Here and elsewhere, I have repeatedly written about the many things that can go wrong with acupuncture. This invariably annoys acupuncture fans who usually counter by accusing me of being alarmist. Despite their opposition, I continue to think it is important to regularly point out that acupuncture – contrary to what many acupuncturists would tell us – can result in serious injury. I will therefore carry on reporting new evidence about the harm caused by acupuncture. Here is a very brief review of new (2014) articles on this important topic.

A recent study found that the incidence of any adverse events per patient was 42.4% with traditional acupuncture, 40.7% with minimal acupuncture and 16.7% with non-invasive sham acupuncture. These figures are much higher than those around 10% previously reported.

Other authors described the case of a broken off acupuncture needle in a patient’s abdomen. A very long needle was used which happily is unusual in routine practice.

Pneumothorax has been often noted as a complication of acupuncture – it is by far the most frequently reported serious complication caused by acupuncture; well over 100 instances have been described in the medical literature which, of course, reflects only the tip of an iceberg – new cases are being reported almost on a monthly basis.

Cardiac tamponade is even more dangerous but fortunately also much rarer. A case of life-threatening cardiac tamponade due to penetration of an acupuncture needle directly into the right ventricle was recently published. Cardiac tamponade can happen when the patient is unfortunate enough to have a sternal foramen, an congenital abnormality that is not normally detected by simple inspection or palpation. An investigation found that the frequency of a sternal foramen is approximately 10.5%. The authors concluded that sternal acupuncture should be planned in the region of corpus-previous CT should be done to rule out this variation. Furthermore, we strongly recommend the acupuncture technique which prescribes a safe superficial-oblique approach to the sternum.

A review from Egypt noted that acupuncture presented a significant risks for acquiring hepatitis C infections.

Other types of infections can also be transmitted by acupuncture needles, if the therapist fails to adhere to proper procedures of sterility. One report described the diagnosis, treatment and >1 year follow-up of 30 patients presenting with acupuncture-induced primary inoculation tuberculosis.

Similarly, Chinese authors reported the case of a 54-year-old woman who presented with progressive low back pain and fever. She underwent surgical decompression, with an immediate improvement of her pain. A culture of the epidural abscess grew Serratia marcescens. One year postoperatively, magnetic resonance imaging revealed the almost complete eradication of the abscess. This case is the first case of Serratia marcescens-associated spinal epidural abscess formation secondary to acupuncture.

Other authors reported a rare case of isolated unilateral hypoglossal nerve injury following ipsilateral acupuncture for migraines in a 53-year-old lady.

Finally, Greek authors published a case of severe rhabdomyolysis and acute kidney injury after acupuncture sessions. Rhabdomyolysis is a rare condition that can be caused by muscle injury and presents with muscle weakness and pain. It is characterized by myoglobinuria which, in turn, may cause acute kidney injury.

I can hear the world of acupuncture arguing that all of these events are extreme rarities and that conventional treatments are much more dangerous. This may well be true but it also ignores the following facts:

  • The frequency of such events is essentially unknown. Contrary to conventional medicine, alternative medicine has no functioning systems to monitor adverse events. Therefore the true incidence figures of acupuncture-related complications are anyone’s guess.
  • Most conventional treatments in common use are backed up by good evidence for efficacy and therefore demonstrably do more good than harm, even if they regularly cause adverse effects. This is not the case for acupuncture. In the absence of solid evidence for efficacy, even relatively rare or minor adverse effects would mean that the risk/benefit profile of acupuncture is not positive.

For these reasons, it is an ethical imperative, I think, to keep a keen eye on the harm caused by acupuncture and to inform the public about the fact that it is undeniably not free of risks.

50 Responses to New evidence on the risks of acupuncture

  • So in essence the risks are unacceptable, because it doesn’t work beyond placebo. Correct?

  • And in the main with acupuncture studies, there’s some mild effect, but no better than sham acupuncture, so on this basis acupuncture is a placebo, and a dangerous one at that.
    Is that kind of in the ball park?

    • I’d say that, in most situations, the risk/benefit balance fails to be convincingly positive.

      • And that’s on the basis of the results being no better than placebo. Hence your article suggesting acupuncture is theatrical placebo?
        And the conclusion was reached through use of ‘sham’ acupuncture. It feels like a needle, but isn’t one. Are these all ideas you recognise?

        • Ok since you don’t seem to be engaged with this but are happy chattering away on the end of the comments section. You happily assume that sham acupuncture is indeed sham and functions as a placebo. This is debateable. Modern TCM suggests that acupuncture points are in anatomically predictable locations. This is only so true, there is considerable variation in location. Basing any study on specific anatomical location would lead to questionable results. Classical texts are very vague anatomically, points must be defined by palpation not anatomy. In terms of specific anatomy defining point location, if this is part of the methodology of a study then it is flawed.
          Sham needling stimulates sensation in the skin. If it duplicates needling sensation it will have greater sensory and physical impact than, say, a moxa cone burnt on the skin. Moxibustion is a whole modality all of its own involving the burning of herbs on the skin, so we have the term ‘acupuncture AND moxibustion’. If we are studying the medicine system, we must study it on its own terms. If moxibustion can be said to affect change in a point and so the body, then the greater percussive impact of a ‘sham’ needle seems very likely to similarly affect change. If this is part of the methodology of a study then it is flawed.
          The ‘sinew meridians’ run through the fascial structures of the body. They are said to run under the skin. Although they aren’t frequently taught in the UK , they are nonetheless a therapeutic system within Classical Chinese medicine. They have no relationship with ‘deqi’ sensation. They may be affected through touch or very superficial needling. ‘Sham’ needling would almost certainly affect them. The assumption that’ sham’ needling has no effect on a point may be true, but it will affect another powerful structure which will have a knock on effect across the system. If this is part of the methodology of a study then it is flawed.
          These are the terms on which acupuncture claims to work and assessment of acupuncture as a modality must be made in those terms, whether you think or feel it is all rubbish or not.

          • @Bob

            There are a lot of claims and assertions in that. Can you provide good evidence for them?

          • @fedup

            Which of Bob Dobbs’ claims (if any) do you believe that paper substantiates?

            But of course… Scanning Dead Salmon in fMRI Machine Highlights Risk of Red Herrings

          • @Alan Heness. I’m at a bit of a loss here. These concepts are detailed in classical literature apart from moxibustion which is described in TCM text books. I’m suggesting sham acupuncture may well not be sham or ‘sham’ enough to justify operating as a control in a study.
            I’m also suggesting that anatomy may not accurately describe a points location. Moxa evidently has very little physical sensation, less than a needle, less than a sham needle. It’s just….warm yet in chinese medicine this has an effect on a point. And a sham needle doesn’t, at all. Does that make any sense?
            Classical texts were deliberately anatomically vague. The assertion by a classical scholar with whom I studied was that it encouraged palpatory skill. Knowing what I know of taoist sects secrecy may well have been a factor. ‘Evidence’ is tricky, but clasical texts didn’t have detailed maps of channels. When you needle a point based on anatomical location, you may or may not be needling where chinese medicine says you need to needle.
            The sinew meridians, not often taught, but there they are, tracing the fascial structures described by Tom Myers, in pre Song Dynasty texts. Affected by non deqi, light superficial needling or touch. If you’re going to create a control for studying Chinese medicine then you have to do its own terms. Points aren’t exact, the body is affected by touch and very superficial needling and very light stimulation and temperature change can affect a point as well as needling beneath the skin surface.
            In the light of these aspects of chinese medicine, ‘sham’ needling looks methodologically quite unsound.

  • I acupuncture patients (not often). It is, to my mind, in the right patient, an eloborate but useful placebo. I think i agree with the end of the blog with acupuncutre advocates – that acupuncture is probably a lot safer than is made out.

    Hepatitis risk in Egypt? Of course that is plausible but in this country, we have sterile needling techniques. Practitioners have to be competent / are assessed on this criteria. Local councils have policies that involve someone from environmental health coming to visit a premisis/practice wanting to carry out acupuncture.

    Also, if you speak with a lot of A&E doctors they will usually say that given the calibre of an acupuncture needle, in reality, in the event of it penetrating the thorax, it would not cause a symptomatic pneumothorax and would right itself relatively quickly. And clearly, it is not common to needle the thorax, particularly if you were ‘treating’ a foot.

    As for ‘adverse events’ in the data collected in some audits of acupuncture services, mild bruising, minor bleeding, pain (of course pain, someone is sticking a needle in you), ‘not enjoying it’, etc etc are considered adverse events and actually, aren’t that adverse.

    I dont know anything about cardiac tamponade but could quite believe it.

    Probably the most common significant adverse effect my colleagues and i see are brief vaso vagal events from acupuncture (in the same way you see with patients having injection therapy for musculoskeletal problems).

    The risks, in reality, are probably minimal but then the effect is usually minimal.

    • @James Noble
      Has it never occurred to you that it is unethical to lie to a patient? The moment you tell him that you are going to use a method you do not yourself think does more than minimal good, you are not honest to your patient. A good talk and honest information is what patients usually need and you can for that matter explain to him that you do not want to deceive him by using a useless method. In am convinced this helps much better than performing a theatrical and deiceiptful act.

  • @ Bjorn
    Actually, most clinicians use placebos. Sometimes this is conscious (which could be construed as deceitful) and often subconscious i.e. the clinician believes in it and this rubs off on the patient. It also suggests that you dont understand the physiology that may underpin the placebo effect. The placebo effect is a real physiological phenomenon, not just a psychological one. For example, in the pain sciences, it has been shown that if a patient believes an intervention will improve their pain, that this may indeed cause a real analgesic effect, psychologically and physiologically. For example, there are studies that have shown placebo injection therapy for shoulder pain are as good as ultrasound guided steroid injection. This may be accounted for the fact that that the expectation from the treatment and the ritual of the injection elicit the pain killing and healing neuropeptides that we all produce.

    I would agree with you in so far as it is morally wrong to offer a placebo for a systemic condition such as diabetes or cancer, where the consequences of using a placebo would be at best harmful and at worst lethal. But for benign problems (lets face it, acupuncture is usuallly used for benign problems) acupuncture can work a treat. I would like to think that i carefully consider each patient interaction and intervention that i offer, understanding that the interaction process often accounts for a chunk of the effect.

    • really?
      ‘most’ means >50%!
      do you have any evidence for this amazing statement?

    • James, please show me solid evidence of placebos being able to reduce the neurological-level output from pain receptors or the ability of placebos to increase the attenuation in the transmission path to the brain. I.e. “the real physiological phenomenon” that you claim.

      I’m familiar with the branches of quackery that make unsubstantiated claims, such as modifying ion channel gating, in their pathetic attempts to gain credibility. I’m also familiar with the evidenced-based psychology techniques that are definitely not placebos because they have proven to be efficacious in pain management.

      Obviously, the nervous system consists of many highly-complex subsystems, not least of which is the brain! I suggest that it is you, not Björn, who does not understand the physiology that underpins the placebo effect.

      Prodding extremely complex autonomous objects with a randomly placed needle or three is only going to confuse you — it will never enlighten you.

      • @ Pete 628

        I wouldnt claim to understand the placebo effect in its entirety. I dont think anyone does. The physiology of descending noxious inhibitory control is one physiological method by which the brain produces an analgesic effect (endogenous opioid production). There are others. I agree, ion gating is an unsubstantiated claim. The Australian based Nuffield Orthopaedic Institiute (NOI) have published a lot on the pain sciences, the mechanism by which placebo can work and of the evidence for ‘talking nicely to patients’ as an evidence based mechanism in its own right for improving pain.

        As for ‘neurological output from pain receptors.’ I would argue, in keeping with Moselely’s definition (2003/2007) of pain, that pain is an output mechanism of the brain, or, the IASP definition of pain an an unpleasant experience. There arent really such things as pain receptors. There are nocicpetors or ‘danger signallers’ that encode potentially noxious stimuls into the CNS. An organism only feels pain if the brain gets interested. The point i’m making is that ‘the issue is not always in the tissue and the joint is not always the point’ (Butler NOI group). Some of the mechanisms that account for placebo responses or responses to proper treatments in pain states arent accounted for by looking for an effect on ‘pain receptors’ in peripheral tissues.

        As for confusing me, i dont think acupuncture does that. Its just a useful ‘tool’ to have in the box in the treaatment of pain.

        • @ James,
          Many thanks for taking the time to write your detailed reply. Pain is indeed an output mechanism of the brain. Although it has been argued many times that ‘pain receptors’ don’t actually exist, neurectomy can be an effective last resort procedure for severe chronic pain that doesn’t respond to other forms of treatment. So, in effect, ‘pain receptors’ exist as an immensely powerful input mechanism to the brain.

          You wrote: “An organism only feels pain if the brain gets interested.” This is sort of true, but what it really means is that the sensation of pain reduces as the level of distraction away from the ‘pain receptors’ increases. E.g. our emergency fight—flight-or-freeze response fixates our locus of attention on dealing with the immediate threat to our survival, which heavily suppresses our perception of pain.

          Understanding the placebo effect in its entirety is probably impossible. However, it isn’t necessary to understand its entirety. Theatrical placebos are generally effective forms of distraction — temporarily shifting our locus of attention away from our unwanted perceptions (especially physical and emotional pain).

          Going to the theatre, listening to music, watching television, sharing food with friends, and physical exercise, are all efficacious distractions. I totally understand that acupuncture is one of the useful tools that you have in your toolbox and that you use it sparingly. My hope is that you will eventually replace this tool with another placebo that you find equally effective and is less potentially hazardous.

          Note to readers: The use of alt-med in place of evidence-based physiological and psychological interventions is highly unethical.

    • Thank you Mr. Noble for this condescending and revealing collection of thoughts. I see why you need to resort to theatrical placebo to fill the voids in your capabilities.

      • Hello Bjorn,
        Perhaps look at some of the other comments I make (with cited evidence) . I think you might be missing the point a little. Though entertaining to read, I’m not sure I or my colleagues would agree I occasionally use acupuncture to fill a void in capability, lol

  • Trust me I’m a Professor, acupuncture is a theatrical placebo. I think!

    “Saleyha’s brain scan, like those of Prof MacPherson’s other subjects, shows a deactivation (measured by a decrease in blood flow) in the limbic system inside the brain. The limbic system, known as the pain matrix, is the part of the brain believed to be responsible for the perception of pain.

    Instead of stimulating the perception of pain, as you may expect, having needles stuck in her hand has appeared to reduce the activity of the pain matrix. It’s evidence of an effect that might explain how acupuncture could work as a painkiller, although it’s not evidence as to why it can cause this decrease in the pain matrix.

    It’s possible that the needles may stimulate the nervous system to release neurotransmitters involved in pain-suppressing mechanisms – but it’s also possible that the changes in the brain are due to the placebo effect where the mere expectation that something will relieve pain results in a reduction in pain.

    Whatever the mechanism, though, it does seem that acupuncture can be as effective a painkiller as some traditional pain medication.”

    • Clamping part of a patient’s body in a bench vice for five minutes will provide temporary efficacious pain relief after being released from the vice. The physiology and psychology involved in this effect is reasonably well understood by those who bother to keep up to date with recent findings in neuroscience and medicine. However, quacks are increasingly demonstrating that they don’t even begin to understand the complex mechanisms involved and that they don’t want to learn about them. Instead, they just cling to their treatments and speak about them using word salads adorned with “believed”, “perhaps”, “possible”, “could work”, “appeared to”, “it seems that”.

      • Pete, just watch “trust me I’m a doctor” no clamping involved, straw man, just medical doctors looking at new research. This (prof) quack is using mri of the brain to find a mechanism for the results.

  • james

    You are giving lesson about placebo effect but you are mixing things :
    – First, you don’t need to give a treatement for placebo effect, it’s called “caring”. The most important things to get a strong placebo effect : the patient need to feel he got control over the disease. Make suggestion that avoid to remember pain to the patient. A firm diagnosis and of course the patient-doctor relationship. No accunpuncture here.

    Of course it’s a real physiological phenomenom (I think it can alter pain perception by neurodopaminergic axis because of strong placebo effet in Parkinson’s people, and it’s what most of the studies suggest about the subject), and for some neurological disorder affecting pain perception or dopaminergic axis (like depression, it’s why caring is the most important thing in this case) it can be very useful to exploit it and may be more useful to exploit it when not much treatement exist for the condition.

    But, in ANY case, you will not need mumbo jumbo to get it, see the difference ?

    And this kind of claims :

    “For example, there are studies that have shown placebo injection therapy for shoulder pain are as good as ultrasound guided steroid injection.”

    No, you are taking it reverse. I don’t know “ultrasound guided steroid injection”, but you don’t say “because this is as good as a placebo, let’s use placebo” but “it’s no more efficient than a placebo so the therapy is useless” (something that YOU and other quacker don’t seems to be able to understand !).

    You can’t even argue that you don’t have time to care for patient, because you take time to put needles in them. What about less deceiving and more constructive exchange with the patient ?

    • ‘See the difference?’ Actually, I don’t really get the point you are trying to make.

      I’m not a quacker either. Nor did I propose that I didn’t have time to care for patients. The point was that sometimes acupuncture can be a useful adjunct to other interventions. Indeed, the time spent with the patient and the development of relationship between clinician and patient may account for some of the improvement……… In your words ‘caring’

      • “Actually, I don’t really get the point you are trying to make.”

        Well, it’s easy : Why would you use acupuncture ? Because like I said (and many say) before, you don’t need that to get the good part of placebo effect. In another word, acunpuncture got no “specific” effect that could be more useful than placebo effect alone when you are just good with the patient.
        Provide at least one good reason to use acupuncture (and “because sometimes it’s good” is not a good reason).
        Being good with the patient do not involve lying, so it’s ethical compared to acupuncture.

        (And i’m not even talking about the fact that you are just going reverse to science based medicine)

        Now, do you see the point ?

  • Did anyone see the Trust me I’m a Doctor on the BBC. Apparently Acupuncture works (but they not sure how) : )

    Any comments from anyone especially Prof Ernst would be welcome.

    • I did not see the programme; acupuncture does work, of course, but mostly via a placebo-response, according to the best available evidence.

    • I watched it – it was terrible science, presented in a highly misleading way, leaving – I think – the public with the completely wrong impression about the evidence for acupuncture.

      There are a few comments on the OU website about this: OU on the BBC: Trust Me, I’m a Doctor

      • in this case, someone should file a complaint.

        • “Trust Me, I’m a Doctor is a health magazine show which cuts through the hype and media confusion on all things health related. It strives to present viewers with the unbiased facts allowing them to come to their own conclusions. It takes its science very seriously, and does not shy away from presenting conflicting viewpoints where experts genuinely disagree or the evidence just isn’t there yet.”

          The exact opposite to this blog.

          • I just saw this programme myself. They seem to have been honest in their presentation, but their conclusion is far-fetched to say the least. All they have shown, is that people’s brains notice when you stick needles into them.

            I submit that if someone sticks needles into you and your brain does not notice, that would be a good indication that there is something seriously wrong with you. You could be dead, for example.

      • LOL Zeno “thinks” he knows more about the science than the Prof doing the research using MRI. Typical skeptic response. I don’t agree with the science provided, therfore it must be terrible and misleading. Funny it seemed to mislead the Doctor doing the piece, the doctor who was skeptical before being shown the evidence who has now changed her mind. No blinkers.

  • @ Edzard Enst

    I agree, most would mean >50%.

    You could argue a distinction should be made between (a) knowingly using a placebo and (b) clinicians who carry out an intervention thinking that it is a an effective treatment but perhaps where the evidence shows is no better than placebo / that is placebo.

    An example of (a) might include a paper in the BMJ in 2004 that asked doctors and nurses whether they knowingly used placebos. I think just over half admitted to doing it once a week or so. Another example might be the review paper in 2009 by Miller & Colloca which acknowledged that physicians frequently recommend placebo treatments. Interestingly, they concluded that acupuncture for pain relief might be one of the placebo treatments they regarded as ethical. There is a bunch of literature (some of it of a reasonable quality) out there but I would struggle off the top of my head. Also the literature around communication style and clinician attributes ‘words that harm and words that heal’ can account for some of the benefit people report in the improvement in their symptoms.

    A starting example of (b) would include orthopaedic surgeons who perform routine knee arthroscopy for mild degenerative joint disease, for degenerative meniscal tears. There is growing evidence that these procedures are not effective in reducing pain or disability. Presumably, orthopaedic doctors think that what they are doing is valuable. Interestingly, on this very topic, a study in the New England journal of Medicine 2002 showed that sham arthroscopy did slightly better than the real surgery at 6 months (there wasn’t any real clinically significant improvement in both groups if I remember right though). Indeed, it has been reported in a number of papers that knee arthroscopy in these patients is a placebo – and yet these surgeons continue performing knee arthroscopy on these type of patients. Or perhaps the snake oil salesman in sports medicine who regularly provide elite athletes with unproven ‘cutting edge’ treatments (see editorial by Fanklyn Miller in the British Journal of Sports Medicine 2009). Again, presumably these clinicians are trying to act in the best interest of the patient but provide snake oil treatments.

    And then there’s the anecdotal stuff. Most of the docs and physio’s I’ve worked recognise that they use the placebo effect regularly in their clinical practice. Whether that is the act of reassuring an anxious patient by carrying out an unnecessary examination technique, or by offering reassurance that ‘things will be ok’ to the teenager with growing pains in their knees.

    I guess it depends on whether you consider the placebo effect as ‘real’ (I would argue it is real in pain studies at least where it may be part of the descending-noxious-inhibitory-control mechanism) part of medicine or something that is inert and an inconvenience to RCT’s. Either way, on balance I’d still argue that the majority of clinicians use the placebo effect as part of their practice – consciously or unconsciously.


      • I agree entirely….. so you would agree that clinicians use the placebo effect? Maybe even more than 50%? (As part of their treatment, and ideally, as part of a robust eviden based treatment plan)

        • as a clinician, you cannot help using the placebo-effect: almost everything you do comes with an inevitable placebo-response.

          • That was part of the point I was trying to make. Would perhaps make an interesting topic for a blog ‘what role does/should the placebo effect play in modern healthcare.

          • James, two other interesting topics for a blog would be:
            1. What role does/should scientific illiteracy play in the advocacy and practice of alt-med treatments?
            2. What role does/should sadism play in the advocacy and practice of alt-med treatments, such as acupuncture and Gua Sha?

        • I agree entirely….. so you would agree that clinicians use the placebo effect? Maybe even more than 50%? (As part of their treatment, and ideally, as part of a robust eviden based treatment plan)

          Wrong !!
          Real clinicians do not USE the placebo effect. Good, caring, knowledgeable and HONEST clinicians effortlessly ELICIT a supplementary placebo effect by being kind, caring and above all honest. This effect reinforces the genuine medical/surgical care that the clinician is USING. As well, this induces confidence and calm.
          “Acupuncture” is an invasive act without proven effect. Should acupuncture, despite accumulating evidence to the contrary, have a specific effect, this effect is demonstrably negligible and does not justify the time, cost and risk. There are much better, effective and acceptably safe means of controlling pain and whatever other effects acupuncture has been believed to possess.
          It is well documented that the practice of acupuncture is NOT risk free. As it is not (or negligibly) effective, the risk/benefit ratio does not justify its clinical use.
          The act of sticking needles needlessly into people is NOT a placebo inducing intervention. The placebo effect is precipitated by the erroneous expectations induced by whatever deceitful drivel the “acupuncturist” USES to lie[sic] to the patient, often reinforced by the awe-inspiring illusion of the TCM fallacy.
          This is why, as a clinician (you are a physiotherapist, right?) you DO NOT and SHOULD NOT have to USE non-effective and risk filled, invasive interventions to reinforce your (hopefully?) effective clinical interventions unless you lack skills, caring or honesty.

          As Edzard implies, placebo is an inevitable response to good clinical work.

  • yes, the placebo is an inevitable response to good clinical work isnt it……….Thats the point. Call it supplementary – it depends on the context doesnt it? And i dont disagree that honest, caring healthcare workers ‘induce confidence and calm’

    I have never knowingly lied to a patient, and some patients have (admittedly sometime erroneously) outlined their expectations explicitly – that acupuncture is what they want and is what they think will help them.

    I do NOT recognise TCM as a paradigm because there is no evidence for it and it sounds quite wacky. I have never made reference to TCM. A lot of docs and physio’s i’ve worked with dont recognise it either but would still support occassional acupuncture use in the right patient. ‘Trigger point’ dry needling what ever you want to call it.

    Of course there are better modalities for providing pain relief than acupuncture. Would be silly to argue the contrary. I’m not arguing that position.

    I dont disagree with you that there is NO evidence for the use of acupuncture in most conditions, but in the treatment of pain it may help a little. Why are you so quiet about the point surrounding uneffective SURGERY if you think that acupuncture carries such a pronounced risk?

    So, try not to pigeon hole me as a TCM nut.

    I’m afraid I wont be able to follow this blog for a couple of weeks but would be interested in keeping reading such. Including Pete 628’s condescening poorly informed remarks

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