerosolized particles. Plexiglass between both masked and
unmasked singers will catch some (but not all) droplets and
medium-sized particles with potential for aerosolization.
Plexiglass will not mitigate disease transmission due to con-
tinued aerosolization of the small and medium particles that
escape the sides of, or travel through, cloth masks, and they
may even disrupt airflow in a room’s ventilation pattern
which could lead to higher viral loads.
20
With many SARS-CoV-2 infected individuals being
asymptomatic, it is important for individuals who are older
or more susceptible to infection for other reasons, or who
live with someone who falls into those categories, to be cau-
tious of asymptomatic, younger persons in individual and
group settings. A recent publication on safer singing practi-
ces reports how to mitigate risk of SARS-CoV-2 transmis-
sion for singers.
21
3. Lasting lung damage/ respiratory sequelae
“Chi sa respirare, sa cantare," a phrase central to Bel Canto
voice pedagogy, states that “one who breathes well, sings
well."
22
While it is true that one cannot ascribe all singing
voice problems to the breath, most pedagogues agree that
the efficient use of the breath is central to healthy phona-
tion. If the respiratory system is compromised due to illness
or injury, singing can become more effortful, leading many
to use potentially injurious compensatory vocal strategies.
Singers and teachers of singing are vocal athletes who
depend on optimal respiration.
The risks of lung disease and the respiratory sequelae of
COVID-19 may be underestimated. Prior to the current
pandemic, respiratory illness was remarkably common. In
2017, the Global Burden of Disease Chronic Respiratory
Disease Collaborators estimated that 544.9 million people
worldwide suffered disability and death due to chronic lung
disease.
23
Prevalence was highest (>10%−11% of the popu-
lation) in wealthier countries, a finding consistent with the
American Lung Association’s estimate that over 35 million
Americans suffer chronic, preventable, and possibly undiag-
nosed lung disease.
24
Given that the population of the
United States is roughly 331 million
25
people, this represents
a one-in-ten risk for chronic respiratory disease prior to
COVID-19.
COVID-19 is a new disease, and studies on its long-term
effects will continue to emerge. Many severe COVID-19
infections require treatment in the intensive care unit and
can lead to lasting postrecovery sequelae
26
including
ARTICLE IN PRESS
Lynn Helding, et al COVID-19 After Effects: Concerns for Singers 3
breathing, physical, cognitive, and psychological prob-
lems.
27
These symptoms are referred to as postintensive care
syndrome, an umbrella term for ICU sequelae that can have
long-term quality of life implications.
28
According to Mur-
ray et al, about 50% of patients hospitalized for COVID-19
will require some form of ongoing care to improve their
long-term outcomes.
29
Respiratory changes following COVID-19 are often com-
pared to SARS and MERS pandemics.
30,31
Chan et al stud-
ied patients who recovered from SARS and found that 6%
−20% suffered muscle weakness and mild-to-moderate
restrictive lung disease 6−8 weeks post discharge.
32
In
another study, 94 SARS survivors (about a third of the
study participants) presented with persistent pulmonary
function impairment at 1-year follow-up. The overall health
of these SARS survivors was also significantly worse than
the general population.
33
Hui et al studied the long-term
effects of SARS and found that 27.8% of patients had
abnormal chest radiograph findings and persisting reduc-
tions in exercise capacity (6-minute walk test (6MWT)) at
12 months.
34
Zhang et al reported that patients who recover
from SARS can experience persistent lung damage, even
15 years later.
35
COVID-19 is not as deadly as SARS or
MERS, and its symptomology is more heterogenous, affect-
ing more diverse systems.
36
Nevertheless, it seems plausible
that the respiratory sequelae of COVID-19 will resemble
those seen following these earlier pandemics.
37
Emerging studies are shaping our understanding of the
respiratory effects of COVID-19. Carfiet al found that
87.4% of patients experienced at least 1 symptom following
recovery, with fatigue (53%) and dyspnea/shortness of
breath (43%) being the most commonly reported.
38
Wang
et al studied patients hospitalized with COVID-19 pneumo-
nia. Sixty-six of the 70 patients discharged (94%) had resid-
ual disease on final CT scans, with "ground-glass" opacity
the most common pattern. These lesions were dense clumps
of hardened tissue blocking blood vessels within and around
the alveoli.
39
It is important to note that these subjects were
hospitalized, implying that they had severe COVID-19
infections. These percentages may not be the same for
patients with more mild disease, and further study is needed.
Nevertheless, reports summarized below suggest that respi-
ratory sequelae may occur even following COVID-19 infec-
tion in persons without severe symptoms.
In another preliminary study, LeBorgne surveyed 55 pro-
fessional Broadway, national tour, and cruise ship perform-
ers who experienced COVID-19 symptom onset from
March 1−31, 2020.
40
Of these participants, roughly half
tested positive for COVID-19 or COVID-19 antibodies, and
half were unable to receive testing but had symptoms consis-
tent with COVID-19 infection. Four percent were hospital-
ized and 11% were asymptomatic but tested positive. Three-
month post-acute virus, 28% of participants continued to
experience respiratory compromise, and 26% complained of
vocal fatigue. These early findings suggest that although
these elite artists survive the virus, many suffer lingering
reduction of respiratory and phonatory function.
Surprisingly, one does not need to be seriously ill with
COVID-19 to suffer lung damage. A study by Long et al
examined 37 asymptomatic COVID-19 patients. Chest com-
puted tomography (CT) scans of revealed lung abnormali-
ties in 56.8% of these patients.
41
These included ground-
glass opacities, stripe shadows and/or diffuse consolidation
similar to those found by Wang et al.
The pulmonary lesions associated with COVID-19 can
cause chronic, long-lasting lung disease.
42
Some lesions will
gradually heal or disappear, but many will harden into
layers of scar tissue called pulmonary fibrosis, and the prev-
alence of COVID-19 fibrotic lung disease is predicted to be
high.
43
Pulmonary fibrosis can stiffen the lungs, cause short-
ness of breath, and limit the ability to be physically active.
Whereas mild or moderate reductions in respiratory func-
tion may not be debilitating for the average person, they
could be career-ending for singers and teachers of singing.
4. Laryngeal and other nonrespiratory sequelae
Generally speaking, a medical condition is considered
chronic if it lasts longer than 12 weeks. Thus, the array of
post-COVID-19-related medical complications is just begin-
ning to be elucidated. Beyond the respiratory/pulmonary
complications described in detail above, other post COVID-
19 medical conditions that affect vocal production most
directly can be grouped broadly into 4 categories: (1) Intu-
bation and cough related injury; (2) Postviral vocal fold
paralysis or paresis; (3) Postviral laryngeal sensory neuropa-
thy; and (4) Chronic fatigue.
4.1. Intubation and cough-related injury
The nature and extent of intubation and/or cough-related
injury to the larynx and vocal folds associated with
COVID-19 is likely similar to other conditions that require
emergent and/or prolonged intubation. Thus, the prevalence
is estimated to be sharply increasing.
44
Chronic effects of
these injuries include airway stenosis, laryngeal stenosis
below, at, or above the vocal folds, vocal fold mucosal/
vibration abnormalities and scarring, vocal fold fixation,
and postintubation phonatory insufficiency. While each of
these conditions can occur with varying degrees of severity,
even mild perturbations to precise laryngeal functioning
may lead to substantial functional compromise in singing.
Additionally, the ability to restore full vocal function fol-
lowing these types of injury is limited, at best.
45
4.2. Postviral vocal fold paralysis or paresis
Vocal fold paralysis and paresis can result from even short
periods of intubation, and also can result from viral-related
injury to the vagus nerve—one of twelve cranial nerves and
the one responsible for vocal fold muscle function and sen-
sation to part of the larynx. Other conditions also may be
responsible for laryngeal nerve injury. While present under-
standing is nascent, patients with lower cranial neuropathies
post COVID-19 including vagal nerve involvement have
ARTICLE IN PRESS
4Journal of Voice, Vol. &&, No. &&, 2020
been reported.
46−49
Presumably, the incidence of vocal fold
paralysis and paresis following COVID-19 infection appears
low given the prevalence of infection and the paucity of
reports. However, mild vocal fold paresis in singers often
leads to symptoms that might not be noticed by the general
population but would be noticed by trained singers and
singing teachers (such as vocal fatigue, effort, and range
issues). Furthermore, access to comprehensive laryngologic
evaluation, dynamic voice assessment, and strobovideolar-
yngoscopy has been limited by pandemic. Thus, the preva-
lence, severity and consequence of vocal fold paresis in
singers post COVID-19 remain to be determined.
4.3. Postviral laryngeal sensory neuropathy
In addition to the motor neuropathies described above, sen-
sory neuropathies of the larynx are associated with viral
infections.
50
The most common presentations of laryngeal
sensory neuropathy are chronic cough and swallowing dys-
function, yet much remains unknown about this elusive con-
dition. Studies investigating high demand vocal function in
patients with sensory neuropathy of the larynx are lacking.
The incidence and prevalence of laryngeal sensory neuropa-
thy post COVID-19 is unknown but is likely to occur as it
can following any viral infection. It is logical to postulate
that loss of feeling and proprioception in the larynx could
lead to decrease in fine motor control with adverse effects
on singing capabilities, particularly among those whose
work involves singing styles that demand exquisitely precise
motor movement.
4.4. Chronic fatigue
Chronic fatigue is emerging as a common sequela of
COVID-19 infection, and its importance for singers has
been recognized.
51
In several pilot studies over 53% of indi-
viduals experienced chronic fatigue associated with
COVID-19.
38,52
While not directly affecting vocal produc-
tion, chronic fatigue can be associated with voice com-
plaints. This association has been reported specifically in a
study of younger singers,
53
and its symptoms typically
worsen after physical, mental, or emotional exertion.
54
Chronic fatigue post COVID-19 may prove to be fairly
common and, logically, may have a significant impact on
singers with high vocal, mental, or emotional demands.
5. Risk assessment
This section contains risk assessment tools for singers and
teachers of singing. These tools may assist the reader in
making informed decisions about how, when, and where
they will pursue singing in the months ahead.
5.1. COVID-19 screening app
The authors suggest that readers make use of a smart
phone-based screening app (eg, https://www.apple.com/
covid19). Such an app can be used daily to evaluate one’s
current health, in combination with a check of basal
temperature each morning before rising. Medical help
should be sought immediately by anyone who suspects that
he/she might have COVID-19.
5.2. Online COVID-19 survival calculator
Several online calculators are available to readers determine
their chances of contracting and surviving COVID-19. One
notable example can be found at: https://www.covid19survi
valcalculator.com
This calculator gives the user a detailed summary of per-
sonal risk and assists researchers by collecting data for
future studies.
5.3. Risk assessment tool
Risk assessment can help estimate the likelihood of con-
tracting COVID-19. Factors to be considered include a per-
son’s age, place of residence, occupation, use of public
transit, extracurricular activities, travel history, the number
of persons with whom one interacts closely, and compliance
with CDC/WHO guidance on behavior. This information
can be used to estimate one’s probability of harm. An exam-
ple calculator application can be found at http://www.myco
vid19risk.com/. The likelihood that complications might
result if one contracted COVID-19 depends upon such fac-
tors as age, pre-existing medical conditions, gender, ethnic-
ity, and access to medical care. These factors help determine
one’s magnitude of harm. The example provided above in
Section ``Online survival calculator'' https://www.covid19
survivalcalculator.com/en/calculator could be used to deter-
mine magnitude of (potential) harm. Estimates of
probability of harm and magnitude of harm can then be
combined informally to help an individual determine his or
her overall personal risk level.
5.4. Decision assistance tool
As part of the National Association of Teachers of Singing
webinar, “After COVID—Concerns for Singers”(available
at https://youtu.be/xPg7FLkYDYY), the authors compiled
a singer-specific“decision assistance tool.”This tool
(Figure 2 below) summarizes much of what we know about
the risks associated with COVID-19 and teaching singing.
In general, “dose”multiplied by “exposure time”equals
“risk of infection”:
The risks of COVID-19 to all voice users are substantial.
In addition to the multifold sequelae discussed in this article,
the mental health, professional standing/employment, and
finances of those who contract this disease may be compro-
mised. For some singers, these post-COVID-19 conditions
may seem worse than dying itself. As shocking as this senti-
ment may seem, musicians in one study who had lost the
ability to play their instrument due to injury described the
emotional effects as “drastic,”“traumatic'' and “devastat-
ing.”One musician stated, “it was almost like my life had
stopped”while another simply explained “music's my
ARTICLE IN PRESS
Lynn Helding, et al COVID-19 After Effects: Concerns for Singers 5
life."
55
Such problems are well known and have been dis-
cussed in other literature.
56,57
Some singers and teachers of singing express confidence
in their ability to safely contract, suffer through and emerge
unscathed following COVID-19 illness. “Let's just get it and
get over it”is a frequently expressed sentiment. The authors
believe that voice users should seriously consider the risks of
COVID-19 sequelae outlined in this paper, recognizing the
warnings of physicians and other scientists that COVID-19
infection in anyone of any age can be devastating or even
fatal.
Conversely, there are those who are fearful of this illness,
doing everything possible to avoid contracting it. Some may
be shamed into silence about expressing their fears of the
workplace and may need to cite their unwillingness to risk
the potential COVID-19 sequelae in an effort to come to
an agreeable work arrangement with their employer. Real
fears of being fired or labeled as disloyal to their enterprise
likely play a significant role in the potential avoidance
of this important conversation between employer and
employee. In many instances, the collaboration of a knowl-
edgeable physician may be invaluable for the employee and
employer.
CONCLUSION
In assessing the risk of contracting COVID-19 illness,
society must account for four, not three, possibilities. In
addition to avoiding infection altogether, contracting
and recovering unharmed, and contracting and dying,
the fourth potential COVID-19 illness outcome—con-
tracting and living with its potentially life and career
altering after-effects—should play a prominent role in
the decisions voice users make as they consider returning
to the workplace.
CONFLICT OF INTEREST
The authors certify that they have NO affiliations with or
involvement in any organization or entity with any financial
interest (such as honoraria; educational grants; participa-
tion in speakers’bureaus; membership, employment, con-
sultancies, stock ownership, or other equity interest; and
expert testimony or patent-licensing arrangements) in the
materials (eg, websites) discussed in this manuscript.
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