WHY SUPPORT THE XLNT FOUNDATION FUNDRAISER: 
“HELP SUE THE NRC TO END THE USE OF THE LNT MODEL”?

 

Fundraiser website: https://gofund.me/ca245812 


The LNT model was adopted without any supporting evidence: A major error was committed in the 1950s by the advisory bodies such as the predecessor of National Council on Radiation Protection and Measurements (NCRP) when they adopted the use of the linear no-threshold (LNT) model for radiation protection, because they adopted the model with no evidence to support it (1). According to the LNT model, even the smallest radiation exposure would increase harm such as cancer. However, there was no evidence for increased cancer or other harm from low levels of radiation.


Flawed evidence for the LNT model: Whereas many publications have been quoted to support the LNT model, upon close examination, such publications have been found to not support the LNT model because of major flaws in data, analyses, and/or interpretation, and this has been demonstrated repeatedly (2, 3). 

There is supportive evidence for the opposite of the LNT model: High-level radiation is known to increase cancer risk, but low-level radiation has been observed to reduce cancer risk, e.g., as observed in the incidence of leukemia in Hiroshima atomic bomb survivors, as seen in the Figure below (4). 

Figure Caption. Evidence of a threshold at 1.1 Gy for radiation-induced leukemia from analyses of the 1950–1957 data of 95,819 Hiroshima atomic bomb survivors, from (4).


Additional examples of evidence for reduction of cancer risk from low radiation doses are:
(a) the nuclear shipyard worker study showed a 15% reduction in cancer mortality rate in the workers exposed to low radiation levels (5), 
(b) the study of Taiwan apartment residents who lived in buildings constructed with steel contaminated with radioactivity showed a 16% reduction of cancers in the irradiated population (6), and 
(c) the study of British radiologists registered during 1955-1979 who received exposure to low-level radiation showed a 27% reduction in the cancer mortality rates (7). 

 

In addition, low-level radiation treatment, given to the whole body or half of the body 15 times over a period of 5 weeks, was found to have a cancer therapeutic effect (8). 
 

The concept that a high dose of an agent is harmful while a low dose of the same agent is beneficial is known as hormesis.  It  is a common phenomenon observed throughout nature. Examples of this include vitamins, medicines, water, and food.


What the radiation protection community should be doing: In view of the absence of valid evidence for the LNT model and the presence of evidence for radiation hormesis, the radiation protection community should be working to prevent exposure to high-level radiation, and radiation protection regulations should be designed to prevent exposure to high-level radiation. Such regulations would not result in concerns regarding low levels of radiation, and they would protect the public and workers from the harmful effects of high-level radiation.


The radiation protection community benefits financially from the use of the LNT model: The use of the LNT model led to concerns regarding the smallest amount of radiation, justifying and leading to expenditures of vast amounts for designing regulations related to low-level radiation, complying with the regulations, monitoring, reducing, and documenting low-level radiation exposures, etc. (9) These vast public expenditures became large incomes to the radiation protection community, which includes advisory bodies, regulatory agencies, radiation protection staff, radiation-related professional organizations, scientists in the radiation protection field, and the radiation protection industry.


Vested interest of the radiation protection community: In spite of much observed evidence for radiation hormesis, the radiation protection community has ignored it and has continued to use the LNT model. The vast public expenditures for radiation protection have not benefited the public at all, but have benefited the radiation protection community. It is clear that this community has a vested interest in continuing the use of the LNT model.


Harm from radiophobia: The use of the LNT model has led to the fear of even very low levels of radiation, i.e., radiophobia, because of the claim that even the lowest level of radiation increases cancer risk.  


- Radiophobia has blocked the study of low-level radiation for preventing cancer. If such studies had been conducted in the 1970s when some evidence for radiation hormesis had been observed (10), the cancer preventive effect of low-level radiation would have been confirmed in clinical trials, and the world would have started using low-level radiation for preventing cancer. In that case, cancer incidence and mortality rates would have been reduced by about 20%, based on the above cited evidence (5-7). But the world did not benefit from this reduction. The global annual death toll from cancer was 4.3 million in 1980 (11) and 10 million in 2020 (12). Based on such data, assuming 20% of cancer deaths would have been prevented using radiation hormesis, the reduction in the worldwide cancer mortality, if the LNT model had not been adopted, would be over 50 million for the period of 1980-2020 (13). Thus, the LNT model, instead of protecting the public from harm, has been causing a huge amount of cancer mortality. 


- Radiophobia resulted in the panic evacuation of Fukushima residents following the nuclear reactor accidents in 2011. The evacuation caused considerable casualties, tremendous economic loss, and long-term disruption of normal life. There was no benefit to the residents from the evacuation because, in the absence of the evacuation, they would have received exposure to low-level radiation only and this would have decreased their cancer risk, based on evidence. In fact, people in many parts of the world receive natural background radiation doses similar to the doses they would have received, if they had not been evacuated, and people in such areas do not have increased cancer risk (14) but there is some evidence for reduced cancer risk with increased natural background radiation levels (10).


- Radiophobia has suppressed the growth of nuclear power in the world though it has proven to be the safest (15), most reliable (16), and most environmentally-friendly (17) method of reliable power generation. 


- Radiophobia has led to some patients refusing CT scans (18) potentially harming them due to delayed diagnoses. It has also led physicians to recommend not performing CT scans in some situations (19) whereas studies have shown that performing CT scans would lead to better patient outcomes (20).  Radiophobia has also led to excessive dose reduction efforts in performing CT scans resulting in non-diagnostic CT scans (21), potentially harming patients due to missed diagnoses (22).
 

Formation of the Scientists for Accurate Radiation Information (SARI): In 2013, after observing the tremendous harm caused by the radiophobia-based Fukushima evacuations, a number of concerned professionals joined together to form an international group known as the Scientists for Accurate Radiation Information (SARI), with the goal of providing accurate information about radiation health effects to reduce radiophobia and the harm from it (23). SARI submitted several appeals to the various advisory bodies, regulatory agencies, and professional organizations pointing out the evidence for radiation hormesis and asking them to discontinue their support for the LNT model. However, these appeals fell on deaf ears and did not result in any change. 


Why the XLNT Foundation was formed: Based on the experience with the advisory bodies, professional organizations, regulatory agencies, and individual responses to SARI initiatives, several SARI members recognized that providing accurate information regarding low-dose radiation health effects is not sufficient to overcome the use of the LNT model by the radiation protection community. Some of the additional steps that need to be taken include organizing debates on the subject to facilitate a scientific resolution of the issue, informing the public and professionals about the observed health effects of radiation, and launching legal challenges to regulations not based on solid science. These steps would be beyond the scope of SARI because of its structure as a discussion group and its lack of financial resources. Therefore, an independent nonprofit organization, the XLNT Foundation, was formed in 2015 by several SARI members in collaboration with additional interested individuals. The foundation’s goal is to take the necessary steps to overcome the LNT model problem.


NRC rejects three petitions asking it to end its use of the LNT Model: In 2015 three petitions were submitted to the Nuclear Regulatory Commission (NRC) asking it to discontinue using the LNT model for radiation protection regulations and to use radiation hormesis as the basis of the regulations (24). In these petitions, some examples of evidence for radiation hormesis were presented to justify the change. Instead of discussing the merits of the evidence presented, the NRC quoted advisory bodies such as the NCRP and rejected the petitions (25). 


Evidence for the LNT model quoted by NCRP and NAS has been refuted:

NCRP, in the Commentary No. 27 published in 2018 (26), discussed several epidemiological studies with varying levels of support for the LNT model. The first study it quoted as providing strong support for the LNT model was the study by Grant, et al. on the cancer incidence of atomic bomb survivors (27). However, this publication states, in its abstract “At this time, uncertainties in the shape of the dose response preclude definitive conclusions to confidently guide radiation protection policies”. Such an indeterminate conclusion implies that the Grant et al. publication does not support any model. Thus, without even discussing the technical details of the publication, it is clear that the first strong evidence presented by the NCRP supporting the LNT model is not valid. It is concerning that the authors of the NCRP Commentary drew such a wrong conclusion from the publication. The other evidence presented in the Commentary also do not provide support for the LNT model (2, 28). 


The BEIR VII Report by the National Academy of Sciences (NAS), published in 2006 (29), stated that the atomic bomb survivor data, which it claimed to be the most reliable evidence, provided support for the LNT model. However, after an update was published for the data in 2012 (30), the data are no longer consistent with the LNT model (31). Another piece of evidence the BEIR VII report used to support the LNT model is the 15-country study of radiation workers (32). However, with the withdrawal of the Canadian data due to major identified defects (33), these data no longer support the LNT model (34). 


NCRP has not been transparent in its decisions regarding low-dose radiation health effects: NCRP, which is a publicly funded organization, has not been transparent in its activities. For example, in 2017, NCRP published the draft of a Commentary regarding the LNT model and asked for public comments. Some SARI members submitted comments pointing out examples of evidence for radiation hormesis and pointing out the flaws in the evidence NCRP had presented supporting the LNT model. NCRP neither acknowledged nor responded to the comments, but published the NCRP Commentary No. 27 in 2018 without explaining why the submitted comments were ignored. SARI and XLNT Foundation set up an Exhibit Booth at the American Association of Physicists in Medicine (AAPM) Annual Meeting in 2018 in which a Poster critical of the NCRP Commentary No. 27 was displayed. There were many visitors to the booth. Several members of the NCRP visited the booth, but would not enter into discussion of the evidence quoted in the NCRP Commentary or defend the Commentary.


NCRP did not refute the evidence for radiation hormesis: In a Letter to the Editor responding to the NCRP Commentary No. 27, several pieces of evidence for radiation hormesis were presented (35). The Letter to the Editor says, in part:


“…. many epidemiologic studies have indeed shown reduction of cancers following exposure to low radiation doses and radiation exposures at low dose rates, e.g. (Davis et al 1989, Berrington et al 2001, Sponsler and Cameron 2005, Hwang et al 2006, Doss 2018b, Tubiana et al 2011). In addition, exposure of the whole body or half body to low-dose radiation (10 cGy), 15 times in five weeks, resulted in improving the survival of non-Hodgkin’s lymphoma patients, indicating that the repeated exposures to low radiation doses had a cancer therapeutic effect (Sakamoto 1997). Whereas these studies did not determine the shape of the dose response by examining the cancer risk at a large number of doses, they did determine the cancer risk following exposure to low radiation doses and at low dose rates. Since these studies showed significantly reduced cancer risk following such radiation exposures, they directly contradict the LNT model. There are also alternative analyses or interpretations of the atomic bomb survivor data, which support the concept that following low radiation doses the cancer risk decreases, contradicting the LNT model (Doss 2013, Sasaki et al 2014).”

In their response (36), the authors of the NCRP Commentary claimed that the (above) quoted evidence (for radiation hormesis) is weak because in the studies quoted, the cancer risk of the study population is “biased downwards because occupational cohorts tend to be selected for good health compared with the wide range of health status in the general population”. Below is a list of the studies quoted and the cohorts compared in the Letter to the Editor.

Studies cited and cohorts compared
Davis et al 1989 (37)

 - TB Patients
Berrington et al 2001 (7)

 - Male Radiologists vs. Male Doctors
Sponsler and Cameron 2005 (5)

 - Radiation vs. non-Radiation workers
Hwang et al 2006 (38), Doss 2018b (6)

 - Residents of radio-contaminated buildings vs. a reference population
Tubiana et al 2011 (39)

 - Cancer patients
Sakamoto 1997 (8)

 - Cancer patients
Doss 2013 (31) , Sasaki et al 2014 (40)

 - Atomic bomb survivors

As seen in the above list, none of the evidence quoted were such comparisons of occupational cohorts and the general population, and so their criticism is invalid.

NCRP has violated its Congressional Charter: NCRP’s Congressional Charter (41) states that the objects and purposes of the corporation shall be “to collect, analyze, develop, and disseminate in the public interest information and recommendations about protection against radiation ….”. By stating in its Commentary that the (Grant, 2017) study on the atomic bomb survivors strongly supports the LNT model when it doesn’t, and neglecting to consider publications supporting radiation hormesis without giving a valid reason, NCRP has misled the public about the health effects of low-dose radiation and so the NCRP’s actions are not in the public interest. NCRP has violated its Congressional Charter.

 
Evidence for radiation hormesis has not been refuted: In 2020, XLNT Foundation set up an online debate website (42) where it presented several examples of evidence for radiation hormesis and provided a facility for comments where those opposed to the evidence could present their views. Many individuals and representatives of organizations supporting the LNT model including representatives of NCRP and NRC were informed by email about the debate and asked to participate in the debate. However, no one has refuted the evidence presented.  


Why there aren’t many objections to the use of the LNT model: The radiation protection community benefits from the LNT model because of the increased work and the resulting income, and so we cannot expect the radiation protection community to object to the use of the LNT model. Many radiation-related industries have faced increased costs due to the LNT model-based regulations, but they have been passing on the increased costs to the public, and so they have not objected. Also, many workers in such industries would lose their jobs if the LNT model is discarded, and so many nuclear industry workers would not object to the LNT model.  In addition, there could be concerns about retaliatory actions by regulatory agencies if objections were raised. The victims of the LNT model are the members of the public, as they face increased costs, unreliable power, increased illnesses, etc. but they are not aware how they have been harmed by the radiation protection community, and so they do not object.


Benefits for the public from ending the use of the LNT model: Ending the use of the LNT model would have many beneficial effects for the public. 


(1) It would enable clinical trials on the cancer-preventive effect of low-dose radiation and could result in considerable reduction in the cancer incidence and mortality rates worldwide, based on currently available evidence. 
(2) It would facilitate the study of low-level radiation for treating cancer. The advantage of this method is that it has very few adverse side effects in contrast to treatments like chemotherapy. 
(3) It would enable clinical trials of low-dose radiation for preventing diseases such as Alzheimer’s and Parkinson’s, for which there are no methods available for prevention or effective treatment. Animal studies have indicated low-dose radiation would have a preventive effect for such diseases (43, 44).
(4) It would reduce and eliminate many regulations based on the LNT model which do not improve the safety of nuclear power. The cost of nuclear-generated electricity would decline, enabling nuclear energy to flourish, and enabling developing nations to enjoy the benefits of nuclear power with minimal pollution of the environment. 
(5) It would reduce the cost of other applications of radiation such as CT scans, PET scans, nuclear medicine scans, food irradiation, medical sterilization, research involving radiation, and radiation therapy.
(6) It would avoid panic evacuation and harm from the evacuation in case of release of radioactive materials into the environment from any future radiation accidents or from dirty bomb attacks.
Who should support ending the use of the LNT model: Since the public is the beneficiary, the public should support ending the use of the LNT model. The radiation protection community, which benefits from the LNT model, would not support ending the use of the LNT model.


Addressing public concerns regarding ending the use of the LNT model: It is quite natural for the members of the public to be concerned about ending the use of the LNT model and starting the use of radiation hormesis because they have been given misinformation regarding radiation health effects for many decades. Therefore, many concerned individuals and organizations are likely to raise objections to the lawsuit and to the end of the use of the LNT model. A good information campaign would need to be launched providing the reasoning and evidence supporting the lawsuit to allay such concerns.


Are children more vulnerable to low-dose radiation? One concern that has been raised about discarding the use of the LNT model is that children may be more vulnerable to radiation-induced cancer and relaxing the regulations would increase their cancer risk. However, this concern is derived from (e.g.) the data at high radiation doses in the atomic bomb survivors (30) and is not applicable for low radiation doses, because cancer rates did not increase in the atomic bomb survivors for low radiation doses. The study of second cancers in childhood cancer survivors who underwent radiation therapy has shown that those parts of the body that received low radiation doses from the radiation treatments had a reduced rate of tumors per kg of tissue when compared to parts of body with no radiation exposure from the radiation treatments, demonstrating the occurrence of radiation hormesis in children (39). For the parts of the body exposed to high radiation doses, there was an increased risk of second cancers per kg of tissue. Thus, there should be no concerns regarding low radiation exposures in children.


Why a lawsuit is needed: Over the past four decades, many attempts have been made to bring the evidence for radiation hormesis to the attention of the advisory bodies and regulatory agencies, but they have refused to accept, or even review such evidence and continue to use the LNT model. They have also failed to reject the faulty evidence supporting the LNT model. Such an unscientific approach by the advisory bodies and regulatory agencies leaves no choice but to attempt to use legal means to correct their behavior and reduce the public harm from the LNT model so that the public may benefit fully from the various uses of low-dose radiation. Though our opponents are formidable, evidence, science, and the legal branch’s concern for public safety are on our side, and we shall use these advantages to the fullest extent to expose the bias of the regulatory agencies and advisory bodies and win the lawsuit. 


The lawsuit is relevant for other countries also: Though the lawsuit being planned relates to regulations in the United States, considering the leading role the United States plays in world affairs, the success of the lawsuit would likely result in dismantling of the regulations based on the LNT model in other countries also, benefiting members of the public in other countries. Hence, the people in other countries should also consider donating to this fundraiser.


The need for larger individual donations: Since the subject of the LNT model and the harm it has caused would be esoteric for most of the public, the number of people who appreciate the importance of the lawsuit is relatively small, and so we cannot expect the vast majority of the public to support our efforts against the LNT model. Therefore, for us to reach our goal, those that understand the importance of the lawsuit would need to make more substantial contributions. For example, if there are 100 donors, then $1500 from each donor would be necessary. Foreclosing the use of the LNT model, which could result from such donations, would have a tremendous positive impact on the health and well-being of the global population.


How you can make a big difference: When the demise of the LNT Model and the benefits from its demise are written history, wouldn’t it be good to be one of the 100 that made the big difference? Please donate to make the big difference for all those that live on this planet.


Your help: Presently, we have a unique courtroom opportunity because the NRC has denied the petitions to discontinue using the LNT model. We believe the NRC denied the petitions illegally and we have a certain amount of time to sue and to force the NRC to reconsider the petitions based on the best available science. Please support our lawsuit with a generous donation. 


Fundraiser website: https://gofund.me/ca245812


The lawsuit will be launched after $150,000 has been raised in donations.

Sincerely, 
Bennett Greenspan, MD, MS
Chairman, XLNT Foundation

Date: January 9, 2022
Website: https://www.x-lnt.org/ 
 
The mission of the XLNT Foundation is to inform the public about the observed beneficial health effects of low-dose ionizing radiation, and to campaign for eliminating use of the linear no-threshold (LNT) model in order to enhance public health.

References


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https://www.x-lnt.org/50-million-cancer-deaths


(14) Tao Z, Zha Y, Akiba S, Sun Q, Zou J, Li J, et al. Cancer mortality in the high background radiation areas of Yangjiang, China during the period between 1979 and 1995. J Radiat Res (Tokyo). 2000;41 Suppl:31-41. https://pubmed.ncbi.nlm.nih.gov/11142210/

 
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(16) Office of NUCLEAR ENERGY. Nuclear Power is the Most Reliable Energy Source and It's Not Even Close. 2021.   https://www.energy.gov/ne/articles/nuclear-power-most-reliable-energy-source-and-its-not-even-close


(17) Office of Nuclear Energy. 3 Reasons Why Nuclear is Clean and Sustainable. 2021.   https://www.energy.gov/ne/articles/3-reasons-why-nuclear-clean-and-sustainable


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(24) Petitions submitted to NRC by Carol S. Marcus, Mark L. Miller, and Mohan Doss (on behalf of SARI). 2015.   https://www.nrc.gov/docs/ML1505/ML15051A503.pdf; https://www.nrc.gov/docs/ML1505/ML15057A349.pdf; https://www.nrc.gov/docs/ML1507/ML15075A200.pdf


(25) NRC. DENIAL OF PETITIONS FOR RULEMAKING REGARDING LINEAR NO-THRESHOLD MODEL AND STANDARDS FOR PROTECTION AGAINST RADIATION (PRM-20-28, PRM-20-29,  AND PRM-20-30). 2021.   https://www.nrc.gov/docs/ML2123/ML21230A138.pdf


(26) NCRP. Commentary No. 27 - Implications of recent epidemiologic studies for the linear-nonthreshold model and radiation protection. Bethesda, MD: National Council on Radiation Protection and Measurements; 2018. https://www.ncrppublications.org/Commentaries/27


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(28) Ulsh BA. A critical evaluation of the NCRP COMMENTARY 27 endorsement of the linear no-threshold model of radiation effects. Environ Res. 2018;167:472-87. https://www.ncbi.nlm.nih.gov/pubmed/30138826


(29) NRC. Health risks from exposure to low levels of ionizing radiation : BEIR VII Phase 2, National Research Council (U.S.). Committee to Assess Health Risks from Exposure to Low Level of Ionizing Radiation. Washington, D.C.: National Academies Press; 2006. xvi, 406 p. p. http://www.nap.edu/openbook.php?isbn=030909156X


(30) Ozasa K, Shimizu Y, Suyama A, Kasagi F, Soda M, Grant EJ, et al. Studies of the mortality of atomic bomb survivors, Report 14, 1950-2003: an overview of cancer and noncancer diseases. Radiat Res. 2012;177(3):229-43. https://www.ncbi.nlm.nih.gov/pubmed/22171960


(31) Doss M. Linear no-threshold model vs. radiation hormesis. Dose Response. 2013;11(4):480-97. http://www.ncbi.nlm.nih.gov/pubmed/24298226


(32) Cardis E, Vrijheid M, Blettner M, Gilbert E, Hakama M, Hill C, et al. Risk of cancer after low doses of ionising radiation: retrospective cohort study in 15 countries. BMJ. 2005;331(7508):77. http://www.ncbi.nlm.nih.gov/pubmed/15987704


(33) CNSC. Verifying Canadian Nuclear Energy Worker Radiation Risk: A Reanalysis of Cancer Mortality in Canadian Nuclear Energy Workers (1957-1994), Summary Report, INFO-0811, 2011.: Canadian Nuclear Safety Commission.   http://nuclearsafety.gc.ca/pubs_catalogue/uploads/INFO0811_e.pdf


(34) Zablotska LB, Lane RS, Thompson PA. A reanalysis of cancer mortality in Canadian nuclear workers (1956-1994) based on revised exposure and cohort data. Br J Cancer. 2014;110(1):214-23. http://www.ncbi.nlm.nih.gov/pubmed/24231946


(35) Doss M. Comment on 'Implications of recent epidemiologic studies for the linear nonthreshold model and radiation protection'. J Radiol Prot. 2019;39(2):650-4. https://www.ncbi.nlm.nih.gov/pubmed/31125319


(36) Shore RE, Beck HL, Boice JD, Caffrey EA, Davis S, Grogan HA, et al. Reply to Comment on 'Implications of recent epidemiologic studies for the linear nonthreshold model and radiation protection'. J Radiol Prot. 2019;39(2):655-9. https://www.ncbi.nlm.nih.gov/pubmed/31125317


(37) Davis FG, Boice JD, Jr., Hrubec Z, Monson RR. Cancer mortality in a radiation-exposed cohort of Massachusetts tuberculosis patients. Cancer Res. 1989;49(21):6130-6. http://www.ncbi.nlm.nih.gov/pubmed/2790825

(38) Hwang SL, Guo HR, Hsieh WA, Hwang JS, Lee SD, Tang JL, et al. Cancer risks in a population with prolonged low dose-rate gamma-radiation exposure in radiocontaminated buildings, 1983-2002. Int J Radiat Biol. 2006;82(12):849-58. http://www.ncbi.nlm.nih.gov/pubmed/17178625


(39) Tubiana M, Diallo I, Chavaudra J, Lefkopoulos D, Bourhis J, Girinsky T, et al. A new method of assessing the dose-carcinogenic effect relationship in patients exposed to ionizing radiation. A concise presentation of preliminary data. Health Phys. 2011;100(3):296-9. https://www.ncbi.nlm.nih.gov/pubmed/21595074


(40) Sasaki MS, Tachibana A, Takeda S. Cancer risk at low doses of ionizing radiation: artificial neural networks inference from atomic bomb survivors. J Radiat Res. 2014;55(3):391-406. http://www.ncbi.nlm.nih.gov/pubmed/24366315


(41) H. R. 10437, July 14, 1964; An Act to incorporate the National Committee on Radiation Protection and Measurements.   https://ncrponline.org/about/congressional-charter/


(42) XLNT Foundation. Debate on Radiation Hormesis, 2020.   https://www.x-lnt.org/debate


(43) Wei LC, Ding YX, Liu YH, Duan L, Bai Y, Shi M, et al. Low-dose radiation stimulates Wnt/beta-catenin signaling, neural stem cell proliferation and neurogenesis of the mouse hippocampus in vitro and in vivo. Current Alzheimer Research. 2012;9(3):278-89. http://www.ncbi.nlm.nih.gov/pubmed/22272614


(44) El-Ghazaly MA, Sadik NA, Rashed ER, Abd El-Fattah AA. Neuroprotective effect of EGb761(R) and low-dose whole-body gamma-irradiationin a rat model of Parkinson's disease. Toxicol Ind Health. 2013. http://www.ncbi.nlm.nih.gov/pubmed/23696346