Wind Concerns Ontario is a province-wide advocacy organization whose mission is to provide information on the potential impact of industrial-scale wind power generation on the economy, human health, and the natural environment.
“A careful reading of this paper shows that the conclusions are not supported by the data provided …”
A paper by Jalali et al was published in the journal Environmental Research last year, concluding that psychological factors contributed to distress and changes in sleep pattern, not the actual wind turbine noise emissions. Many people already living close to wind turbines were disappointed (not to say, astonished) by its conclusions, particularly those who trusted the research team and allowed them into their homes in the hopes of a meaningful and accurate research study.
Engineer and Ontario resident William Palmer did a detailed analysis of the Jalali paper; his comments have just been published by Environmental Research.
It remains a continuing disappointment that ideology (wind power is good and trumps all other concerns) seems to underlie research into the growing public health/environmental health issue associated with industrial-scale wind turbines and the noise emissions they produce. It is also disappointing that researchers continue to look for “psychological” factors instead of taking a public health approach to doing real-world investigation into a real-world health effect.
We say, BELIEVE the complaints from people. Then look for the cause of the problems.
Short-Communication: Revisiting conclusions of the report titled, “The impact of psychological factors on self-reported sleep disturbance among people living in the vicinity of wind turbines”.
by Leila Jalali, Mohammad-Reza Nezhad-Ahmadi, Mahmood Gohari, Philip Bigelow, & Stephen McColl, published in environmental research, volume 148, July 2016, 401–410
The research report concluded, “It appears that self-reported sleep reported of participants may be associated to the indirect effects of visual and attitudinal cue and concern about property devaluation rather than distance to the nearest WT’s or noise as itself.”
Careful reading of the report shows that the conclusions presented are not supported by the data provided in the report.
The Office of the National Wind Farm Commissioner recently released its first full Annual Report to the Parliament of Australia.
In the Summary, the Commissioner reported:
With regard to complaints received, our Office has received a total of 90 complaints about wind farms during the period up to 31 December 2016.
Of these 90 complaints received, 46 complaints were about operating wind farms and related to nine wind farms. As at 31 December 2016, a total of 32 of these complaints have been closed by our Office.
A further 42 complaints received by our Office were about proposed wind farms and related to 19 wind farms. As at 31 December 2016, 33 of these complaints have been closed by our Office.
The remaining two complaints did not specify a wind farm and have been closed.
Almost immediately, pro-wind forces in Australia claimed that the number of complaints noted was very small relative to what had been expected, and noted further that a significant number of the complaint files were closed because the individuals reporting chose not to pursue the matter further.
An obvious explanation for that is, like Ontario, people file complaints with the wind power developers and government but when their reports of adverse health effects and disturbance are met with inaction, they give up.
Conflict of interest
The Commissioner noted that the practice of using acoustics experts so developers may provide reports to government indicating compliance with noise regulations is open to a conflict of interest.
It is very common that the experts engaged to perform the design assessments and reports during the planning phase are the same experts engaged by the developer to perform the post-construction assessments. Developers often use the same experts on multiple projects.
The selection and use of the same expert in both the design and then operating phases of a wind farm may give rise to perceived or real conflicts of interest between the developer and the expert. As a compliance with the noise standard and is then engaged to assess the operating wind farm for actual compliance, may be placed in a difficult situation if the acoustician discovers the operating wind farm is in fact non-compliant, particularly if areas of non-compliance may be a result of errors made in the original acoustician’s pre-construction assessment.
There is certainly scope for a better separation between the experts used for the predictive assessments versus the experts used for the post-construction assessments of a wind farm, along with peer review of the expert’s work so as to minimise errors, maximise transparency and better manage perceived or real conflicts of interest. (page 28)
Wind power companies not managing complaints properly
What the pro-wind forces fail to point out too, is that the Commissioner was harsh in his criticism of how wind turbine noise complaints are managed by the wind power companies.
… our observations are that many wind farms are not following their own documented procedures when handling complaints, leading to situations including:
• multiple complaints from a resident about the same issue with no action being taken by the wind farm operator to investigate or resolve
a lack of rigour in investigations and correspondence, and
• a lack of clarity regarding next steps in the process leading to numerous complaints that remain unresolved and/or have not been closed.
Even if the endorsed complaint handling procedures were being followed, there is also a wide range of wind farm complaint handling procedures in place that vary by developer and project, resulting often in a lack of consistency in the quality and effectiveness of the procedures. Although wind farm operators possess a wide range of complaint handling skills, there are further opportunities to improve the capability of staff and effectiveness of the wind farm industry’s complaint handling procedures.
We have encouraged a number of wind farm developers and operators to voluntarily publish their complaint handling procedures on the wind farm’s website… (page 29)
Moreover, the Commissioner said, noise emission audits are not covering the full range of noise produced by the turbines, including “tonal” or “low frequency noise.”
In assessing noise-related complaints, the objective ‘tests’ currently in place do not necessarily capture the tonal character of noise emissions that a complainant may be experiencing. For instance, insufficient maintenance of infrastructure (for instance, a turbine or a substation transformer) may lead to harmonic frequencies that produce a harsher tone to the human ear. While this is not typically represented in noise assessment data, contemporary noise measurement or recording devices can be used to indicate that the tonal character of a particular noise emission may reasonably be considered to be disturbing or offensive to a complainant. (page 29)
Adverse health effects
As to specific adverse health effects reported, the Commissioner said that in the absence of actual medical reports it was difficult to make any conclusions.
Complaints regarding health concerns received by our Office, to date, have provided only anecdotal evidence regarding stated health issues and causality. It has therefore been difficult to confirm whether or not the stated health conditions reported by complainants are a direct result of the wind farm’s operations or from some other cause.
It is possible that stated health conditions may be caused by other known causes not related to the wind farm’s operations. Of concern is the potential situation whereby a resident may fail to seek and obtain appropriate medical advice for a treatable condition due to the possibly incorrect assumption that an operating wind farm is perceived as the cause of the health condition.
Health conditions may also arise as a result of stress, annoyance or anxiety related to the presence of an operating wind farm or concerns about the effects of a proposed wind farm. Further, uncertainties in relation to whether a proposed wind farm will actually proceed (a period which may extend for several years) may also contribute to stress and anxiety. Again, affected residents may need to seek appropriate medical treatment for their health conditions as well as seek ways to resolve their concerns.
The Commission recommended:
9.2.1. Federal and state governments should continue to assess the outcomes of research into wind farms and health, including outcomes of the two NHMRC funded wind farm health studies and recommendations of the ISCOWT. Environmental standards should be monitored and reviewed in line with any recommendations arising from these programs.
9.2.2. Residents living in the vicinity of an operating or proposed wind farm that are experiencing health conditions should be encouraged to seek appropriate medical advice to properly diagnose and treat any health-related conditions accordingly.
9.2.3. Medical practitioners who identify causational links between a patient’s health condition and their proximity to the operation of a wind farm should report such incidences in an appropriate way to the relevant professional body, association and/or government agency.
9.2.4. Residents who are experiencing unacceptable noise levels from a wind farm should be encouraged to report such incidents to the wind farm operator, the compliance authority and/or the appropriate regulator.
Don’t stop reporting
People wishing to report excessive noise or vibration from industrial-scale wind turbines should call the Ontario Ministry of the Environment and Climate Change at 1-800-268-6060; if the call is placed during business hours, the caller may be referred to the local District Office.
The caller should receive an INCIDENT REPORT NUMBER.
The MOECC has told Wind Concerns Ontario that callers should be prepared to provide:
name and telephone number
direction of the wind
wind speed (this is available from the weather network on TV or on your “smart” phone)
location relative to the nearest turbine(s)
a rating of the noise and/or vibration/pressure on a scale of 1-10, with 10 being most severe.
MOECC admission of ‘tonality’ a step forward but more action needed
(C) Wind Concerns Ontario
Residents living near the K2 wind power project in the Township of Ashfield-Colborne-Wawanosh have received a report from the Ontario Ministry of the Environment and Climate Change following noise testing done at their property, Wind Concerns Ontario has learned.
WCO received a copy of the MOECC report and other correspondence from the residents, who are members of the coalition of Ontario community groups and individuals in Ontario concerned about the impact of wind turbines on the economy, natural environment, and human health.
The noise testing was done at their request, connected to complaints made to the MOECC about excessive noise and sound pressure or vibration being emitted from industrial-scale wind turbines at the K2 power project.
The MOECC report’s Executive Summary states that
Based on the results of the analysis, it is acknowledged that sound from the wind turbines was audible during the measuring campaign at levels that appear to exceed the applicable sound level limits, and based on C3 measurements conducted at a nearby receptor (the distance is about 1250 m from R876; where the same turbine(s) within 1500 m distance impact both receptors) it was further concluded that there is a possibility that sound from the nearby turbines could be tonal. To confirm compliance, it is recommended that a tonal audibility assessment and detailed noise audit be undertaken in accordance with Part D of the draft Compliance Protocol for Wind Turbines Noise, NPC 350, 2017.
This is remarkable as it is the first time MOECC supervisory staff have admitted to “tonality” in wind turbine noise emissions. And also because, in previous noise testing by the MOECC, the Ministry claimed results were “inconclusive” due to other noises such as birds chirping and tree leaf movement.
A tonal audibility assessment is a step forward.
Is it enough?
The Ministry needs to acknowledge that there is a problem with wind turbine noise emissions, and in the case of this particular report and recommendation, immediate action is required, including comprehensive testing including for infrasound which was excluded by the equipment used for these tests.
It is time for government to accept responsibility for its wind power program and the impacts on people who were given no choice but to live with them.
Testing being done for audible noise alone–residents’ symptoms indicate other problems
Two Ontario municipalities are supporting the call for the Ministry of the Environment and Climate Change to do comprehensive testing for the full range of noise emissions from wind turbines.
Last night, Kincardine Council supported residents Norma and Ron Schmidt, who have been forced from their home because of adverse health effects from the noise and pressure produced by turbines near them, in sending a letter to the Ministry.
The situation echoes that of Port Elgin where hundreds of complaints have been filed with the Ministry about the turbine on the property owned by Unifor. The municipality of Saugeen Shores has repeatedly asked the Ministry to conduct the necessary investigations, to no avail.
“The government said they were safe”
See the video by CTV London reporter Scott Miller here.
Prince Edward County remains in a state of emergency today following an accident in which a barge being used to transport materials to the Windlectric wind power project on Amherst Island sank, polluting the waters of Picton Bay with diesel fuel. At the time of the incident, Windlectric had no Marine Logistics Plan in place.
The Association to Protect Amherst Island has called for cancellation of the power project, and issued this statement today.
Dear Premier Wynne:
Prince Edward County Mayor Robert Quaiff has declared a water emergency as a result of contaminants approaching the Picton-Bloomfield water intake due to a partially sunken barge in Picton Harbour under contract to McNeil Marine and ultimately under contract to Algonquin Power/Windlectric for the proposed Amherst Island Wind Project.
The silence from Algonquin Power/Windlectric is deafening.
Indeed Algonquin/Windlectric had the audacity to attempt to continue aggregate delivery from Picton Terminals to Amherst Island yesterday (Tuesday March 28 2017) but was thwarted either because either the water was too low or the dock too high, yet another example of the comedy of errors associated with this ill-conceived project.
The Association to Protect Amherst Island reiterates its request for MOECC to issue an immediate stop work order for the Amherst Island Wind Project until such time as a comprehensive report is available for the Picton Harbour incident and a preventative action plan is is place to address the high risk to public and environmental safety of all aspects of the project. and to address the need for a Major Design Modification to address the changed project location to include Picton Terminals.
At the same time, the Association reaffirms its request to reject the proposed amendment to the Certificate of Property Use for the contaminated Invista Lands on Bath Road (EBR 012-9749) designated as parkland. Similar to the Picton Harbour situation, a water intake exists in proximity to the proposed mainland dock for the Amherst Island Wind Project and serves a local industrial park. Algonquin/Windlectric in its Marine Safety Plan now advises that fuelling of barges is proposed at the mainland dock location. Not only is the land contaminated with the possibility of pollution of Lake Ontario, the company plans to fuel in proximity to a water intake.
The same “Marine Safety Plan” fails to address any aspect of transport of materials from Picton terminals except for a vague reference that “The bulk barge and the ATV (Aggregate Transfer Vessel) will approach and leave the island dock area from the west, . . . ” as if from the Land of Oz. The Association is in the process of reviewing this “too little, too late” document and will have further comments about use of barges in ice conditions, the lack of traffic volume, lack of simulation of barges crossing the ferry path, incomplete information about the installation of the high voltage transmission line from the mainland to the Island and the total lack of risk assessment, failure to mention Picton Terminals,among other matters.
The use of an “Aggregate Transfer Vessel” was not identified in the REA submission and no stockpiling of aggregate was proposed other than in immediate proximity to the proposed cement batching plant by the Island school.
The Association has emphasized the importance of marine safety since this project was proposed and has pleaded with politicians, MOECC, Ontario’s Chief Drinking Water Official and the Chief Fire Marshall and Head of Emergency Preparedness.
Please take immediate action to stop the Amherst Island Wind Project before a tragedy occurs.
TITLE: Industrial wind turbines can harm humans
PRESENTER: Carmen M Krogh
DATE: Wednesday, March 29, 2017. 10:00am.
LOCATION: DC 1302 (Davis Centre), University of Waterloo
The topic of the risk of harm to human health associated with wind energy facilities is controversial and debated worldwide. On May 7, 2014, Carmen Krogh presented a seminar at the University of Waterloo which considered some of the research dating back to the early 1980s. A snapshot of some of the current research available in 2014 was provided. The research is challenged in part by the complexities and numerous variables and knowledge gaps associated with this subject. This presentation will explore some of these research challenges and provide an update on the growing body of evidence regarding human health risk factors. Included will be the emerging research indicating risks to those working in this field.
Carmen M Krogh is a full time volunteer and published researcher regarding health effects and industrial wind energy facilities and shares information with communities; individuals; federal, provincial and public health authorities, wind energy developers; the industry, and others. She is an author and a co-author of peer reviewed articles and conference papers presented at wind turbine scientific noise conferences. Ms Krogh is a retired pharmacist whose career includes: senior executive positions at a teaching hospital (Director of Pharmacy); a drug information researcher at another teaching hospital; a Director of a professional organization; and a Director (A) at Health Canada (PMRA). She is the former Director of Publications and Editor in Chief of the Compendium of Pharmaceuticals and Specialties (CPS), the book used by physicians, nurses, and health professionals for prescribing information in Canada.
Selected publications by Carmen Krogh as author or co-author:
In the January edition of respected publication Sound & Vibration, is an article “Health Effects from Wind Turbine Low Frequency Noise & Infrasound,” published by four authors billed as :”very experienced independent investigators.”
The debate about adverse health claims has “raged for at least a decade,” the authors write, “and is now at an impasse.”
“Permitting authorities for new projects must evaluate adverse health effect claims presented as proven factual data by opposition forces, countered by project advocates who state that no physical link to health effects has ever been demonstrated”.
The lead author, George Hessler of Virginia, USA, says that all four authors “do not doubt for a moment the sincerity and suffering of some residents close to wind farms and other low-frequency sources…this is the reason all four would like to conduct, contribute or participate in some studies that would shed some light on this issue.”
“It must also be said,” Hessler continues, “that it is human nature to exaggerate grievances …”
Responses are being developed by various individuals, including colleagues involved in acoustics, and citizen groups, which we will publish when available.
Wind Concerns Ontario sent a letter to the editor expressing concern that although the word “health” is in the article title, and is the focus of the paper, not one of the four authors has any medical expertise. Moreover, WCO said, the methodology proposed by the authors fails to “include current directions of research on the rapidly changing understanding of wind turbine noise.”
“Based on the reports of the impact of wind turbines on the people living among the many Ontario projects,” WCO president Jane Wilson wrote, “we know that the emissions from wind turbines are challenging existing methodologies and analysis paradigms used by acousticians. The range of sound pressure waves emitted by wind turbines are multi-dimensional; a full understanding of the issue can come only from acousticians who are willing to move outside of existing procedures and investigate complaints without preconceived notions of answers when working on the topic.
“It is not clear that the authors of the article were willing to do this.”
Wind Concerns suggested to the Editor, and the authors, that a good starting point is to “assume that people’s complaints are valid”; we also referred to the work done in Australia by Steven Cooper. As well, reliance on A-weighted noise measurement is no longer adequate to really assess the type of noise emissions produced by industrial-scale wind turbines.
A resident of Dover Centre in Chatham-Kent is calling for leaseholders in wind turbine projects to be released from the non-disclosure or “gag” clauses that are preventing full awareness of the situation regarding contaminated well water in the region, says a resident writing in the Sydenham Current.
When the recent appeal of the North Kent 1 wind power project was dismissed, the only expert advice offered was the technical report completed by Golder & Associates, paid for by the wind power developer.
“What if accepting the wind developer’s Golder report the Mayor and Mr. Norton put all of Chatham township’s property at risk from an environmental stigma?” asks letter writer Peter Hensel.
” A stigma that the aquifer below would be contaminated with vibrations and is no longer capable of providing safe clean water. You think your property won’t drop like a stone in value? Think again.
“What if accepting the Wind developer’s Golder report the Mayor and Mr Norton allowed pile driven turbine foundations that increased the heavy metal concentrations in the source water – the water in the aquifer below Chatham township? What price do you put on your families’ health?”
The Environmental Review Tribunal refused appellant Kevin Jakubec time to have other experts review the Golder report, which jeopardized his appeal.
“It was only because the MOECC [Environmental] Tribunal Branch refused a time extension to let Mr. Jakubec bring in well test results from Dover into the Trubunal’s final hearing did Mr. Jakubec make the best of Tribunal process and took what gains he could get from the mediation.
“Ask Mr. Jakubec if he stopped investigating Dover,” says Mr Hensel. “Ask Mr. Jakubec if the Tribunal process is fair and that everything is neatly wrapped up now as Mayor Hope and [C-K legal counsel] Mr. Norton would want you to believe.”
Here is a paper from the Energy Collective, which includes a summary of noise regulations and setbacks. The writer’s conclusion is that worldwide regulation is needed, otherwise local regulation of noise is developed, with heavy influence from the wind power industry.
December 19, 2016
Europe and the US have been building onshore wind turbine plants in rural areas for more than 25 years. Anyone living within about 1.0 mile of such plants would hear the noises year-round, year after year. Those nearby people would be experiencing:
Decreasing property values.
Damage to their health, due to lack of sleep and peace of mind.
Living with closed windows and doors, due to year-round noises.
Exposure to infrasound.
The wind turbine noise problem is worldwide. Due to a lack of worldwide guidelines, various political entities have been developing their own codes for the past 30 years. The World Health Organization is finally addressing the lack of detailed guidelines regarding such noises.
World Health Organization Noise Guidelines: WHO, publishes detailed guidelines regarding various, everyday noises, such as near highways and airports, within urban communities and in work places. The guidelines serve as input to local noise codes.
In general, wind turbines are located in rural areas. When they had low rated outputs, say about 500 kW in the 1960s and 1970s, they made little audible noise, and the infrasound was weak. However, when rated outputs increased to 1000 kW or greater, the audible and infrasound noises became excessive and complaints were made by nearby people all over the world.
Worldwide guidelines regarding wind turbine noises are needed to protect nearby rural people, such as regarding:
The maximum outdoor dBA value, how that value is arrived at, such as by averaging over one hour, where that value is measured, such as near a residence, or at the resident property line to enable that resident to continue to enjoy his entire property.
How to measure, or calculate the outdoor-to-indoor sound attenuation of a residence.
How much setback is needed, such as one mile to minimize infrasound impacts on nearby residents.
The maximum dB value of infrasound, how that value is arrived at, where that value is measured.
How to determine the need for a 5 dB annoyance penalty.
The lack of such guidelines has resulted in various political jurisdictions creating their own codes. That process has been heavily influenced by well-financed, pro-wind interests, which aim to have the least possible regulation to maximize profits.
Comparison of Wind Turbine Codes: Below are some highlights from the noise codes of various political entities to illustrate their diversity:
1) DENMARK: Because Denmark was an early developer of wind turbine plants, its noise code is more detailed than of most political entities. It has a buffer zone of 4 times total height of a wind turbine, about 4 x 500 = 2,000 ft, about 0.61 km (no exceptions), and it also has the following requirements regarding outdoor and indoor noise:
For dwellings, summer cottages, etc.: 39 dBA (wind speeds of 8 m/s, 18 mph) and 37 dBA (wind speeds of 6 m/s, 13 mph)
For dwellings in open country: 44 dBA (wind speeds of 8 m/s) and 42 dBA (wind speeds of 6 m/s)
The belowregulations describe the methods and time periods over which sounds are to be measured:
Page 4, par 5.1.1 mentions averaging over various periods. Only the worst average readings of a period are to be considered for compliance.
Page 4, par 5.1.2 mentions a 5 dB annoyance penalty must be added to the worst average readings for a period for clearly audible tonal and impulse sounds with frequencies greater than 160 Hz, which would apply to wind turbine sounds.
Page 6, par 5.4 mentions limits for indoor A-weighted low frequency noise 10 – 160 Hz, and G-weighted infrasound 5 – 20 Hz.
“If the perceived noise contains either clearly audible tones, or clearly audible impulses, a 5 dB annoyance penalty shall be added to the measured equivalent sound pressure level” That means, if a measured outdoor reading is 40 dBA (open country, wind speed 6 m/s), and annoyance is present, the reading is increased to 45 dBA, which would not be in compliance with the above-required 42 dBA limit.
In some cases, a proposed wind turbine plant would not be approved, because of the 5 dB annoyance penalties. The noise of wind turbines varies up and down. The annoyance conditions associated with wind turbines occur year-round. The annoyance conditions associated with other noise sources usually occur much less frequently.
NOTE: The 5 dB penalty does not apply to indoor and outdoor low frequency and infrasound noises, i.e., 160 Hz or less.
– For both categories (dwellings, summer cottages, etc.; open country), the mandatory limit for low frequency noise is 20 dBA (Vermont’s limit is 30 dBA), which applies to the calculated indoor noise level in the 1/3-octave bands 10 – 160 Hz, at both 6 and 8 m/s wind speed. The purpose of the regulation is to ensure neither the usual noise, nor the low frequency noise, will annoy nearby people when the wind turbines are in operation.
Denmark’s Controversial Noise Attenuation Calculations: The controversy in Denmark is regarding the Danish EPA assuming high attenuation factors for calculating attenuation from 44 dBA (outdoor) to 20 dBA (indoor, windows closed) for frequencies above 63 Hz, which yield calculated indoor noise levels less than 20 dBA. The Danish EPA prefers assuming high factors, because they result in compliance, which is favorable for wind turbines.
However, acousticsengineers have made indoor field measurements (supposedly “too difficult to measure”, according to the Danish EPA), which indicate many houses near wind turbine plants have lower than assumed attenuation factors, which results in indoor noise levels greater than 20 dBA, i.e., non-compliance, which is not favorable for wind turbines.
However, the final arbiters should not be government personnel using assumptions, but the nearby people. Increasingly, those people are venting their frustrations at public hearings and in public demonstrations.
2) POLAND is considering a proposed a law with a 2.0 km (1.24 mile) buffer zone between a wind turbine and any building. That means at least 65% of Poland would be off limits to wind turbines. Future wind turbine plants likely would be offshore. …
Four years ago, Dr Robert McMurtry (former Dean of Medicine and Western University, companion of the Order of Canada) and independent health researcher (retired pharmacist and health care executive) Carmen Krogh published a “case definition” and diagnostic criteria as a diagnostic tool to help family physicians and others caring for patients who may have been exposed to wind turbine noise emissions. The paper was first published in the Journal of the Royal Society of Medicine, in 2014.
The diagnostic criteria, McMurtry and Krogh explain, were “intended to be used by licensed medical practitioners trained in diagnostic procedures. The case definition requires application of professional medical judgment and diligence including the conduct of a thorough history, physical examination and investigation to rule out alternative explanations” for the patient’s symptoms.
Dr. Robert McCunney and Dr David Colby, with two other authors, published a critique of the case definition which was published in 2015. Among other comments, the doctors alleged that Dr McMurtry and Carmen Krogh failed to give any “indication of potential conflicts of interest” in their original article.
McCunney and Colby fail to disclose wind industry payments
In the article published yesterday, McMurtry and Krogh responded that as health care professionals both were quite aware of the need to disclose any conflict of interest … there simply wasn’t any. Moreover, they wrote in rebuttal, “the obligation to state potential conflicts of interest would also extend to the authors McCunney et al. Any statement should include Drs McCunney, Mundt and Colby relationships with the wind industry including, but not limited to, payments received from the wind industry to serve as experts and/or prepare reports. ”
“The declaration by McCunney et al. is incomplete,” McMurtry and Krogh conclude, “as it omits disclosure of payments received for other services …”
Mathematical exercise could mislead
Other aspects of the McCunney group critique are discussed and refuted, and McMurtry and Krogh make the particular point that the “display of combinatorics” by McCunney and colleagues was an exercise in math that had the potential to “mislead readers as it fails to use the case definition as it is presented and intended.”