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[1] Abraham J. Gitlitz Memorial Lecture: Development of a BroadSpectrum Antiviral-based Intranasal Spray as a Pandemic Preparedness Strategy. Kenneth E. Palmer, Ph.D, Center for Predictive Medicine for Biodefense and Emerging Infectious Diseases and Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY In early 2020, the public health emergency prompted many researchers to contemplate how they might contribute to control of the COVID-19 pandemic. This presentation will detail the research steps taken to bring a novel broad spectrum antiviral protein into a first in humans clinical trial. We had been developing a broad spectrum antiviral protein, the lectin Q-Griffithsin (Q-GRFT), as a topical microbicide for HIV-1 prevention. We knew that Q-GRFT also inhibited replication of many members of the Coronavirus family of pathogens, so initiated a rapid preclinical and clinical development program of a Q-GRFT intranasal spray as a prophylaxis modality against SARS-CoV-2, the virus that causes COVID-19. We finalized a suitable formulation to deliver Q-GRFT to the nasopharynx, the initial site of replication of SARS-CoV-2. Non-clinical toxicology studies supported first-in-human clinical studies. Efficacy studies in mice and hamsters provided proof of concept that Q-GRFT can protect animals against challenge. We filed an investigational new drug (IND) application, and received study may proceed authorization from the FDA. We conducted a randomized, placebo-controlled single dose safety and pharmacokinetics clinical study in 18 volunteers, all of whom had been vaccinated against SARS-CoV-2. The product was safe, and enhanced the levels of SARS-CoV-2 as well as MERS-CoV inhibitory activity present in the nasal and naso-pharyngeal swabs. The safety and pharmacokinetics profile of our Q-GRFT intranasal spray supports a multi-dose Phase 1b clinical study, and further development as a general pandemic preparedness strategy. Upon completion of this activity, participants should be able to: describe the preclinical and clinical strategies employed to support a first in humans clinical trial of a novel broad-spectrum antiviral protein containing nasal spray; discuss planning, design and execution of a first-in-humans Phase 1a clinical trial for evaluation of safety, and selection of a dosing strategy for a Phase 1b multiple dose safety and pharmacokinetics study. [2] Acetylation pharmacogenomics: paradigm for informed individual risk assessment following environmental carcinogen exposure. David W. Hein, Ph.D, University of Louisville, Louisville, KY Human epidemiological studies associating chemical exposures to cancer risk often are inconsistently validated across studies. Examples include the effect of smoking on cancer etiology other than the lung, such as urinary bladder and breast. Research findings from the laboratory have improved the understanding of arylamine carcinogen metabolism leading to improved design and interpretation of human molecular epidemiology investigations. Laboratory studies that infer and test biological plausibility, including cancer risks modified by differential metabolism of arylamine carcinogens in rapid and slow arylamine N-acetyltransferase (NAT2) acetylators, have been critical for investigating the role of smoking in the etiology of human cancers. This chapter will illustrate these concepts with an example of a cancer in which the role of smoking has largely been validated (urinary bladder cancer) and examples where a consensus has yet to be achieved. Portions of this work were funded by the following NIH grants: R01-CA034627; T32-ES011564; P42-ES023716; P20-GM113226; R25-CA134283; and P30-ES030283. Upon completion of this activity, participants should be able to: 1. Assess the role of genetic polymorphisms in individual risk assessments following exposures to environmental carcinogens. 2. Recognize the importance of laboratory-based data in the biological plausibility of individual risk assessments. 3. Recognize the genetic complexity inherent in human epidemiological studies. [3] Rolling with the punches: A biosafety program at a research university addresses COVID-19. Allen Helm, PhD, The University of Chicago, Chicago, IL This presentation describes the biosafety program at a research university and medical center, demonstrating how the program was modified during the COVID-19 pandemic. Biosafety professionals are tasked with facilitating biomedical research by enacting coordinated efforts to protect research staff and students, the larger research community, and the environment and ecosystem from biological hazards used in the laboratory. These hazards include recombinant organisms ranging from microorganisms to animals, microbial pathogens, human-derived material, and biological toxins. The University of Chicago (UChicago) is an academic research institution affiliated with an urban medical center. There are approximately 300 biomedical principal investigator-led laboratories conducting investigations in basic, translational, and clinical science. The biosafety program at UChicago is part of the Office of Research Safety and consists of a director and four biosafety officers who perform a variety of duties, including: 1) Assisting researchers in planning experiments that utilize biohazards; 2) Developing and delivering biosafety training courses; 3) Performing annual inspections of laboratories; 4) Working with the university's Institutional Biosafety Committee; 5) Ensuring compliance with local, state, and federal agencies. The COVID-19 pandemic affected the biosafety program in several ways, as follows: 1) Altering administrative operations; 2) Developing biosafety standards for investigators working with SARS-CoV-2; 3) Establishing a "COVID Core" to handle influx of said researchers; 4) Enhanced biosafety interactions with clinical laboratories due to a demand for vaccines and treatments. Upon completion of this activity, participants should be able to: 1. Identify the role of biosafety professionals in basic, translational, and clinical research. 2. Recognize how a pandemic can alter the way biosafety services are delivered to research programs. 3. Recognize the need for flexibility in a successful biosafety program. [4] An interdisciplinary Post Operative Personalized Pain Management Clinical Trial. Loralie J. Langman1, Jeremy Gaskins2, Gwendolyn A. McMillin3, Paul J. Jannetto1, Brandi Hartley4, Arthur Malkani4, and Saeed A. Jortani5, department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, 2Departments of Bioinformatics and Biostatistics, University of Louisville School of Medicine, Louisville, KY, 3Department of Pathology, University of Utah, ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, 4Departments of Orthopedic Surgery, University of Louisville School of Medicine, Louisville, KY, and 5Departments of Pathology, and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY Various sources of variability in response and toxicity to hydrocodone were investigated. In a cohort of orthopedic surgery patients, we interrogated the associations between genetic, intrinsic and extrinsic patient factors, plasma concentrations of hydrocodone and metabolites, common side effects, and pain score. Data for each patient was collected by the review of the electronic medical record and a patient interview at the time of sample collection. Patients with trauma or undergoing scheduled elective surgery for total knee or total hip replacement at the University of Louisville, Baptist East, and Jewish Hospitals, Louisville, KY. Plasma opiate concentrations and a targeted genotyping panel were performed. We observed statistically significant correlations for daily (p<0.001) and total dose (p=0.002) of hydrocodone. Duration of in-hospital and duration of opioid therapy for patients were also significantly different based on their genotypes. The length of opioid administration was significantly shorter in CYP2D6 EM/UM compared to patients with CYP2D6 PM/IM genotypes (p=0.018). Subjects with the OPRM1 c.118G polymorphism were also on opioids for a longer period of time (p=0.022). Co-administration of medications with CYP2D6 inhibitor activity had a significant effect on the length of opioid therapy (P<0.001). Both the hospital stay period and days of opioid use post hospital discharge were greater in patients with the inhibitor-adjusted CYP2D6 phenotype (p<0.001). This trial showed that patients should be evaluated for the use of inhibitors of CYP2D6. Interaction with these therapeutics while administering hydrocodone therapy can alter the phenotype of the patient (phenocopy) and result in longer opioid therapy duration. Upon completion of this activity, participants should be able to: 1. to discuss various sources of variability to response and toxicity of analgesics. 2. to present the post-operative pain management trial in a cohort of women just undergone Cesarean Section. 3. to present the post-operative pain management trial in a cohort of lower extremity orthopedic patients. [6] Claude P. Brown Memorial Lecture: The Many Roads to Steatohepatitis and its Treatment. Craig J. McClain, MD, University of Louisville School of Medicine,Louisville, KY Hepatic steatosis and steatohepatitis are common histologic findings that can be caused by multiple etiologies. The three most frequent causes for steatosis/ steatohepatitis are alcohol (alcohol-associated steatohepatitis, ASH), obesity/metabolic syndrome (nonalcoholic steatohepatitis, NASH), and environmental toxicants (toxicant-associated steatohepatitis, TASH). Hepatic steatosis is an early occurrence in all three forms of liver disease, and they often share common pathways to disease progression/severity. Disease progression is a result of both direct effects on the liver as well as indirect alterations in other organs/tissues such as intestine, adipose tissue, and the immune system. Although the three liver diseases (ASH, NASH, and TASH) sharemany common pathogenic mechanisms, they also exhibit distinct differences. Both shared and divergent mechanisms can be potential therapeutic targets. I will provide an overview of selected important mechanistic similarities and differences in ASH, NASH, and TASH, and discuss the importance of a multidisciplinary and personalized approach. Upon completion of this activity, participants should be able to: 1. understand the mechanisms including similarities and differences between ASH, NASH and TASH. 2. understand targets to treat ASH, NASH and TASH. 3. recognize tests to help distinguish between ASH, NASH and TASH. [7] Bioactive lipid metabolites: biomarkers and therapeutic targets in alcohol-associated liver disease. Dennis Warner, Josiah Hardesty, Jeff Warner, Craig McClain, Irina Kirpich, University of Louisville, Louisville, KY Alcohol-associated liver disease (ALD) is a spectrum of liver disorders ranging from steatosis to steatohepatitis, fibrosis and cirrhosis. The mechanisms and mediators of ALD progression are not well understood and effective therapeutic options are limited. Various bioactive oxidized lipid mediators (oxylipins) have recently emerged as important factors in ALD pathogenesis. The current study aimed to examine plasma linoleic acid (LA)-derived lipid metabolites in heavy drinking individuals and to evaluate associations between these molecules and markers of liver injury. Analysis of plasma LA-derived metabolites was performed by HPLC/MS on 66 heavy drinking individuals and 29 socially drinking but otherwise healthy volunteers. Based on plasma ALT levels, 15 patients had no liver injury (ALT ≤ 40 U/L), 33 patients had mild liver injury (ALT > 40 U/L), and 18 were diagnosed with moderate Alcohol-associated Hepatitis (mAH). Statistically significant differences (set at p<0.05) were determined by One-way ANOVA. Lipoxygenase-derived LA metabolites, 13-HODE and 13-oxoODE, were markedly elevated only in mAH patients. The CYP450-derived LA epoxides, 9,10-EpOME and 12.13-EpOME were decreased in all patients regardless of the presence or the absence of liver injury. LA-derived diols, 9,10-DiHOME and 12.13-DiHOME, were elevated only in the mAH group. The current study provides evidence that specific changes in LA-metabolites in heavy drinking individuals can distinguish individuals with mAH from those with mild ALD. Upon completion of this activity, participants should be able to: 1. identify effects of alcohol consumption on circulating oxylipins; 2. determine the role of oxylipins in ALD pathogenesis; 3. associate severity of ALD with the specific changes in oxylipins [8] Hepatic protein and phosphoprotein signatures of alcohol-associated hepatitis. Josiah Hardesty, Jeffrey Warner, Dennis Warner, Craig McClain, and Irina Kirpich, University of Louisville, Louisville, KY The objective of the current study was to identify hepatic proteome and phosphoproteome signatures of alcohol-associated hepatitis (AH). AH is a clinical manifestation of ALD characterized by compromised liver function contributing to a 6-month mortality rate as high as 50%. Proteomic and phosphoproteomic analyses were conducted on explant liver tissue from AH patients (n=6) and non-AH controls (n=12). Data were statistically compared by an unpaired Student's t-test and a p < 0.05 was considered statistically significant. Alterations the expression of multiple proteins involved in various biological processes were observed in AH. Among significant findings in AH included elevated expression of pro-fibrotic transcription factors, reduced albumin (ALBU) phosphorylation, and diminished expression of functional mitochondria proteins. One transcription factor involved in fibrogenesis, yes1-associated transcriptional regulator (YAP1) was elevated in AH (p=0.003), along with increased phosphorylation at pS105 (p=0.01). In addition, expression of hepatic ALBU was elevated in AH (p=0.04) concomitant with diminished ALBU phosphorylation (p=0.02), which may prevent ALBU release leading to hypoalbuminemia. Lastly, we found a loss in the expression of mitochondria proteins in AH, including enzymes essential for mitochondria function and biogenesis (e.g., hydroxyacyl-CoA dehydrogenase trifunctional multienzyme complex subunit alpha, [ECHA] p=0.04). This study identified hepatic protein and phosphoprotein signatures of AH which may facilitate the development of novel therapeutic strategies. Upon completion of this activity, participants should be able to: 1. understand the hepatic proteomic changes that occur in AH, 2. recognize hepatic protein and phosphoprotein signatures of AH and 3. identify novel mechanisms and pathways implicated in AH. [9] Soluble epoxide hydrolase inhibition in alcohol-associated liver disease: liver-specific drug delivery. Jeffrey Warner, Josiah Hardesty, Ying Song, Philip Bauer, Chirag Soni, Claudio Maldonado, Craig McClain, Dennis Warner, Irina Kirpich, University of Louisville, Louisville, KY Alcohol-associated liver disease (ALD) is a prevalent condition resulting from excessive alcohol consumption. Advanced stages of ALD, such as alcohol-associated hepatitis (AH), cause significant mortality and lack effective therapies. Previous data established that soluble epoxide hydrolase (sEH, an enzyme which degrades beneficial lipid epoxides) is induced in clinical/ experimental ALD, and that sEH inhibition may be an effective treatment for this disease. This study aimed to improve this approach by using liverspecific drug delivery via fusogenic lipid vesicles (FLVs) to increase efficacy and avoid extra-hepatic side effects. We prepared fluorescent-labeled FLVs loaded with the sEH inhibitor t-TUCB (t-TUCB-FLVs) at various doses. t-TUCB-FLV preparations had an appropriate size and charge and were confirmed to target the liver by fluorescent microscopy. Flow cytometry demonstrated that hepatocytes and macrophages were most responsible for t-TUCB-FLV uptake. In a dose response experiment using a chronic-binge ethanol feeding model mimicking AH, mice receiving ethanol+3.0 mg/kg t-TUCB-FLVs had the greatest reduction in liver injury by plasma ALT. This treatment was more efficacious than systemically delivered (non-FLV-encapsulated) t-TUCB at the same dose. t-TUCB-FLVs also decreased liver cell death and ER stress but had no effect on steatosis or neutrophil infiltration. These data demonstrated that liver-specific delivery of t-TUCB was more efficacious than systemic delivery. This drug delivery platform may help increase the efficacy of sEH inhibition in ALD while reducing extra-hepatic side effects, improving translation to humans. Upon completion of this activity, participants should be able to: 1.recognize the pathogenic role of sEH in ALD; 2. Describe basic concepts in liver-specific drug delivery by nanoparticle systems; and 3. Evaluate the beneficial effects of a liver-targeted sEH inhibitor in experimental ALD in mice. [10] COVID-19 and early post-primary TB: commonalities of pathobiology in pneumonitis and therapies. Robert L. Hunter and Robert E.Brown, UTHealth McGovern Medical School Houston, TX Concurrent infection with COVID-19 and M. tuberculosis has been reported to be more severe than either alone, resulting in increased mortality. Our objective was to define the shared pathobiology of COVID-19 and the developmental stage of TB in the lung and explore adjunctive therapies to treat such commonalities. We used similar morphoproteomic analyses to study lung tissues of patients with early postprimary tuberculosis or COVID-19 infection.These studies showed colocalization of the COVID-19 virus and M. tuberculosis antigens with cyclo-oxygenase-2 and fatty acid synthase in the reactive alveolar pneumocytes and with programmed death-ligand 1 expression on the alveolar interstitium and alveolar pneumocytes.This was associated with accumulation of pro-infectious M2 polarized macrophages in the alveolar spaces.The commonalities in these pathways suggest that they might be susceptible to adjunctive therapies with metformin and vitamin D3. This is supported by published studies that metformin and vitamin D3 could reduce the severity of both COVID-19 and early post-primary TB infections. Upon completion of this activity, participants should be able to identify and define the commonalities in the pathobiology of COVID-19 and early post-primary TB pneumonitis and describe the potential targets for therapy with metformin and vitamin D3. [11] Plasma ctDNA for Monitoring Response to Immune Check Point Inhibitors. Mark W. Linder PhD, DABCC, FAACC. Professor Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY Circulating tumor DNA (ctDNA) measurements from a variety of malignancies are aggressively being investigated in the context of a "liquid biopsy" to provide for a minimally invasive means of monitoring tumor status and therapeutic response. This session will discuss what is known about the biologic and physiological characteristics of plasma ctDNA. We will then describe the what is known regarding the relationship between plasma ctDNA and tumor characteristics such as tumor burden, proliferative activity and therapeutic response . Understanding of these relationships is central to developing a fundamental framework for interpretation longitudinal plasma ctDNA measurements in light of other routine measurements such as radiographic assessments and other blood based biomarkers. Upon completion of this activity, participants should be able to: 1. Explain the sources and methods of measurement of ctDNA. 2. Describe the relationships between plasma ctDNA, disease burden and therapeutic response. 3. Discuss how these relationships influence the clinical utility of routine plasma ctDNA testing. [12] Quantitative Methods of Monitoring Circulating Tumor DNA. Evan M. Alexander, PhD, Roland Valdes Jr., PhD, DABCC, Mark Linder, PhD, DABCC, Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY Circulating tumor DNA (ctDNA) is emerging as a new, robust biomarker that can be used for early cancer diagnosis, disease prognosis and even guiding treatment through precision medicine. This non-invasive tumor monitoring tool can be performed on the scale of a single gene mutation to an entire sequenced genome. Quantitation of ctDNA is complicated by two factors: wide ranges and low concentrations (0.003%-95% mutant allele frequency (MAF); 5-1500 ng/mL). Currently, the field of monitoring ctDNA is dominated by next-generation sequencing (NGS) and polymerase chain reaction (PCR) based technologies. Understandably, these different monitoring techniques require specialized analytical instrumentation. Furthermore, the sensitivity and specificity of these methods are not universal. There are many considerations a clinician needs to be mindful of when utilizing these technologies to monitor ctDNA (known vs unknown mutation, absolute quantitation vs MAF). Understanding the strengths and weaknesses of ct DNA quantification methods in a given clinical situation is paramount in utilizing this biomarker to its fullest and most appropriate potential. Upon completion of this activity, participants should be able to: 1. Identify which quantitation technique for ctDNA is most appropriate to use in a given clinical scenario 2. Recognize the difference between quantitation of mutant allele frequency and absolute quantitation of ctDNA 3. Recognize the importance of assay sensitivity when serially monitoring patient cancer progression. [13] The Value of Next Generation Sequencing in Myeloid Neoplasia. Mustafa Al-Kawaaz, University of Louisville, Louisville, KY This presentation will demonstrate some of the most important utilities of next generation sequencing (NGS) in a spectrum of acute myeloid leukemia (AML), myeloproliferative neoplasms (MPN), myelodysplastic syndrome (MDS) and overlap syndromes. Interrogation of nucleic acid (DNA and/or RNA) to look for certain genomic alterations is essential for diagnostic, prognostic, and therapeutic purposes. Classification of myeloid neoplasms continues to evolve by including entities defined by specific genomic alterations. NGS is an essential utility to guide management decisions. Upon completion of this activity, participants should be able to: 1. Recognize changes to classification of myeloid neoplasms and some categories definite by genetic alterations. 2. Identify the utility of different vendors/ platforms offering certain advantages in next generation sequencing. 3. Recommend testing utility by evaluating the targeted genetic alteration as well as clinical scenario. [14] Forecasting clinical behavior and therapeutic response of breast carcinoma using gene expression. James L. Wittliff and Michael W. Daniels, University of Louisville, Louisville, KY Our goal is to associate expression of nuclear and peptide hormone receptor genes with biomarker status of breast carcinoma and risk of recurrence, to advance clinical management. Cellular heterogeneity of tissue specimens is a complicating factor in determining analyte (protein or gene) levels of specific cell types. A unique deidentified database was analyzed that contained microarray results of 22,000 genes derived only from total RNA extracted from breast carcinoma cells procured by laser capture microdissection (Pixcell IIe:Arcturus®/ Thermo Fisher) of 247 de-identified primary tissue biopsies. Relative expression levels of each gene candidate for 49 nuclear receptors as well as 61 peptide/protein hormones and 81 of their cognate receptor proteins were selected for this retrospective investigation. Assessment of a patient's risk of recurrence primarily utilizes estrogen (ER) and progestin receptor proteins (PR), quantified by radio-ligand binding (NEN/DuPont) and/or enzyme immunoassay (Abbott Labs). Parameters and clinical outcomes were analyzed by univariable and multivariable Cox regressions, Fisher's Exact Test, Kaplan Meier plots and with R software v4.0.0. Examples of multivariable Cox regression models of candidates of nuclear receptor genes, fit to predict disease-free survival (DFS) and overall survival (OS), revealed that only NR4A2, PGR, PPARA and THRB were required to predict DFS and NR3C2, PGR and THRB were necessary to predict OS. Of 142 candidate genes for peptide hormones and their cognate receptors, 30 exhibited expression levels that individually predicted DFS and/or OS. When pairs of genes for a peptide hormone and its receptor were evaluated by multivariable Cox Regression with interaction, complexes were identified that predicted DFS and OS (EDN1-ENDRA, GHRL-GHSR, INHBB-ACVR2B, NPY-NPY1R, INHBB-ACVR1B, RLN2-RXFP3 and NPY-NPY6R) based on unadjusted p-value for the interaction term. These investigations also revealed numerous over-expressed genes in carcinomas with poor clinical outcomes suggesting candidates for development of novel therapeutics. Collectively, use of small molecular signatures (gene subsets) with quantified ER/PR protein or ESR1/ PGR expression in a breast carcinoma with clinical outcomes enhanced prediction of risk of recurrence and identification drug development candidates. Upon completion of this activity, participants should be able to: 1. recognize the power of LCM to non-disruptively capture populations of specific cell types for genomics testing, 2. differentiate gene expression patterns based upon protein tumor marker status groups and 3. predict risk of recurrence for patients based upon expression of gene molecular sign. [15] Imaging Mass Spectrometry: Applications in Biomedical Research and Clinical Diagnosis. Yusheng Zhu, PhD; Pennsylvania State University College of Medicine Hershey Medical Center, Hershey, PA Mass spectrometry tissue imaging is a technology used in mass spectrometry to visualize the spatial distribution of molecules in tissues by their molecular masses. Compared to traditional tissue imaging methods such as immunohistochemistry, mass spectrometry imaging does not need any antibodies and tracers; it can detect and map multiple analytes including proteins, peptides, nucleic acids, lipids, carbohydrates, metabolites, drugs, toxins, and even elements simultaneously; researchers do not need prior knowledge of molecules in the samples; the analysis can be qualitative and/or quantitative. Therefore, mass spectrometry imaging has become a powerful technology for biomedical research and biomarker discovery. It is widely used in proteomic, peptidomic, lipidomic, glycomic, metabolomic, pharmacological and toxicological studies. This session will introduce common mass spectrometry imaging techniques including matrix assistant laser desorption ionization-time of flight (MALDI-TOF) imaging, time of flight-secondary ion mass spectrometry (TOF-SIMS) imaging, and desorption electrospray ionization (DESI)-mass spectrometry imaging. In addition, the basic principle, procedure, and application of these methods in biomedical research and clinical diagnosis will be discussed. Upon completion of this activity, participants should be able to: 1. Define tissue imaging mass spectrometry. 2. Explain basic principle of common types of imaging mass spectrometry. 3. Describe application of tissue imaging mass spectrometry in biomedical research and clinical diagnosis. [16] Immune Landscape in Sentinel Lymph Nodes from Melanoma Patients by Single-Cell Mass Cytometry (CyTOF) Analysis. Kavitha Yaddanapudi, University of Louisville, Louisville, KY We describe the development of a multiscale immune profiling strategy to map the immune landscape of sentinel lymph nodes (SLN) in our search for tumor-driven immune changes that can guide the design of novel immunotherapeutic strategies for patients with early-stage melanoma. We used mass cytometry by time-of-flight (CyTOF), flow cytometry, and T cell receptor immunosequencing to conduct simultaneous single-cell analyses of immune cells in the SLNs of melanoma patients. We identified unique tumordriven T, NK, and innate immune cell signatures that are present in stage III melanoma-bearing SLNs, but absent in stage I/II non-melanoma-bearing SLNs. We found increased effector-memory T cells and TCR clonality selectively in the melanoma-bearing SLNs relative to non-melanoma-bearing SLNs, consistent with possible activation of an anti-tumor immune response. However, we also observed a markedly immunotolerant environment in the melanoma-bearing SLNs indicated by reduced and impaired NK cells and increased levels of CD8+CD57+PD-1+ cells which are known to display low melanoma killing capabilities. Other changes observed in melanoma-bearing SLNs when compared to non-melanoma bearing SLNs include reduced CD8+CD69+ T cells/T regulatory cells ratio and high PD-1 expression on CD4+ and CD8+ T cells. Our data suggests that these immunological changes compromise anti-melanoma immunity and contribute to a high relapse rate. Upon completion of this activity, participants should be able to describe mass cytometry analysis of melanoma patient sentinel lymph node samples, identify new immunologic and therapeutic targets for preventing melanoma recurrence and identify unique melanoma-driven immune cell signatures. [17] Application of MassARRAY System in Molecular Diagnostics - Pharmacogenomics and Oncology. Shuko Harada and Alexander C. Mackinnon, University of Alabama at Birmingham, Birmingham, AL In molecular diagnostic laboratories, multiplex genetic analysis, for example Next Generation Sequencing (NGS), is increasingly utilized. NGS is expensive, laborious, and requires complicated bioinformatics analysis. The MassARRAY system provides accurate, low cost, facile, multiplexed analysis of hundreds of clinically relevant mutations with relatively simple analytics. In this study, we evaluated the utility of this system for two multiplex, molecular diagnostic applications: detection of somatic variants found in brain (CNS) tumors and germline variants (SNPs) found in metabolic enzymes as part of a pharmacogenomics (PGDX) assay. The CNS assay utilizes a custom design to identify deletions involving chromosomes 1p and 19q and somatic variants in IDH1, IDH2 and TERT. The PGDX panel targets 68 SNPs and several copy number variants (CNV) in 20 metabolic genes implicated in drug metabolisms. Genetic targets are PCR amplified followed by primer extension using allele-specific, specialized primers. Allotypes are detected by the MassARRAY system and results are generated using the MassArray software. Thirty CNS tumor samples with known 1p19q and IDH1/IDH2 mutation status were analyzed using the CNS panel. The results were >95% concordant to orthogonal test results. 48 samples with known various genotypes were analyzed using the PGDX assay. The results were >99% concordant; intra- and inter-run reproducibility was 100% (n=7). Overall, the MassARRAY system is reliable, cost effective and easy to operate. Performance is consistent and analysis is streamlined. The MassARRAY platform has broad application across multiple indications for molecular diagnostic testing. Upon completion of this activity, participants should be able to understand the utility of MassARRAY system in molecular diagnostics. [18] Alzheimer's disease CSF biomarkers in clinical practice: analytical and clinical considerations. Alicia Algeciras-Schimnich, Susan Ashrafzadeh-Kian, Wentao Li, Michelle R. Campbell, Ronald Petersen, and Joshua Bornhorst, Mayo Clinic, Rochester, MN This presentation will describe analytical and clinical considerations for the appropriate use of the cerebrospinal fluid (CSF) Alzheimer's disease (AD) biomarkers: amyloid beta 1-42 (Aβ4 2), total Tau (t-Tau), and phosphorylated Tau (p-Tau). Changes in these biomarkers reflect key changes in AD pathophysiology and are being incorporated into clinical practice. One of the challenges with the interpretation of CSF biomarkers has been the lack of standardized procedures for sample collection and handling as well as the lack of robust assays to measure these biomarkers. The analytical characteristics of the Roche Elecsys immunoassays for the quantitation of Aβ42, t-Tau, and p-Tau in CSF were established. All assays demonstrated robust analytical performance suitable for clinical laboratory utilization. To evaluate clinical performance, these biomarkers were measured in a cohort of clinically characterized samples (n=161). Using a p-Tau/Aβ42 ratio cutoff of >0.023, 20% of cognitively unimpaired, 41% of mild cognitive impairment, and 100% of AD dementia patients were classified as positive. The use of the p-Tau/Aβ42 ratio showed optimal concordance with amyloid PET exhibiting 100% negative and 86% positive concordance. Finally, the pattern of these biomarkers was evaluated in 535 Mayo Clinic patients that underwent testing as part of a cognitive evaluation over a 1-year period. In 27% of patients all biomarkers were normal and not consistent with AD; in 25% of patients all biomarkers were consistent with AD. A normal p-Tau/ Aβ42 ratio with low/abnormal Aβ42 was observed in 19% of patients and was most often associated with the clinical presentation of normal pressure hydrocephalus (NPH). An abnormal p-Tau/Aβ42 ratio displayed the strongest relationship with AD. Upon completion of this activity, participants should be able to 1. identify the role of Aβ42, t-Tau, and p-Tau in the differential diagnosis of AD and 2 discuss how various biomarker patterns are associated with other non-AD cognitive disorders. [19] Evaluation of SARS-CoV-2viral RNA detection, using Massarray, RT-qPCR and UltraFast RT-PCR assays. Bene Ekene-Afolabi1, John Patrick Alao1, Solomon Rotimi1,2, and John Bolodeoku1,3, 1ZEAB Therapeutic Ltd. Discovery Park, Ramsgate Road, Sandwich, Kent CF13 9FF, United Kingdom, 2Department of Biochemistry, Covenant University, Ota, Nigeria, and 3JB Consulting MDP Ltd, 1 Bell Street, Maidenhead, Berkshire, SL6 1 BU, United Kingdom The Covid-19 pandemic caused by the SARS-CoV-2 virus revealed short comings in the global ability to effectively deal with such crises. In particular, the molecular diagnostics market was flooded with a diverse array of RT-PCR kits. These kits target different regions of the SARS-CoV-2 genome with the United States Centres for Disease Control (CDC) recommended nucleocapsid N1 and N2 genes being the most common. In addition, these kits use various cycling parameters and cut-offs despite being approved for diagnostic testing in various countries. Detailed information on the suitability of these tests for the clinical detection of SARS-CoV-2 and their performance under laboratory conditions remain scarce. In this study, three assays evaluated viral genes in synthetic RNA and RNA extracted from SARS-CoV-2 samples stored in viral transport medium (VTM) (30 panel certified reference materials), UK NEQAS samples and 100 patient samples: 1) Agilent SARS-CoV-2 RT-qPCR kit for detecting the N1 and N2; 2) Agena Bioscience MassArray (MALDI-ToF) SARS-CoV-2 for detecting N1, N2, N3, ORF1 & ORF1ab, variant SARS detection, and 3) Molecular Biology System UltraFast RT-PCR SARS-CoV-2 Kit for detecting N1, N2, and ORF1ab These assays showed good performance, sensitivity and specificity with a limit of detection (LOD) as low as 1 copy/ μL. The specificity and sensitivity are 100% and 98% respectively. These kits thus provide a robust assay for the detection of SARS-CoV-2 in clinical samples. Conclusion: These assays are suitable for routine diagnostic. The UltraFast NextGenPCR is the fastest with average time (30mins), followed by Agilent (2 hrs) and MassArray (6hrs). Upon completion of this activity, participants should be able to examine, measure and compare results from different assays for SARS detection, evaluate and diagnose accurately, as well as being able to plan, organize and recommend a diagnostic procedure for diagnostic laboratory. Key words: SARS-CoV-2, RNA extraction, RT-PCR, limit of detection, quantification cycle, COVID-19, in vitro diagnostic tests, Agilent, Massarray, Ultrafast. [20] From the Microbiology Lab to the Operating Room: Advanced Development of the MasSpec Pen for Broad Clinical Use. Livia Eberlin, PhD, Associate Professor, Department of Surgery, Baylor College of Medicine, Houston, TX Ambient ionization mass spectrometry techniques that enable direct, gentle, and rapid analysis of samples offer exciting opportunities to provide clinicians with rich molecular data to enhance decision-making. Here, an overview of several ongoing clinical projects in the Eberlin laboratory related to the development of a handheld MSbased device, the MasSpec Pen technology, for improving patient care will be discussed. In particular, I will describe results centered around our efforts in employing the MasSpec Pen for intraoperative tissue analysis and cancer detection, identification of infectious microorganisms, and detection of drugs of abuse. Current challenges and opportunities towards incorporating this technology into clinical practice will also be addressed. Upon completion of this activity, participants should be able to 1. describe operating principles of direct mass spectrometry techniques for rapid molecular analysis that are being explored for clinical use; 2. evaluate analytical and diagnostic performance metrics of direct mass spectrometry techniques to address unmet clinical needs. [21] Triggered MRM for Urine Drug Testing: Finding What You Aren't Looking For. Joshua Hayden, Norton Healthcare, Louisville, KY This work aimed to develop a triggered multiple reaction monitoring (MRM) method for urine drug testing that allows simultaneous targeted quantitation of commonly used/abused drugs and qualitative detection of a larger array of uncommonly used drugs. Targeted quantitation is most often accomplished with triple quadruple mass spectrometers but these instruments suffer in their ability to do untargeted analysis. This limitation is especially challenging given the ever increasing number of drugs that are produced and abused-including fentanyl analogues, bath salts, and a broad group of drugs known as spice. Ideally, clinical laboratories would be able to perform both targeted quantitation and some level of qualitative detection of infrequently encountered drugs. Towards this end, we developed a method that allows us to utilize our triple quadruple mass spectrometer to do targeted quantitation of commonly used/ abused drugs and qualitative detection of a larger range of drugs. This qualitative detection is accomplished using a triggered MRM method and a spectral database. To validate this method, deidentified, remnant urine samples were spiked with a variety of uncommonly encountered illicit drugs including various spice derivatives, bath salts, and fentanyl derivatives. The performance of the method was evaluated based on its ability to perform accurate quantitation of targeted compounds and its ability to qualitatively detect the presence of the spiked drugs. The method demonstrated excellence performance. The success of this method suggests such an approach could find widespread use in clinical laboratories; however, questions remain with regards to the regulatory requirements (quality control, proficiency testing, etc). Upon completion of this activity, participants should be able to: 1 .Describe the advantages and limitations of triple quadruple mass spectrometers, 2. Discuss the advantage of screening for a wide array of illicit drugs, 3.Summarize how a triggered MRM method might add value to a urine drug assay. [22] Advances in the assessment of Orexin-A (hypocretin-1) deficiency in the diagnosis of Type 1 Narcolepsy. Joshua Bornhorst, Bethany Larson, and Alicia Algeciras-Schimnich, Mayo Clinic, Rochester, MN This presentation will describe the clinical performance s of an assay for orexin-A (also known as hypocretin-1), which is a neuropeptide involved in the sleep/wake cycle. Impairment of orexin-A production and orexin-A modulated neurotransmission is associated with narcolepsy with cataplexy (episodes of muscle weakness in response to emotional stimuli), and deficiency of orexin-A in cerebrospinal fluid (CSF) is a hallmark of type 1 narcolepsy. The diagnostic criteria for type 1 narcolepsy in the third edition of the International Classification of Sleep Disorders (2014) includes the presence of cataplexy and/ or measured CSF orexin concentrations less than or equal to 110 pg/mL. However, clinical testing for orexin-A in CSF had been unavailable in the United States. A competitive radioimmunoassay for orexin-A quantitation in CSF was characterized for clinical use in the diagnosis of type 1 narcolepsy. This assay demonstrates acceptable analytical precision, accuracy, and stability. To evaluate clinical performance, 100 residual CSF specimens from individuals without suspicion of type 1 narcolepsy all exhibited orexin-A concentrations of >200 pg/mL (mean: 531pg/mL). Additionally, samples from 20 patients with clinical suspicion of type 1 narcolepsy were evaluated. All nine confirmed 9 type 1 narcolepsy patients exhibited orexin concentrations of <50 pg/mL. All 11 patients that were subsequently deemed to have hypersomnias other than type 1 narcolepsy had orexin concentrations of >200pg/mL (range 352-600 pg/mL). Clinical introduction of this test fulfilled a pressing diagnostic need for differentiation of type 1 narcolepsy from other causes of hypersomnolence. Emerging information on how this assay compares to other methods of patient assessment for potential type 1 narcolepsy will also be discussed. Upon completion of this activity, participants should be able to identify the role of orexin deficiency in type 1 narcolepsy as well as recommend appropriate testing for the evaluation of individuals who potential have this disorder. [23] Zika outbreak in Dominican Republic 2016: A review. Frederick L. Kiechle1, Angelica Freddo1, and Henry Quezada2. 1Pompano Beach, FL and 2Santo Domingo, Dominican Republic We mined the data in the Biorepository at Boca Biolistics obtained during the Zika outbreak for symptomatic pregnant (PG) and non-pregnant (NP) women in the Dominican Republic in 2016. Zika virus (ZIKV) is a Flavivirus transmitted in humans by Aedes mosquitoes. There was a biphasic distribution of 305 symptomatic (NP) and 65 (PG) women (266 NAAT positive by Hologic, Aptima ZIKV assay) in April and late May/June 2016. To determine previous exposure to dengue (DENV) infection, anti-DENV IgG was measured in serum or plasma by ELISA (Euroimmun). (Science 2019; 363: 307). In 65 symptomatic PG women the outcome was 4.6 % spontaneous abortion, 2 % fetal demise and 4.6 % other. We evaluated the presence of 6 presenting symptoms and 3 lab tests (Aptima ZIKA assay; EUROIMMUN ELISA IgG; CDC MAC-ELISA ZiKV IgM - performed by FL Dept of Health) over 8 time intervals (12 - 36 repeat PG or NP patients per interval; total PR 131, total NP 171). The prevalence of 4 symptoms were less frequent in PG women vs NP, including fever, severe eye pain, head pain and joint and muscle pain. Conjunctivitis occurred more frequently in PG vs NP and rash had an equal occurrence. ZIKV IgG and MAC-ELISA-IgM were positive with similar frequency in both groups 1 through 8. NAAT ZIKV results were positive for all 8 intervals (87.5% to 72.2%) in PG patients and in NP (52% in interval 1 and 0.0 to 4.0% in intervals 2 to 8). PG patients with rash were 98% positive for DENV IgG. In conclusion, NP and PG women exhibited a biphasic spike of ZIKV positive infections; from 0 to 86 days post symptoms, PG exhibited a lower prevalence of fever, head pain, severe eye pain and joint and muscle pain compared to NP ZIKV symptomatic patients. The results suggest that PG provides protection from clinical symptoms compared to NP during infection cycle in spite of persistent viremia in PG vs NP. Upon completion of this activity, participants should be able to describe the clinical and laboratory findings in Zika infection and differences in PG and NP patient presentation. [24] Rapidly evolving and fatal miliary tuberculosis and COVID-19 infection inan infant.Anindita Ghosh1,Amanda Tchakarov1, Norma Perez1, Nina Tatevian2, Meenakshi Bhattacharjee1. 1University of Texas Health Science Center at Houston, Houston, TX, and 2Women and Infant Hospital of Rhode Island, Providence, RI Background: Tuberculosis (TB) and SARS-CoV-2 (COVID-19) are two important infectious diseases causing morbidity and mortality worldwide. Active TB infection can stimulate host immune responses and together with COVID-19, may lead to cytokine storm and immune dysregulation leading to multi-organ failure. Studies have reported flare up of pulmonary TB after SARS-CoV-2 infection in adults. We present a unique case of both miliary tuberculosis and SARS-CoV-2 coinfection in an infant, indicating that children can acquire both infections concurrently, and have rapid progression with fatal outcome. Case: Our patient was a 6-month-old previously healthy term boy. He had persistent cough and congestion, became severely ill, and was brought to emergency department. Chest X-ray showed diffuse alveolar and interstitial airspace opacities. He was found to be COVID-19 positive by PCR test. Laboratory studies showed pancytopenia with left shift, elevated transaminases (ALT 77, AST 313), low albumin, elevated inflammatory markers (CRP 103, IL-6 19000), and abnormal coagulation profile with coagulopathy and disseminated intravascular coagulation. He developed strokes, severe sepsis and electrolyte abnormalities, and declined rapidly with death within 6 days. Autopsy examination showed hepatosplenomegaly. His lungs, liver, kidneys, and spleen showed multifocal micro-abscesses, which on microscopic examination showed necrotic foci teeming with mycobacteria, and were culture positive for M. tuberculosis, i.e. miliary tuberculosis. Neuropathological examination showed infarction in the right middle and posterior cerebral artery territories. Conclusions: This patient helps illuminate some immunological and pathological aspects of two co-occurring infectious diseases and the susceptibility for development of fatal complications with SARS-CoV-2 infection in the pediatric population. Upon completion this activity the learner will be able to: 1. recognition of COVID-19 (SARS-CoV-2) infection cooccurrence with another infectious disease in children. 2. challenges in treatment of COVID-19 infection with other/associated infectious disease. 3. recognition of the complexity of pathological processes in childhood infectious disease. [25] A Postulated Cross Talk between Insulin Growth Factor Binding Protein 3 (IGFBP-3) and IGFBP-7 May Suggest a Critical Role in Carcinogenesis. Fan Shen1 and Consolato M. Sergi1,2. 1Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada and 2Anatomic Pathology Division, Children's Hospital of Eastern Ontario, University of Ottawa, ON, Canada Objective: The insulin/insulin-like growth factors (IGFs) have crucial tasks in the growth, differentiation, and proliferation of healthy and pernicious cells. They are involved in coordinated complexes, including receptors, ligands, binding proteins, and proteases. However, the systems can become dysregulated in tumorigenesis. Insulinlike growth factor-binding protein 7 (IGFBP7) is a protein belonging to the IGFBP superfamily. We intended to explore the cross-talk between IGFBP-3 and IGFBP-7. Methods: Analysis of text/ data mining tools using the NCBI platform was used. Results: Numerous studies have provided evidence that IGFBP-3 and IGFBP-7 are involved in a variety of cancers, including hepatocellular carcinoma (HCC), breast cancer, gastroesophageal cancer, colon cancer, prostate cancer, among many others. Still, very few suggest an interaction between these two molecules. We found that both proteins share some crucial signaling pathways. P53, and growth inhibitory agents, including retinoic acid (RA), transforming growth factor beta (TGF-β), and anti-estrogens, can give rise to increased expression of IGFBP-3. IGFBP-7 can regulate the growth-suppressing effects of the TGF-β superfamily, and similarly the expression of IGFBP-7 can be upregulated by cellular treatment with TGF-β1 and RA. Conclusions: A comprehensive overview of the relationship between IGFBP-3, IGFBP-7, and cancer highlighted the IGFBP-3 crosstalk with IGFBP-7, which may suggest a promotion other than initiation in carcinogenesis. Upon completion of this learning activity participants should be able to: 1. to define to role of Insulin Growth Factor Binding Protein superfamily in carcinogenesis 2. to compare the respective role of IGFBP-3 and IGFBP7 in cancer 3. to determine the relevance of a cross talk between IGFBP-3 and IGFBP-7 for carcinogenesis [26] Measure Directly, Treat Efficiently. Critical Bleeding Management at the Speed of Sound. Oksana Volod, Cedars Sinai, Los Angeles, CA, USA Viscoelastic Testing (VET) is a category of functional whole blood tests used to assay hemostatic competence and optimize blood product transfusions in patients during or after surgical procedures where acute bleeding may occur. Efficient use of these tests has become an elevated need for a comprehensive patient blood management program. Cup and pin legacy systems and those that display the traditional interpretation "curves", such as with thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), require varying levels of oversight to maintain compliance and optimal efficient clinical use. Over the last decade, advances have been made with the integration of cartridge-based VET systems to improve upon those legacy systems. During this presentation, the legacy and new generation VETs available in the US are compared based on their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. The balance between the needs to act on relevant critical data in near real-time and compliance with the laboratory that must ensure quality is also discussed. The Quantra® system is the newest VET. It is a fully sealed, cartridgebased, automated, four-channel device that provides the fastest hemostasis assessment (12 minutes on average). The Quantra is based on a new ultrasound technology termed sonic estimation of elasticity via resonance (SEER). The important differences between Quantra and other VETs are its ease of interpretation, optimizations for use at the point of patient need, and its ability to directly measure blood viscoelastic properties. Through real case examples, this talk will also focus on Quantra specific hemostasis alterations and optimal management strategies for bleeding patients. Upon completion of this learning activity participants should be able to: 1. Describe Viscoelastic Testing as part of a Patient Blood Management initiative. 2. Categorize various viscoelastic assay methods and classify clinical and operational needs related to implementation and accessibility (i.e., speed, ease of use and location) 3. Interpret and explain the results of Quantra via participation in real-world case example. [27] Managing the challenges of running a transfusion service during the COVID-19 pandemic Claire Meena-Leist, Amanda Riggs and Mohamed Elkady, University of Louisville School of Medicine, Louisville, KY Hospitals have developed systems to adjust to periodic blood product shortages. Apheresis platelets and group O Rh(D) negative red blood cell shortages are common during summer months and holidays and can be managed well by having a strong blood management program and obtaining contracts with secondary blood suppliers. The COVID-19 pandemic, however, caused historic blood product shortages that resulted in red blood cell rationing and requests from our primary blood supplier for hospitals to consider canceling non-urgent surgical procedures. With virtually no lead time, in December 2021, our blood supplier began rationing all group O red blood cells to their customers. For the first time blood was allotted to customers based on blood center supply, not patient need. The rationing quickly expanded to include all group A and B red blood cells, with no information about how long the shortage would last. Hospitals were forced to develop more creative blood management methods, and to develop criteria for surgery cancellations. We discuss our experience with providing patient care in a hospital system that includes the region's only American College of Surgeons (ACS) Verified Level 1 Trauma centers for adults in the Commonwealth of KY. Upon completion of this activity, participants should be able to 1. Describe how one hospital system approached blood management during a historic blood shortage 2. Explain why hospital blood management is not the sole answer to providing patient care during extreme blood shortages 3. Identify ways that blood centers can improve strategic planning for the next pandemic. [28] Cells,wells, & spells: the evolution of HLA testing methods. Tiffany K Bratton, University of Louisville, Louisville, KY Organ transplantation is a life-saving treatment modality for patients with end stage organ failure. However, allograft rejection remains an obstacle for long term outcomes. An evolution in the understanding of transplant immunology over the past fifty years has led to continuous development and improvement of methods for detecting, not only HLA antibodies, but also other markers of the overall immune status of transplant patients. HLA testing began in the 1960's with donor cells; the cytotoxic crossmatch caused a paradigm shift in transplantation with immediate improvements in short term outcomes. In the early 2000's the organ allocation system was radically changed by the development of solid phase technology. This presentation will cover the evolution of HLA testing methods from the very beginning to current state as well as speculation on new technologies that could be developed and used to continue to improve long term outcomes for transplant patients. Upon completion of this learning activity participants should be able to: 1. Describe the different testing methods used for detection of HLA sensitization. 2. Identify the current HLA testing methods. 3. Evaluate new technologies that may be developed for both HLA and overall transplant testing. [29] The CNS-penetrating taxane drug TPI 287 potentiates the antiglioma activity of the AURKA inhibitor alisertib in vivo. Müge Sak, Brian J. Williams, Cory T. Zumbar, Mustafa N. G. Al-Kawaaz, Aastha Kakar, Andrew J. Hey, Leslie M. Scheir, Landon Teer, Joseph Chen and Norman L. Lehman. University of Louisville, Louisville KY Glioblastoma, IDH wildtype (GBM) is the most common malignant primary brain tumor in adults and has a poor prognosis. We previously found cytotoxic synergy between the AURKA inhibitor alisertib and the novel CNS-penetrating taxane TPI 287 against GBM tumor stem-like cells in vitro. Here we used an orthotopic human GBM xenograft mouse model to test the ability of TPI 287 to potentiate alisertib's antitumor activity in vivo. At two weeks, animal tumor volume was significantly decreased by alisertib, TPI 287, and combination treatments compared to controls. At four weeks both alisertib and TPI 287 groups had reduced tumor volume and a statistically significant decrease was again observed in the combination therapy group. Alisertib monotherapy improved animal survival, which was further improved with the addition of TPI 287 (p=0.0058). TPI 287 alone did not significantly improve animal survival. We also investigated the mechanism of apoptotic synergy between alisertib and TPI 287. Alisertib + TPI 287 combination treatment decreased Bcl-2 levels in vivo and in vitro. In contrast, this treatment increased expression of pro-apoptotic proteins Bim and Bak in synchronized GBM cells. Bim knockdown by siRNA inhibited synergistic cytotoxicity caused by alisertib + TPI 287 (p=0.0042). These results suggest that these drugs cause synergistic apoptosis in GBM cells partially through effects on Bcl-2 family proteins. Additionally, both alisertib and TPI 287 significantly reduced GBM cell invasion (p<0.0001). However, this effect was greater with TPI 287, and the drug combination was no more effective at inhibiting invasion than TPI 287 alone. These findings support the potential use of this combination therapy against GBM in clinical trials. Upon completion of this activity, participants should be able to understand the Bcl-2 family protein apoptotic cascade, the mechanism of action of taxanes and AURKA inhibitors and the rationale for combination treatment for GBM. [30] SARS-CoV-2 antibody testing in the post-vaccine era: comparing assays for standardization. Sarrah Lahorewala and Xin Yi, Houston Methodist Hospital, Houston, TX The interpretation of results of various SARS-CoV-2 antibody tests is challenging due to non-standardization among assays. The aims of this study were: to compare three commonly used semi-quantitative/quantitative SARS-CoV-2 antibody tests with our institutional Anti-SARS-CoV-2 Spike ELISA assay; and, to validate the ELISA assay against known National Standard (CRM-NIBSC21/234), thus correlating calculated ELISA concentrations (U/ mL) and the international standard units for binding assay formats, i.e. Binding Antibody Units/mL (BAU/ mL). The Anti-SARS-CoV-2 Spike ELISA assay detects IgG antibodies against the viral anti-S Ectodomain. The three commercial tests compared to the ELISA assay were the Roche Elecsys® Anti-SARS-CoV-2S (U/mL), Siemens Atellica COV2G (Index) and VITROS Anti-SARS-CoV-2 IgG Quantitative (BAU/mL). The Roche and Siemens test comparisons included 95 patient samples, with 51 samples evaluated for the VITROS assay. Statistical analyses were performed using the GraphPad Prism9 software. We mapped the antibody concentrations obtained on the ELISA assay against that of CRM-NIBSC21/234 and validated their linear relationship. The commercial assays evaluated showed good correlation with the Anti-SARS-CoV-2 Spike ELISA, across all ELISA titers. The corresponding assay result ranges (lower and upper 95% CI of mean) for each titer group is as follows: <1:50: Roche: <0.4-<0.4; Siemens: 0.0070.020; Vitros: 1.854-4.606; 1:50: Roche: 26.01-88.39; Siemens: 0.585-0.966; Vitros: 33.47-50.83; 1:150: Roche: 622.9-1095; Siemens: 6.82-214.38; Vitros: 52.35-141.4; 1:450: Roche: 1321-2091; Siemens: 16.74-19.55; Vitros: 112.4-192.2; 1:1350: Roche: 2067->2500; Siemens: >20->20; Vitros: >200->200. The calculated concentration (U/mL) obtained by the Anti-SARS-CoV-2 Spike ELISA and the expected concentration of CRM were strongly correlated and results were found to be linear in the range from 3.25-832 BAU/mL covering titers ranging from <1:50 to >1:1350. The calibration of our ELISA assay to the International Standard, and its correlation with commercial assays, allows for standardization between assays and a better understanding of the various antibody titers in the context of immune protection against SARS-CoV-2. Upon completion of this activity, participants should be able to: 1. Describe the clinical utility of antibody testing in SARS-CoV-2 2. Understand the various kinds of SARS-CoV-2 antibody tests commonly utilized 3. Interpret results of commonly used semi-quantitative/quantitative assays and correlate assay titers with the International Standard Units (BAU/ mL). [31] How to be a better surgical pathology consultant. Neda Zarrin-Khameh, Baylor College of Medicine, Houston, TX Consultation on surgical pathology specimens is part of the daily professional practice of every pathologist. We evaluated the characteristics of a good consultant and the habits that should be avoided. A 1-page questionnaire was prepared to evaluate how pathologists select their consultants. The questionnaire was emailed to 106 pathologists. Fifty-eight pathologists completed the questionnaire (55% response rate). The most important criteria for a consultant were knowledge and expertise. Accessibility, turnaround time, and teaching (providing explanation about the case) were selected next for choosing a consultant. The 2 factors that contributed to avoiding a consultant were expensive workup and changing the diagnosis. Open questions about "definition of best/worst consultant," "when to change the consultant," and "if the criteria for consultant have changed over time" provided additional valuable information. Accessibility, short turnaround time, and teaching are the most important reasons for selecting a consultant. Performing an expensive workup and being in the habit of changing the diagnosis are the factors that make a consultant less favorable. Upon completion of this activity, participants should be able to: 1. recognize three characteristics of a consultant that are important for requesting consultation, 2. identify three characteristics that are not recommended for a consultant and 3. determine when a pathologists may decide to change their consultant. [32] The Diagnostic Role of Fusion-Gene Analysis in Ambiguous Soft Tissue Sarcomas. Haider A. Mejbel, Alexander C. Mackinnon, and Shuko Harada, The University of Alabama at Birmingham, Department of Pathology, Birmingham, The diagnosis of soft tissue sarcoma often requires adequate clinicopathologic correlation as well as the appropriate application of immunohistochemical studies. However, certain ambiguous/undifferentiated soft tissue sarcomas can pose a diagnostic challenge. We retrospectively reviewed the cases submitted for RNA-based fusion panel (Archer FusionPlex assay) to evaluate the diagnostic utility of fusion gene analysis in soft tissue sarcomas. Herein we present the clinicopathologic and molecular alterations of three challenging soft tissue sarcomas, on which, the application of fusion-gene analysis has entirely altered the initial diagnosis. These cases include Ewing sarcoma, Ewing sarcoma with melanocytic differentiation, and MEIS1::NOCA1 sarcoma that were initially diagnosed as carcinoid tumor of the lung, melanoma, and low grade endometrial stromal sarcoma, respectively. In addition to providing the valuable prognostic information, the application of fusion-gene analysis has resulted in the reclassification of these neoplasms and altered the type of therapy. Currently, all patients are alive at the 6-, 26-, and 4-month of their final diagnosis. In conclusion, although adequate histopathologic examination and extensive immunohistochemical study were performed, the final diagnoses and classification of these sarcomas were only rendered after the application of the appropriate molecular testing. Upon completion of this activity, participants should be able to understand the role of molecular fusiongene analysis in further classifying ambiguous soft tissue sarcomas that can help arrive at the accurate diagnosis, alter disease stage, and inform therapy. [33] Distinct lesions of host defense and bacterial offense in tuberculosis. Robert L. Hunter and Robert E. Brown, University of Texas Health Science Center, Houston, TX The continued existence of M. tuberculosis depends on production of two distinct disease processes in humans. Primary tuberculosis (TB), the host's defense, protects against disseminated infection. Post-primary TB, in contrast, is the bacteria's offense. It facilitates transmission of infection to new hosts. Host defense is mediated by granulomas as are widely studied in human TB and animal models. People may succumb to lack of defense with disseminated infection, but this does not benefit the organism since it also dies. Bacterial offense, the lesions that mediate transmission of infection to new hosts, is mediated by post-primary TB. It begins as a subclinical obstructive lobular pneumonia that slowly accumulates materials for a sudden massive necrotizing pneumonia that can be coughed out to produce a cavity from which the organism can escape to infect new people. The early lesions of post-primary TB were well known to investigators in the preantibiotic era when autopsies were cutting edge science, but are unknown to the majority of current investigators who study only animal models. While modern technologies are making unprecedented progress in understanding tuberculous granulomas, they are making very little in understanding post-primary TB that does not exist in most animal models. Fortunately, new multiplex technologies make it possible to study human FFPE slides with great depth and precision. Such studies are necessary to gain a better understanding to the key developmental stage of TB. Upon completion of the activity, participants should be able to recognize and describe the differences between primary and post-primary TB. [34] Agonal-stress vesicles in critically ill children confused with microvesicular steatosis. John Hicks, Children's Hospital, Baylor College of Medicine Houston, TX Background: Acute or prolonged systemic organ failure, perinatal demise, or unexpected death in the neonates and children raises a concern for metabolic, lysosomal storage or mitochondrial diseases and infectious etiologies. A potential pitfall is the presence of cytoplasmic vacuoles particularly within hepatocytes that appear as microvesicular steatosis on routine staining. Microvesicular and macrovesicular steatosis may indicate lipid metabolic or mitochondrial disorders. Ultrastructural examination (EM) is useful in identifying abnormal lipid accumulation, mitochondrial structural abnormalities, and metabolic and lysosomal storage diseases. Particular structures indicative of post-mortem agonal or pre-mortem stress have been termed agonal-stress vesicles. It has not been shown, that these agonal-stress vesicles contain acute phase reactants in response to cellular ischemic or asphyxia. Design: EM laboratory archives were searched for cases with vesicles fitting the ultrastructural features of agonal-stress vesicles. 40 cases (20 males; 20 females) were identified with liver tissue submitted for routine processing (paraffin-embedded formalin fixed) and EM. Study population had variety of medical conditions associated with ischemic and asphyxial stress. Immunohistochemical staining (IHC) with acute phase reactant antibodies was performed (c-reactive protein, fibrinogen, alpha-2-macroglobulin, alpha-1-antitrypsin, alpha-1-chymotrypsin). Results: All routinely stained liver tissue sections shows variably-sized vacuoles within hepatocyte cytoplasm, mimicking microvesicular steatosis. IHC for acute phase reactants highlighted the vacuoles with all antibodies (c-reactive protein, fibrinogen, alpha-2-macroglobulin, alpha-1-antitrypsin, alpha-1-chymotrypsin), with greatest intensity with alpha-1-antitrypsin and alpha-1-chymotrypsin. EM showed frequent vesicles with limiting membranes, containing finely granular, homogeneous content. Conclusion: Agonal-stress vesicles are under recognized structure and may be interpreted as microvesicular steatosis, leading to a workup for metabolic or mitochondrial disease. EM assists in identifying these structures as agonal-stress vesicles. Also, residual formalin-fixed, frozen tissue and tissue recovered from paraffin tissue blocks may be utilized for EM. IHC for acute phase reactants in this study confirms the contents of agonal-stress vacuoles being acute phase reactants. Upon completion of this activity, participants should be able to describe the histopathologic, immunohistochemical and ultrastructural features of agonal-stress vacuoles. [35] Transmission Electron Microscopy (TEM): A Tool often Underused for Pediatric Small Round Blue Cell Tumors opening New Venues for Single-Cell Technologies. Consolato M. Sergi1,2, 1Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, and 2Anatomic Pathology Division, Children's Hospital of Eastern Ontario, University of Ottawa, ON, Canada Aims: Pediatric small round blue cell tumors (PSRBCT) are an intriguing and challenging collection of neoplasms. Light microscopy of small round blue cell tumors identifies small round cells. Pediatric small round blue cell tumors include several entities, such as nephroblastoma, neuroblastoma, rhabdomyosarcoma, Ewing's sarcoma, retinoblastoma, malignant lymphoma, and small cell osteosarcoma among others. The differential diagnosis of these neoplasms may be controversial at a light microscopy level, even using immunohistochemistry. A faint staining or an ambiguous background can deter pathologists from making the proper diagnostic decision. Methods: A review of the personal experience at four centers is considered here. In addition, single cell technologies are added to renew the interest of TEM. Results: Molecular biology may provide an overwhelming amount of data challenging to distinguish them, and some translocations may be seen in more than one category. Thus, TEM can be extremely valuable. In particular, tumor cells associated with tangles of cytoplasmic processes containing neurosecretory granules can diagnose neuroblastoma. Conversely, a marked variation in size, shape and cytoplasmic differentiation with most tumor cells containing prominent dilated cisterns of rough endoplasmic reticulum and bundles of thick and thin filaments with well-formed Z-bands may infer the diagnosis of rhabdomyosarcoma. The presence of an intracytoplasmic deposit of glycogen may suggest Ewing's sarcoma. At the same time, a cellular arrangement in a tubular configuration with a well-formed basal lamina may advocate the diagnosis of nephroblastoma. Single-cell sequencing are booming. Conclusion: Single-cell sequencing technologies are useful to discover the genome, transcriptome, metabolome, and epigenome of single cells. These techniques can show the differences and evolutionary relationships of innumerable cells. Here, we speculate that TEM may have an intriguing role for single-cell sequencing technologies and their applications in oncology, microbiology, reproductive and environmental sciences emphasizing the essential role that single-cell sequencing methods play in these areas. Upon completion of this activity, participants should be able to: 1. To define to general role of TEM in pathology. 2. To identify the role of TEM for PSRBCTs. 3. To determine the relevance in applying new technologies to TEM studies. [36] Chondroid Chordoma Presenting as Oropharyngeal Mass in Pediatrics. John Hicks, Texas Children's Hospital, Baylor College of Medicine, Houston, TX Introduction: Chordoma is a low to intermediate grade malignancy, resembling embryonal notochord. This tumor occurs in sacrococcygeal (60%), craniocervical (25%, clivus most common) and vertebral (15%) sites. Chordoma is a rare tumor (incidence 5/10,000,000; 2% of bone tumors). Peak incidence is in 4th decade. Clinical Presentation and Pathology Findings: 8 year-old girl with asthma history presented with 6-12 months of progressively worsening snoring, muffled voice and saliva pooling, attributed to seasonal allergies. Upon oral examination, a firm, protruding right tonsillar bed (oropharyngeal) mass with intact overlying vascularized mucosa was noted. Limited CT imaging identified an oropharyngeal mass with bony destruction. Biopsy was performed which showed a hyalinized chondroid to cartilaginous mass. Tumor cells immunoreacted with brachyury, EMA, S100 and SOX9, while negative for D2-40, with retained nuclear INI-1. Low-grade chondroid chordoma diagnosis was rendered. Molecular tumor testing identified p53 mutation, and KMT2B and ROS1 mutations of unknown significance. Conventional tumor karyotype was 46,XX. Germline testing was negative for p53 mutation. Additional imaging identified an 8.5 cm clivus origin tumor. The patient underwent additional surgery for tumor debulking, followed by oncologic (radiationtherapy) management. Conclusion: Chondroid chordoma involving oro/nasopharyngeal region is rare (0.2% of oro/nasopharyngeal tumors). Differential diagnosis includes chondrosarcoma, chordoid meningioma, myoepithelioma/myoepithelial carcinoma, extraskeletal myxoid chondrosarcoma, and chordoid meningioma. Treatment is surgical, with complete resection difficult due to anatomic location. Although the tumor tends to be radioresistant, high-dose radiation therapy is usuallyemployed. Overall survival with aggressive surgery is up to 75% at 5yrs and up to 65% at 10yrs. Recurrence is common (up to 90% at 10 years). Chondroid variant has somewhat better prognosis. Sonic hedgehog homolog protein gene (7q33), T (brachyury) gene duplication (6q27), and TSC1 or TSC2 (tuberous sclerosis) gene inactivation are associated with chordoma. Autosomal dominant familial tumors associated with T gene duplication are rare. Upon completion of this activity, participants should be able to describe the clinical, radiologic histopathologic, immunohistochemistry and molecular features in the diagnosis of chordoma. [37] Deciduosis adjacent an ileouterine fistula in the setting of Crohn's disease: Case report and literature review. Lance Truong1, Yigit Baykara1, and Nina Tatevian2. 1Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI and 2Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI Deciduosis is a rare diagnosis which refers to extrauterine decidual tissue, found usually in adjacent gynecological structures including the cervix and ovaries, and more rarely in the peritoneum and in other abdominal organs. Fistulas are a known and frequent complication of Crohn's disease, commonly involving adjacent bowel and rarely involving gynecological structures. Here, we report a case of deciduosis of the distal ileum occurring in the setting of long-standing Crohn's disease in a 34-year-old patient at 31 5/7 weeks of gestation, admitted to our hospital with acute right lower quadrant pain. Imaging was suggestive of complex fistulae and abscess formation. She underwent a cesarean delivery followed by hysterectomy and ileocolectomy with an ileouterine fistula tract leading to a complex subserosal uterine abscess on intraoperative and pathological gross examination. On histological examination, a focus of ectopic decidua adjacent the fistula was incidentally found on H&E section. Review of the current literature on gastrointestinal deciduosis identified nine publications reporting cases primarily involving the appendix and only a single previously reported case involving the ileum. Crohn's disease cases with reported ileouterine fistulas are extremely rare, with only four previously reported cases in the literature. The utility in recognizing this extremely rare presentation is in avoiding misinterpreting this entity as a neoplastic process. Upon completion of this activity, participants should be able to 1. define deciduosis, 2. recognize complications associated with Crohn's disease, 3. compare neoplastic mimickers of ectopic decidual tissue [38] Modern implementation of Digital Pathology with Artificial Intelligence in an Academic Medical Center. Dibson Dibe Gondim, Department of Pathology and Laboratory Medicine at University of Louisville, KY Digital pathology refers to the digital transformation of histopathology - turning histologic tissue sections into multi-gigabyte whole slide images. These images can be evaluated by quantitative and reproducible computational techniques, including artificial intelligence-based algorithms. While the value of this technology has been increasingly recognized, clinical adoption has been limited in most of the world, including in the United States. Our academic center and health care system have embraced the concept of digital pathology and artificial intelligence. My goal is to present the digital pathology implementation proposal and discuss our progress. Overall, digital pathology implementation tends to be a slow process occurring over years. However, we decided that the technology was mature enough for an accelerated adoption plan. From the beginning, we focused on 100% prospective glass slide scanning 100%, in contrast with most institutions which start with limited retrospective scanning. To achieve this, we created a multidisciplinary team with expertise in pathology, histotechnology, project management, software engineering, and data science. We integrated scanning in the histology laboratory using LEAN principles and updated our staining equipment to allow compatibility with the slide scanners. We installed high-throughput slide scanners that require minimal user experience or training. We adopted cloud-based software as the platform product from a vendor with expertise in artificial intelligence. This software platform provides image viewer, worklist, storage, and artificial intelligence-based algorithms. Cloud storage allowed us to scale our operation without major overhead. We started scanning 100% of slides in less than 9 months after the beginning of the project. We deployed the integration interface and the first FDA-approved artificial intelligence-based tool in the testing environment within months. Our experience shows that the current technologies allow for an accelerated adoption of digital pathology. However, advanced understanding of digital pathology technologies and assembling a multidisciplinary task force have been instrumental in determining how to best put together all the pieces and to overcome multiple challenges that emerged during the implementation period. Upon completion of this activity, participants should be able to 1. understand how digital pathology fits in the clinical workflow, 2. describe digital pathology implementation strategies, and 3. explain how integration of multiple hospital and laboratory information systems for a productive user experience. [39] Establishing a Hospital AI Committee: Enhancing Precision Medicine. Andrew A. Borkowski, M.D. James A. Haley Veterans' Hospital James A. Haley Veterans' Hospital AI Committee was established in May 2021. Vision: To improve outcomes and experiences for our Veterans by developing trustworthy Artificial Intelligence capabilities to support the Department of Veterans Affairs mission. Mission: To build robust capacity in Artificial Intelligence to develop and apply innovative AI solutions and transform the VA by facilitating a learning environment that supports the delivery of world-class benefits and services to our veterans. Accomplishments: Establishment of the AI email group, MS Teams AI Group, and SharePoint site. AI Ethics Guidelines. Clinical AI Product Evaluation Guidelines. Education programs with "AI Article of the Week", AI Newsletter, and AI Conference. Collaboration with the National AI Institute. Partnership with the Moffitt Machine Learning League. AI in Healthcare Workshop during the 2021 VISN 8 Improvement and Innovation Forum. 2022 VISN 8 AI Conference Upon completion of this activity, participants should be able to familiarize themselves with the formal process of promoting AI throughout their institutions. [40] Artificial Intelligence in Radiology: Hype, Hope, or Hysteria.Narayan Viswanadhan, Chief of Radiology at the Tampa VA, and is a clinical faculty at USF Health Morsani College of Medicine. Tampa, FL There is particularly increasing application of AI tools within Diagnostic Imaging and Pathology. Clinical applications of AI in imaging will be discussed, with focus on current uses, and future directions. Additional areas covered will be utilization of AI in Neuroimaging, population health, Breast Imaging, and Precision Medicine. Utilization of AI in the face of the pandemic will also be discussed.. Upon completion of this activity, participants should be able to 1. develop an understanding of Artificial Intelligence as it relates to imaging 2.understand current clinical use cases and future directions, and 3. appreciate challenges of AI in Radiology. [41] Data literacy in healthcare: a vital component of precision medicine. Joyce J. Ou, Alpert Medical School, Brown University, Providence, RI The accelerating volume of heterogenous, multimodal data that is generated in modern healthcare highlights an urgent need for data literacy across a broad range of stakeholders. As information sources, analytics, and use cases rapidly evolve, data-powered augmented intelligence is becoming a major driver of precision medicine. The growing influence of machine generated insights on decisionmaking underscores the importance of ensuring that health data producers and consumers have the skills to critically evaluate, interpret, communicate, and act on these insights. Data literacy has, at times, been equated with specific data science tools and processes. However, fluency with data in the current era requires additional knowledge of its value and limitations with respect to data life cycles and governance, along with technical, social, and ethical implications. To achieve this breadth of understanding, a practical framework can be developed to identify and address gaps in data literacy. This framework focuses on identifying core categories of data skills, assessing stakeholder roles and needs relative to these categories, and developing processes for continuous learning. Implementation of such a model can promote systemic innovation by enabling individuals to stay current with the pace of technological changes that impact all stages of precision medicine discovery and delivery. Upon completion of this activity, participants should be able to 1. Identify core competencies needed to achieve healthcare data literacy 2. Evaluate the impact of a data literacy framework on promoting collaborations between data producers and consumers in precision medicine 3. Describe a data education model that supports continuous learning for healthcare stakeholders. [42] Digital health applications and key characteristics related to at-home testing outcomes. Lee B. Springer, Brio Systems, Bellevue, OH Digital health technology applications (DHT) have been minimally utilized to support at-home rapid testing in the past. With the emergence of SARS-CoV-2, their use has increased significantly. One of the primary contributors to this growth is the widespread adoption of at-home testing throughout the progression of the pandemic to increase the publics access to testing. Given the increased need for at-home testing, digital health technology applications have been utilized to aid users throughout all testing processes and efficiently document results. These applications are considered to play a vital role in ensuring optimal accuracy of the test device and facilitate public health reporting. A step-by-step systematic analysis of digital health technology supporting at-home point-of-care testing was performed to identify key areas of task related dependence to predicted outcome in relation to technological support. The aim of the analysis was to assess the quality and features in relation to engagement during testing phases utilizing the mobile application rating scale (MARS). This analysis included 27 digital health applications designed to complement at-home testing for glucose, creatinine, coagulation, hemoglobin A1c, and SARS-CoV-2 with more than 5,000 downloads or registered users. A nonparametric rank sum test was used to determine correlating performance between sections of the mobile application rating scale and aligned testing phases. High scores in pre-analytical and post-analytical sections of the mobile application rating scale correlated to an overall high level of satisfaction and desired outcome. Additional correlations were seen between sections related to overall functionality, and applications viewed to support pre-analytical processes effectively, these were deemed as being able to consistently produce better patient and result outcomes. Upon completion of this activity, participants should be able to identify digital health technology that would optimize accurate results, predict overall patient engagement in clinical application and design clinical practices around digital health technology to optimize patient outcomes. [43] Validation of Artificial Intelligence-Based System for Prostate Cancer Detection and Grading. Tarymé López Díaz and Dibson Dibe Gondim, Department of Pathology and Laboratory Medicine at University of Louisville, KY Paige Prostate Detect (Paige.AI Inc., New York, USA) is the first FDA-approved artificial intelligence (AI)-based system created to assist pathologists to detect and grade prostate cancer. Our goal is to present the results of a validation study of this system in an academic center. 40 prostate biopsy cases were randomly selected from a list of 60 consecutive cases. All HE-stained slides (619) were scanned in a Leica Aperio GT450 (400x magnification). Paige Prostate Detect was applied to each slide and results were compared with the original diagnoses. Diagnostic discrepancies were evaluated by pathologists. AI output was recorded for each whole slide image. On the other hand, pathologists provided results based on the evaluation of two or more glass slides per biopsy location. 36 disagreements were identified (5.8%) in all slides. Agreement on the case level required that all slides of a case had concordant diagnosis between AI-system and pathologist. 16/40 cases had disagreements. The AI-system helped to detect focal cancer in a case with no prior definitive cancer diagnosis. Multiple discrepancies related to atypical small acinar proliferation (ASAP) were identified. Since the system was not trained to make a diagnosis of ASAP, these cases were either diagnosed as carcinoma or benign. Validation of pathology AI-systems is essential before clinical adoption. This system shows potential to locate low-volume cancer in cases with no definitive diagnosis of malignancy. In the case of ASAP, pathologists should use well-defined criteria to render this diagnosis and should not rely on AI impression. [44] Respiratory Pathology of Acute Respiratory distress Syndrome (ARDS). Henry Oh, PhD, FACSc, FRSB, FAPSR, RRT, MT, CSci, Health Occupations Department, Idaho State University, Pocatello, ID The body's immune system response to infection is primarily an inflammation. Cytokines cause inflammation of tissue by making the cell walls of blood vessels become more permeable, thus allowing leakage of blood with immune cells into the surrounding tissue to start the healing process of the damaged tissue. The inflammation is triggered by the release of cytokines from interferons, interleukins, and tumor necrosis factor (TNF). Cells that release cytokines include leucocytes or interleukins, neutrophils, macrophages, monocytes, and many other cells. When the inflammatory response go out of control, it can cause more harm to the lungs in COVID-19 infection where cytokines can destroy normal, healthy alveoli. Cytokine storm occurs when there is an overwhelming inflammatory response due to the increase release of cytokines. The inflammatory cytokines "storms" the lungs which is the leading cause of mortality rates in patients with COVID-19 infection in ICU. Accumulated dead cells and other debris in the lungs can set the stage for the development of acute respiratory distress syndrome (ARDS). The effects of cytokine storm amplify the severity and extent of ARDS. In ARDS, the alveoli become filled with dead cells, debris and leaked fluids from damaged interstitial cells. The lungs become stiff because of very low compliance. Oxygen saturation levels fall below 90% and the partial pressure of oxygen (PaO2) fall below 60 mmHg which can lead to severe hypoxemia. Patients with ARDS develop refractory hypoxemia which is unresponsive to oxygen therapy. Patient needs to be intubated and connected to a ventilator. The positive pressure effects of mechanical ventilation may not be adequate to improve the oxygenation status of the patient. Positive End Expiratory Pressure (PEEP) would need to be added to keep the oxygen saturation at 90%. However, caution must be observed when ventilating patients with high positive pressure since this can cause detrimental effects on the cardiovascular system. It can decrease blood pressure, cardiac output, urine output leading to cardiovascular collapse, multi-organ failure, and cardiopulmonary arrest. Monitoring of fluids and electrolytes, vital signs, lung compliance, blood gases and patient's response to positive pressure ventilation are extremely important in critical care management. Upon completion of this activity, participants should be able to to briefly discuss how cytokines affect the lungs as a result of COVID-19 infection, to identify ventilator strategies and initial management of patients with ARDS, and to identify the common complications when ventilating patients with ARDS.

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(2015) Sponge species composition of north-east Atlantic cold-water coral reefs compared in a bathyal to inshore gradient. Journal of the Marine Biological Association of the United Kingdom, 95 (7), 1461-1474.        https://doi.org/10.1017/S0025315413001410Vanhöffen, E. (1910) Die Hydroiden der Deutschen Südpolar-Expedition 1901-1903. Deutsche Südpolar-Expedition 1901-1903, 11, Zoologie 3, 269-340.Vervoort, W. (1946) Exotic hydroids in the collections of the Rijksmuseum van Natuurlijke Historie and the Zoological Museum at Amsterdam. Zoologische Mededelingen, Leiden, 26 (1-4), 287-351.Vervoort, W. (1946) Exotic hydroids in the collections of the Rijksmuseum van Natuurlijke Historie and the Zoological Museum at Amsterdam. Zoologische Mededelingen, Leiden, 26 (1-4), 287-351.Vervoort, W. (1972) Hydroids from the Theta, Vema and Yelcho cruises of the Lamont-Doherty geological observatory. Rijksmuseum van Natuurlijke Historie, Leiden, Netherlands, 120, 1-247.Vervoort, W. 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Institut für Meereskunde der Universität Hamburg, 136 pp.Wienberg, C., Titschack, J., Freiwald, A., Frank, N., TomasLundälv, T., Taviani, M., Beuck, L., Schröder-Ritzrau, A., Krengel, T. and Hebbeln, D. (2018) The giant Mauritanian cold-water coral mound province: Oxygen control on coral mound formation. Quaternary Science Reviews, 185, 135-152.        https://doi.org/10.1016/j.quascirev.2018.02.012Wright, T.S. (1859) Observations on British zoophytes. Edinburgh new Philosophical Journal, 10, 105-114.

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Description of the condition Malaria, an infectious disease transmitted by the bite of female mosquitoes from several Anopheles species, occurs in 87 countries with ongoing transmission (WHO 2020). The World Health Organization (WHO) estimated that, in 2019, approximately 229 million cases of malaria occurred worldwide, with 94% occurring in the WHO's African region (WHO 2020). Of these malaria cases, an estimated 409,000 deaths occurred globally, with 67% occurring in children under five years of age (WHO 2020). Malaria also negatively impacts the health of women during pregnancy, childbirth, and the postnatal period (WHO 2020). Sulfadoxine/pyrimethamine (SP), an antifolate antimalarial, has been widely used across sub-Saharan Africa as the first-line treatment for uncomplicated malaria since it was first introduced in Malawi in 1993 (Filler 2006). Due to increasing resistance to SP, in 2000 the WHO recommended that one of several artemisinin-based combination therapies (ACTs) be used instead of SP for the treatment of uncomplicated malaria caused by Plasmodium falciparum (Global Partnership to Roll Back Malaria 2001). However, despite these recommendations, SP continues to be advised for intermittent preventive treatment in pregnancy (IPTp) and intermittent preventive treatment in infants (IPTi), whether the person has malaria or not (WHO 2013). Description of the intervention Folate (vitamin B9) includes both naturally occurring folates and folic acid, the fully oxidized monoglutamic form of the vitamin, used in dietary supplements and fortified food. Folate deficiency (e.g. red blood cell (RBC) folate concentrations of less than 305 nanomoles per litre (nmol/L); serum or plasma concentrations of less than 7 nmol/L) is common in many parts of the world and often presents as megaloblastic anaemia, resulting from inadequate intake, increased requirements, reduced absorption, or abnormal metabolism of folate (Bailey 2015; WHO 2015a). Pregnant women have greater folate requirements; inadequate folate intake (evidenced by RBC folate concentrations of less than 400 nanograms per millilitre (ng/mL), or 906 nmol/L) prior to and during the first month of pregnancy increases the risk of neural tube defects, preterm delivery, low birthweight, and fetal growth restriction (Bourassa 2019). The WHO recommends that all women who are trying to conceive consume 400 micrograms (µg) of folic acid daily from the time they begin trying to conceive through to 12 weeks of gestation (WHO 2017). In 2015, the WHO added the dosage of 0.4 mg of folic acid to the essential drug list (WHO 2015c). Alongside daily oral iron (30 mg to 60 mg elemental iron), folic acid supplementation is recommended for pregnant women to prevent neural tube defects, maternal anaemia, puerperal sepsis, low birthweight, and preterm birth in settings where anaemia in pregnant women is a severe public health problem (i.e. where at least 40% of pregnant women have a blood haemoglobin (Hb) concentration of less than 110 g/L). How the intervention might work Potential interactions between folate status and malaria infection The malaria parasite requires folate for survival and growth; this has led to the hypothesis that folate status may influence malaria risk and severity. In rhesus monkeys, folate deficiency has been found to be protective against Plasmodium cynomolgi malaria infection, compared to folate-replete animals (Metz 2007). Alternatively, malaria may induce or exacerbate folate deficiency due to increased folate utilization from haemolysis and fever. Further, folate status measured via RBC folate is not an appropriate biomarker of folate status in malaria-infected individuals since RBC folate values in these individuals are indicative of both the person's stores and the parasite's folate synthesis. A study in Nigeria found that children with malaria infection had significantly higher RBC folate concentrations compared to children without malaria infection, but plasma folate levels were similar (Bradley-Moore 1985). Why it is important to do this review The malaria parasite needs folate for survival and growth in humans. For individuals, adequate folate levels are critical for health and well-being, and for the prevention of anaemia and neural tube defects. Many countries rely on folic acid supplementation to ensure adequate folate status in at-risk populations. Different formulations for folic acid supplements are available in many international settings, with dosages ranging from 400 µg to 5 mg. Evaluating folic acid dosage levels used in supplementation efforts may increase public health understanding of its potential impacts on malaria risk and severity and on treatment failures. Examining folic acid interactions with antifolate antimalarial medications and with malaria disease progression may help countries in malaria-endemic areas determine what are the most appropriate lower dose folic acid formulations for at-risk populations. The WHO has highlighted the limited evidence available and has indicated the need for further research on biomarkers of folate status, particularly interactions between RBC folate concentrations and tuberculosis, human immunodeficiency virus (HIV), and antifolate antimalarial drugs (WHO 2015b). An earlier Cochrane Review assessed the effects and safety of iron supplementation, with or without folic acid, in children living in hyperendemic or holoendemic malaria areas; it demonstrated that iron supplementation did not increase the risk of malaria, as indicated by fever and the presence of parasites in the blood (Neuberger 2016). Further, this review stated that folic acid may interfere with the efficacy of SP; however, the efficacy and safety of folic acid supplementation on these outcomes has not been established. This review will provide evidence on the effectiveness of daily folic acid supplementation in healthy and malaria-infected individuals living in malaria-endemic areas. Additionally, it will contribute to achieving both the WHO Global Technical Strategy for Malaria 2016-2030 (WHO 2015d), and United Nations Sustainable Development Goal 3 (to ensure healthy lives and to promote well-being for all of all ages) (United Nations 2021), and evaluating whether the potential effects of folic acid supplementation, at different doses (e.g. 0.4 mg, 1 mg, 5 mg daily), interferes with the effect of drugs used for prevention or treatment of malaria. To examine the effects of folic acid supplementation, at various doses, on malaria susceptibility (risk of infection) and severity among people living in areas with various degrees of malaria endemicity. We will examine the interaction between folic acid supplements and antifolate antimalarial drugs. Specifically, we will aim to answer the following. Among uninfected people living in malaria endemic areas, who are taking or not taking antifolate antimalarials for malaria prophylaxis, does taking a folic acid-containing supplement increase susceptibility to or severity of malaria infection? Among people with malaria infection who are being treated with antifolate antimalarials, does folic acid supplementation increase the risk of treatment failure? Criteria for considering studies for this review Types of studies Inclusion criteria Randomized controlled trials (RCTs) Quasi-RCTs with randomization at the individual or cluster level conducted in malaria-endemic areas (areas with ongoing, local malaria transmission, including areas approaching elimination, as listed in the World Malaria Report 2020) (WHO 2020) Exclusion criteria Ecological studies Observational studies In vivo/in vitro studies Economic studies Systematic literature reviews and meta-analyses (relevant systematic literature reviews and meta-analyses will be excluded but flagged for grey literature screening) Types of participants Inclusion criteria Individuals of any age or gender, living in a malaria endemic area, who are taking antifolate antimalarial medications (including but not limited to sulfadoxine/pyrimethamine (SP), pyrimethamine-dapsone, pyrimethamine, chloroquine and proguanil, cotrimoxazole) for the prevention or treatment of malaria (studies will be included if more than 70% of the participants live in malaria-endemic regions) Studies assessing participants with or without anaemia and with or without malaria parasitaemia at baseline will be included Exclusion criteria Individuals not taking antifolate antimalarial medications for prevention or treatment of malaria Individuals living in non-malaria endemic areas Types of interventions Inclusion criteria Folic acid supplementation Form: in tablet, capsule, dispersible tablet at any dose, during administration, or periodically Timing: during, before, or after (within a period of four to six weeks) administration of antifolate antimalarials Iron-folic acid supplementation Folic acid supplementation in combination with co-interventions that are identical between the intervention and control groups. Co-interventions include: anthelminthic treatment; multivitamin or multiple micronutrient supplementation; 5-methyltetrahydrofolate supplementation. Exclusion criteria Folate through folate-fortified water Folic acid administered through large-scale fortification of rice, wheat, or maize Comparators Placebo No treatment No folic acid/different doses of folic acid Iron Types of outcome measures Primary outcomes Uncomplicated malaria (defined as a history of fever with parasitological confirmation; acceptable parasitological confirmation will include rapid diagnostic tests (RDTs), malaria smears, or nucleic acid detection (i.e. polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP), etc.)) (WHO 2010). This outcome is relevant for patients without malaria, given antifolate antimalarials for malaria prophylaxis. Severe malaria (defined as any case with cerebral malaria or acute P. falciparum malaria, with signs of severity or evidence of vital organ dysfunction, or both) (WHO 2010). This outcome is relevant for patients without malaria, given antifolate antimalarials for malaria prophylaxis. Parasite clearance (any Plasmodium species), defined as the time it takes for a patient who tests positive at enrolment and is treated to become smear-negative or PCR negative. This outcome is relevant for patients with malaria, treated with antifolate antimalarials. Treatment failure (defined as the inability to clear malaria parasitaemia or prevent recrudescence after administration of antimalarial medicine, regardless of whether clinical symptoms are resolved) (WHO 2019). This outcome is relevant for patients with malaria, treated with antifolate antimalarials. Secondary outcomes Duration of parasitaemia Parasite density Haemoglobin (Hb) concentrations (g/L) Anaemia: severe anaemia (defined as Hb less than 70 g/L in pregnant women and children aged six to 59 months; and Hb less than 80 g/L in other populations); moderate anaemia (defined as Hb less than 100 g/L in pregnant women and children aged six to 59 months; and less than 110 g/L in others) Death from any cause Among pregnant women: stillbirth (at less than 28 weeks gestation); low birthweight (less than 2500 g); active placental malaria (defined as Plasmodium detected in placental blood by smear or PCR, or by Plasmodium detected on impression smear or placental histology). Search methods for identification of studies A search will be conducted to identify completed and ongoing studies, without date or language restrictions. Electronic searches A search strategy will be designed to include the appropriate subject headings and text word terms related to each intervention of interest and study design of interest (see Appendix 1). Searches will be broken down by these two criteria (intervention of interest and study design of interest) to allow for ease of prioritization, if necessary. The study design filters recommended by the Scottish Intercollegiate Guidelines Network (SIGN), and those designed by Cochrane for identifying clinical trials for MEDLINE and Embase, will be used (SIGN 2020). There will be no date or language restrictions. Non-English articles identified for inclusion will be translated into English. If translations are not possible, advice will be requested from the Cochrane Infectious Diseases Group and the record will be stored in the "Awaiting assessment" section of the review until a translation is available. The following electronic databases will be searched for primary studies. Cochrane Central Register of Controlled Trials. Cumulative Index to Nursing and Allied Health Literature (CINAHL). Embase. MEDLINE. Scopus. Web of Science (both the Social Science Citation Index and the Science Citation Index). We will conduct manual searches of ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), and the United Nations Children's Fund (UNICEF) Evaluation and Research Database (ERD), in order to identify relevant ongoing or planned trials, abstracts, and full-text reports of evaluations, studies, and surveys related to programmes on folic acid supplementation in malaria-endemic areas. Additionally, manual searches of grey literature to identify RCTs that have not yet been published but are potentially eligible for inclusion will be conducted in the following sources. Global Index Medicus (GIM). African Index Medicus (AIM). Index Medicus for the Eastern Mediterranean Region (IMEMR). Latin American & Caribbean Health Sciences Literature (LILACS). Pan American Health Organization (PAHO). Western Pacific Region Index Medicus (WPRO). Index Medicus for the South-East Asian Region (IMSEAR). The Spanish Bibliographic Index in Health Sciences (IBECS) (ibecs.isciii.es/). Indian Journal of Medical Research (IJMR) (journals.lww.com/ijmr/pages/default.aspx). Native Health Database (nativehealthdatabase.net/). Scielo (www.scielo.br/). Searching other resources Handsearches of the five journals with the highest number of included studies in the last 12 months will be conducted to capture any relevant articles that may not have been indexed in the databases at the time of the search. We will contact the authors of included studies and will check reference lists of included papers for the identification of additional records. For assistance in identifying ongoing or unpublished studies, we will contact the Division of Nutrition, Physical Activity, and Obesity (DNPAO) and the Division of Parasitic Diseases and Malaria (DPDM) of the CDC, the United Nations World Food Programme (WFP), Nutrition International (NI), Global Alliance for Improved Nutrition (GAIN), and Hellen Keller International (HKI). Data collection and analysis Selection of studies Two review authors will independently screen the titles and abstracts of articles retrieved by each search to assess eligibility, as determined by the inclusion and exclusion criteria. Studies deemed eligible for inclusion by both review authors in the abstract screening phase will advance to the full-text screening phase, and full-text copies of all eligible papers will be retrieved. If full articles cannot be obtained, we will attempt to contact the authors to obtain further details of the studies. If such information is not obtained, we will classify the study as "awaiting assessment" until further information is published or made available to us. The same two review authors will independently assess the eligibility of full-text articles for inclusion in the systematic review. If any discrepancies occur between the studies selected by the two review authors, a third review author will provide arbitration. Each trial will be scrutinized to identify multiple publications from the same data set, and the justification for excluded trials will be documented. A PRISMA flow diagram of the study selection process will be presented to provide information on the number of records identified in the literature searches, the number of studies included and excluded, and the reasons for exclusion (Moher 2009). The list of excluded studies, along with their reasons for exclusion at the full-text screening phase, will also be created. Data extraction and management Two review authors will independently extract data for the final list of included studies using a standardized data specification form. Discrepancies observed between the data extracted by the two authors will be resolved by involving a third review author and reaching a consensus. Information will be extracted on study design components, baseline participant characteristics, intervention characteristics, and outcomes. For individually randomized trials, we will record the number of participants experiencing the event and the number analyzed in each treatment group or the effect estimate reported (e.g. risk ratio (RR)) for dichotomous outcome measures. For count data, we will record the number of events and the number of person-months of follow-up in each group. If the number of person-months is not reported, the product of the duration of follow-up and the number of children evaluated will be used to estimate this figure. We will calculate the rate ratio and standard error (SE) for each study. Zero events will be replaced by 0.5. We will extract both adjusted and unadjusted covariate incidence rate ratios if they are reported in the original studies. For continuous data, we will extract means (arithmetic or geometric) and a measure of variance (standard deviation (SD), SE, or confidence interval (CI)), percentage or mean change from baseline, and the numbers analyzed in each group. SDs will be computed from SEs or 95% CIs, assuming a normal distribution of the values. Haemoglobin values in g/dL will be calculated by multiplying haematocrit or packed cell volume values by 0.34, and studies reporting haemoglobin values in g/dL will be converted to g/L. In cluster-randomized trials, we will record the unit of randomization (e.g. household, compound, sector, or village), the number of clusters in the trial, and the average cluster size. The statistical methods used to analyze the trials will be documented, along with details describing whether these methods adjusted for clustering or other covariates. We plan to extract estimates of the intra-cluster correlation coefficient (ICC) for each outcome. Where results are adjusted for clustering, we will extract the treatment effect estimate and the SD or CI. If the results are not adjusted for clustering, we will extract the data reported. Assessment of risk of bias in included studies Two review authors (KSC, LFY) will independently assess the risk of bias for each included trial using the Cochrane 'Risk of bias 2' tool (RoB 2) for randomized studies (Sterne 2019). Judgements about the risk of bias of included studies will be made according to the recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021). Disagreements will be resolved by discussion, or by involving a third review author. The interest of our review will be to assess the effect of assignment to the interventions at baseline. We will evaluate each primary outcome using the RoB2 tool. The five domains of the Cochrane RoB2 tool include the following. Bias arising from the randomization process. Bias due to deviations from intended interventions. Bias due to missing outcome data. Bias in measurement of the outcome. Bias in selection of the reported result. Each domain of the RoB2 tool comprises the following. A series of 'signalling' questions. A judgement about the risk of bias for the domain, facilitated by an algorithm that maps responses to the signalling questions to a proposed judgement. Free-text boxes to justify responses to the signalling questions and 'Risk of bias' judgements. An option to predict (and explain) the likely direction of bias. Responses to signalling questions elicit information relevant to an assessment of the risk of bias. These response options are as follows. Yes (may indicate either low or high risk of bias, depending on the most natural way to ask the question). Probably yes. Probably no. No. No information (may indicate no evidence of that problem or an absence of information leading to concerns about there being a problem). Based on the answer to the signalling question, a 'Risk of bias' judgement is assigned to each domain. These judgements include one of the following. High risk of bias Low risk of bias Some concerns To generate the risk of bias judgement for each domain in the randomized studies, we will use the Excel template, available at www.riskofbias.info/welcome/rob-2-0-tool/current-version-of-rob-2. This file will be stored on a scientific data website, available to readers. Risk of bias in cluster randomized controlled trials For the cluster randomized trials, we will be using the RoB2 tool to analyze the five standard domains listed above along with Domain 1b (bias arising from the timing of identification or recruitment of participants) and its related signalling questions. To generate the risk of bias judgement for each domain in the cluster RCTs, we will use the Excel template available at https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials. This file will be stored on a scientific data website, available to readers. Risk of bias in cross-over randomized controlled trials For cross-over randomized trials, we will be using the RoB2 tool to analyze the five standard domains listed above along with Domain 2 (bias due to deviations from intended interventions), and Domain 3 (bias due to missing outcome data), and their respective signalling questions. To generate the risk of bias judgement for each domain in the cross-over RCTs, we will use the Excel template, available at https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-crossover-trials, for each risk of bias judgement of cross-over randomized studies. This file will be stored on a scientific data website, available to readers. Overall risk of bias The overall 'Risk of bias' judgement for each specific trial being assessed will be based on each domain-level judgement. The overall judgements include the following. Low risk of bias (the trial is judged to be at low risk of bias for all domains). Some concerns (the trial is judged to raise some concerns in at least one domain but is not judged to be at high risk of bias for any domain). High risk of bias (the trial is judged to be at high risk of bias in at least one domain, or is judged to have some concerns for multiple domains in a way that substantially lowers confidence in the result). The 'risk of bias' assessments will inform our GRADE evaluations of the certainty of evidence for our primary outcomes presented in the 'Summary of findings' tables and will also be used to inform the sensitivity analyses; (see Sensitivity analysis). If there is insufficient information in study reports to enable an assessment of the risk of bias, studies will be classified as "awaiting assessment" until further information is published or made available to us. Measures of treatment effect Dichotomous data For dichotomous data, we will present proportions and, for two-group comparisons, results as average RR or odds ratio (OR) with 95% CIs. Ordered categorical data Continuous data We will report results for continuous outcomes as the mean difference (MD) with 95% CIs, if outcomes are measured in the same way between trials. Where some studies have reported endpoint data and others have reported change-from-baseline data (with errors), we will combine these in the meta-analysis, if the outcomes were reported using the same scale. We will use the standardized mean difference (SMD), with 95% CIs, to combine trials that measured the same outcome but used different methods. If we do not find three or more studies for a pooled analysis, we will summarize the results in a narrative form. Unit of analysis issues Cluster-randomized trials We plan to combine results from both cluster-randomized and individually randomized studies, providing there is little heterogeneity between the studies. If the authors of cluster-randomized trials conducted their analyses at a different level from that of allocation, and they have not appropriately accounted for the cluster design in their analyses, we will calculate the trials' effective sample sizes to account for the effect of clustering in data. When one or more cluster-RCT reports RRs adjusted for clustering, we will compute cluster-adjusted SEs for the other trials. When none of the cluster-RCTs provide cluster-adjusted RRs, we will adjust the sample size for clustering. We will divide, by the estimated design effects (DE), the number of events and number evaluated for dichotomous outcomes and the number evaluated for continuous outcomes, where DE = 1 + ((average cluster size 1) * ICC). The derivation of the estimated ICCs and DEs will be reported. We will utilize the intra-cluster correlation coefficient (ICC), derived from the trial (if available), or from another source (e.g., using the ICCs derived from other, similar trials) and then calculate the design effect with the formula provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021). If this approach is used, we will report it and undertake sensitivity analysis to investigate the effect of variations in ICC. Studies with more than two treatment groups If we identify studies with more than two intervention groups (multi-arm studies), where possible we will combine groups to create a single pair-wise comparison or use the methods set out in the Cochrane Handbook to avoid double counting study participants (Higgins 2021). For the subgroup analyses, when the control group was shared by two or more study arms, we will divide the control group (events and total population) over the number of relevant subgroups to avoid double counting the participants. Trials with several study arms can be included more than once for different comparisons. Cross-over trials From cross-over trials, we will consider the first period of measurement only and will analyze the results together with parallel-group studies. Multiple outcome events In several outcomes, a participant might experience more than one outcome event during the trial period. For all outcomes, we will extract the number of participants with at least one event. Dealing with missing data We will contact the trial authors if the available data are unclear, missing, or reported in a format that is different from the format needed. We aim to perform a 'per protocol' or 'as observed' analysis; otherwise, we will perform a complete case analysis. This means that for treatment failure, we will base the analyses on the participants who received treatment and the number of participants for which there was an inability to clear malarial parasitaemia or prevent recrudescence after administration of an antimalarial medicine reported in the studies. Assessment of heterogeneity Heterogeneity in the results of the trials will be assessed by visually examining the forest plot to detect non-overlapping CIs, using the Chi2 test of heterogeneity (where a P value of less than 0.1 indicates statistical significance) and the I2 statistic of inconsistency (with a value of greater than 50% denoting moderate levels of heterogeneity). When statistical heterogeneity is present, we will investigate the reasons for it, using subgroup analysis. Assessment of reporting biases We will construct a funnel plot to assess the effect of small studies for the main outcome (when including more than 10 trials). Data synthesis The primary analysis will include all eligible studies that provide data regardless of the overall risk of bias as assessed by the RoB2 tool. Analyses will be conducted using Review Manager 5.4 (Review Manager 2020). Cluster-RCTs will be included in the main analysis after adjustment for clustering (see the previous section on cluster-RCTs). The meta-analysis will be performed using the Mantel-Haenszel random-effects model or the generic inverse variance method (when adjustment for clustering is performed by adjusting SEs), as appropriate. Subgroup analysis and investigation of heterogeneity The overall risk of bias will not be used as the basis in conducting our subgroup analyses. However, where data are available, we plan to conduct the following subgroup analyses, independent of heterogeneity. Dose of folic acid supplementation: higher doses (4 mg or more, daily) versus lower doses (less than 4 mg, daily). Moderate-severe anaemia at baseline (mean haemoglobin of participants in a trial at baseline below 100 g/L for pregnant women and children aged six to 59 months, and below 110 g/L for other populations) versus normal at baseline (mean haemoglobin above 100 g/L for pregnant women and children aged six to 59 months, and above 110 g/L for other populations). Antimalarial drug resistance to parasite: known resistance versus no resistance versus unknown/mixed/unreported parasite resistance. Folate status at baseline: Deficient (e.g. RBC folate concentration of less than 305 nmol/L, or serum folate concentration of less than 7nmol/L) and Insufficient (e.g. RBC folate concentration from 305 to less than 906 nmol/L, or serum folate concentration from 7 to less than 25 nmol/L) versus Sufficient (e.g. RBC folate concentration above 906 nmol/L, or serum folate concentration above 25 nmol/L). Presence of anaemia at baseline: yes versus no. Mandatory fortification status: yes, versus no (voluntary or none). We will only use the primary outcomes in any subgroup analyses, and we will limit subgroup analyses to those outcomes for which three or more trials contributed data. Comparisons between subgroups will be performed using Review Manager 5.4 (Review Manager 2020). Sensitivity analysis We will perform a sensitivity analysis, using the risk of bias as a variable to explore the robustness of the findings in our primary outcomes. We will verify the behaviour of our estimators by adding and removing studies with a high risk of bias overall from the analysis. That is, studies with a low risk of bias versus studies with a high risk of bias. Summary of findings and assessment of the certainty of the evidence For the assessment across studies, we will use the GRADE approach, as outlined in (Schünemann 2021). We will use the five GRADE considerations (study limitations based on RoB2 judgements, consistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence as it relates to the studies which contribute data to the meta-analyses for the primary outcomes. The GRADEpro Guideline Development Tool (GRADEpro) will be used to import data from Review Manager 5.4 (Review Manager 2020) to create 'Summary of Findings' tables. The primary outcomes for the main comparison will be listed with estimates of relative effects, along with the number of participants and studies contributing data for those outcomes. These tables will provide outcome-specific information concerning the overall certainty of evidence from studies included in the comparison, the magnitude of the effect of the interventions examined, and the sum of available data on the outcomes we considered. We will include only primary outcomes in the summary of findings tables. For each individual outcome, two review authors (KSC, LFY) will independently assess the certainty of the evidence using the GRADE approach (Balshem 2011). For assessments of the overall certainty of evidence for each outcome that includes pooled data from included trials, we will downgrade the evidence from 'high certainty' by one level for serious (or by two for very serious) study limitations (risk of bias, indirectness of evidence, serious inconsistency, imprecision of effect estimates, or potential publication bias).

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Our expanded efforts in genomic sequencing to cover additional skipper butterfly (Lepidoptera: Hesperiidae) species and populations, including primary type specimens, call for taxonomic changes to restore monophyly and correct misidentifications by moving taxa between genera and proposing new names. Reconciliation between phenotypic characters and genomic trees suggests three new tribes, two new subtribes, 23 new genera, 17 new subgenera and 10 new species that are proposed here: Psolosini Grishin, <bnew tribe</b (type genus <iPsolos</i Staudinger, 1889), Ismini Grishin, <bnew tribe</b (type genus <iIsma</i Distant, 1886), Eetionini Grishin, <bnew tribe</b (type genus <iEetion</i de Nicéville, 1895), Orphina Grishin, <bnew subtribe</b (type genus <iOrphe</i Godman, 1901), Carystoidina Grishin, <bnew subtribe</b (type genus <iCarystoides</i Godman, 1901), <iFulvatis</i Grishin, <bnew genus</b (type species <iTelegonus fulvius</i Plötz, 1882), <iAdina</i Grishin, <bnew genus</b (type species <iNascus adrastor</i Mabille and Boullet, 1912), <iOrnilius</i Grishin, <bnew genus</b (type species <iOrnilius rotundus</i Grishin, <bnew species</b), <iTolius</i Grishin, <bnew genus</b (type species <iAntigonus tolimus</i Plötz, 1884), <iLennia</i Grishin, <bnew genus</b (type species <iLeona lena</i Evans, 1937), <iTrida</i Grishin, <bnew genus</b (type species <iCyclopides barberae</i Trimen, 1873), <iNoxys</i Grishin, <bnew genus</b (type species <iOxynthes viricuculla</i Hayward, 1951), <iGracilata</i Grishin, <bnew genus</b (type species <iEnosis quadrinotata</i Mabille, 1889), <iHermio</i Grishin, <bnew genus</b (type species <iFalga</i ? <ihermione</i Schaus, 1913), <iEutus</i Grishin, <bnew genus</b (type species <iCobalus rastaca</i Schaus, 1902), <iGufa</i Grishin, <bnew genus</b (type species <iPhlebodes gulala</i Schaus, 1902), <iGodmia</i Grishin, <bnew genus</b (type species <iEuroto chlorocephala</i Godman, 1900), <iRhomba</i Grishin, <bnew genus</b (type species <iEutychide gertschi</i Bell, 1937), <iRectava</i Grishin, <bnew genus</b (type species <iMegistias ignarus</i Bell, 1932), <iContrastia</i Grishin, <bnew genus</b (type species <iHesperia distigma</i Plötz, 1882), <iMit</i Grishin, <bnew genus</b (type species <iMnasitheus badius</i Bell, 1930), <iPicova</i Grishin, <bnew genus</b (type species <iVorates steinbachi</i Bell, 1930), <iLattus</i Grishin, <bnew genus</b (type species <iEutocus arabupuana</i Bell, 1932), <iGubrus</i Grishin, <bnew genus</b (type species <iVehilius lugubris</i Lindsey, 1925), <iKoria</i Grishin, <bnew genus</b (type species <iHesperia kora</i Hewitson, 1877), <iCorta</i Grishin, <bnew genus</b (type species <iEutychide lycortas</i Godman, 1900), <iCalvetta</i Grishin, <bnew genus</b (type species <iHesperia calvina</i Hewitson, 1866), <iOz</i Grishin, <bnew genus</b (type species <iAstictopterus ozias</i Hewitson, 1878), <iPraxa</i Grishin, <bnew subgenus</b (type species <iNascus prax</i Evans, 1952), <iBron</i Grishin, <bnew subgenus</b (type species <iPapilio broteas</i Cramer, 1780), <iTuris</i Grishin, <bnew subgenus</b (type species <iPyrgus (Scelothrix) veturius</i Plötz, 1884), <iTiges</i Grishin, <bnew subgenus</b (type species <iAntigonus liborius</i Plötz, 1884), <iOcrypta</i Grishin, <bnew subgenus</b (type species <iNotocrypta caerulea</i Evans, 1928), <iTixe</i Grishin, <bnew subgenus</b (type species <iCobalus quadrata</i Herrich-Schäffer, 1869), <iNycea</i Grishin, <bnew subgenus</b (type species <iPamphila hycsos</i Mabille, 1891), <iNausia</i Grishin, <bnew subgenus</b (type species <iOenus</i [sic] <inausiphanes</i Schaus, 1913), <iFlor</i Grishin, <bnew subgenus</b (type species <iStomyles florus</i Godman, 1900), <iGeia</i Grishin, <bnew subgenus</b (type species <iPamphila geisa</i Möschler, 1879), <iRotundia</i Grishin, <bnew subgenus</b (type species <iEnosis schausi</i Mielke and Casagrande, 2002), <iVolus</i Grishin, <bnew subgenus</b (type species <iEutocus volasus</i Godman, 1901), <iPseudopapias</i Grishin, <bnew subgenus</b (type species <iPapias tristissimus</i Schaus, 1902), <iSeptia</i Grishin, <bnew subgenus</b (type species <iJustinia septa</i Evans, 1955), <iBrasta</i Grishin, <bnew subgenus</b (type species <iLychnuchus brasta</i Evans, 1955), <iBina</i Grishin, <bnew subgenus</b (type species <iCobalus gabina</i Godman, 1900), <iBalma</i Grishin, <bnew subgenus</b (type species <iCarystoides balza</i Evans, 1955), <iOrnilius rotundus</i Grishin, <bnew species</b (type locality in Brazil: Santa Catarina), <iSalantoia metallica</i Grishin, <bnew species</b (type locality in Guyana: Acarai Mts.), <iDyscophellus australis</i Grishin, <bnew species</b (type locality in Paraguay: Sapucay), <iDyscophellus basialbus</i Grishin, <bnew species</b (type locality in Brazil: Rondônia), <iTelegonus subflavus</i Grishin, <bnew species</b (type locality in Ecuador: Riobamba), <iDecinea colombiana</i Grishin, <bnew species</b (type locality in Colombia: Bogota), <iLerema lucius</i Grishin, <bnew species</b (type locality in Panama: Colón), <iCynea rope</i Grishin, <bnew species</b (type locality in Nicaragua: Chontales), <iLerodea sonex</i Grishin, <bnew species</b (type locality in Peru: Cuzco), and <iMetiscus goth</i Grishin, <bnew species</b (type locality in Costa Rica). <bLectotypes</b are designated for the following 17 taxa: <iTelegonus gildo</i Mabille, 1888, <iNetrocoryne damias</i Plötz, 1882, <iTelegonus erythras</i Mabille, 1888, <iTelegonus galesus</i Mabille, 1888, <iEudamus cretellus</i Herrich-Schäffer, 1869, <iLeucochitonea chaeremon</i Mabille, 1891, <iAntigonus aura</i Plötz, 1884, <iPamphila voranus</i Mabille, 1891, <iHesperia pupillus</i Plötz, 1882, <iCobalus lumina</i Herrich-Schäffer, 1869, <iCobalus stigmula</i Mabille, 1891, <iMegistias isus</i Godman, 1900, <iCobalopsis latonia</i Schaus, 1913, <iPamphila nubila</i Mabille, 1891, <iMetiscus atheas</i Godman, 1900, <iMnasalcas amatala</i Schaus, 1902, and <iHesperia ina</i Plötz, 1882. The lectotype of <iHesperia infuscata</i Plötz, 1882 is <binvalid</b because it does not agree with the original description and illustration by Plötz, is not from the locality listed in the original description, and therefore is not a syntype. <bNeotypes</b are designated for the following five taxa: <iTelegonus corentinus</i Plötz, 1882, <iHesperia dido</i Plötz, 1882, <iHesperia distigma</i Plötz, 1882, <iHesperia infuscata</i Plötz, 1882, and <iHesperia pruinosa</i Plötz, 1882. As a result, the following five taxa are <bjunior objective synonyms</b: <iTelegonus diophorus</i Möschler, 1883 of <iTelegonus corentinus</i Plötz, 1882, <iPamphila puxillius</i Mabille, 1891 of <iHesperia pupillus</i Plötz, 1882, <iCobalus stigmula</i Mabille, 1891 of <iHesperia distigma</i Plötz, 1882, <iMnasalcas amatala</i Schaus, 1902 of <iHesperia infuscata</i Plötz, 1882, and <iHesperia pruinosa</i Plötz, 1882 of <iHesperia uza</i Hewitson, 1877. <iMorys valerius valda</i Evans, 1955 is fixed as the <btype species</b of <iMorys</i Godman, 1900, and <iPamphila compta</i Butler, 1877 is reaffirmed as the <btype species</b of <iEuroto</i Godman, 1900. Furthermore, the following <btaxonomic changes</b are suggested. <iProsopalpus</i Holland, 1896, <iLepella</i Evans, 1937, and <iCreteus</i de Nicéville, 1895 are placed in Aeromachini Tutt, 1906. <iTriskelionia</i Larsen and Congdon, 2011 is transferred from Celaenorrhinini Swinhoe, 1912 to Tagiadini Mabille, 1878. <iKobelana</i Larsen and Collins, 2013 is transferred from Tagiadini Mabille, 1878 to Celaenorrhinini Swinhoe, 1912. The following nine genus-group names are <bresurrected from synonymy</b and treated as valid genera: <iAbaratha</i Moore, 1881 (not in <iCaprona</i Wallengren, 1857), <iBibla</i Mabille, 1904 (not in <iTaractrocera</i Butler, 1870), <iKerana</i Distant, 1886 and <iTamela</i Swinhoe, 1913 (not in <iAncistroides</i Butler, 1874), <iMetrocles</i Godman, 1900 (not in <iMetron</i Godman, 1900), <iAlerema</i Hayward, 1942 (not in <iTigasis</i Godman, 1900), <iMetiscus</i Godman, 1900 (not in <iEnosis</i Mabille, 1889), <iVistigma</i Hayward, 1939 (not in <iPhlebodes</i Hübner, [1819]), and <iMnasalcas</i Godman, 1900 (not in <iMnasitheus</i Godman, 1900). The genus-group names <iDaimio</i Murray, 1875 and <iPterygospidea</i Wallengren, 1857 are <bresurrected from synonymy</b and treated as valid subgenera of <iTagiades</i Hübner, [1819]. We confirm <iApallaga</i Strand, 1911 as a valid genus. The following 24 genera are placed as subgenera, <bnew status</b: <iPseudonascus</i Austin, 2008 of <iNascus</i Watson, 1893; <iAlbiphasma</i Huang, Chiba, Wang and Fan, 2016 of <iPintara</i Evans, 1932; <iCtenoptilum</i de Nicéville, 1890 of <iTapena</i Moore, [1881]; <iOdontoptilum</i de Nicéville, 1890 of <iAbaratha</i Moore, 1881; <iCaprona</i Wallengren, 1857 of <iAbantis</i Hopffer, 1855; <iTimochreon</i Godman and Salvin, 1896 of <iZopyrion</i Godman and Salvin, 1896; <iPulchroptera</i Hou, Fan and Chiba, 2021 of <iHeteropterus</i Duméril, 1806; <iStimula</i de Nicéville, 1898 of <iKoruthaialos</i Watson, 1893; <iUdaspes</i Moore, [1881] and <iNotocrypta</i de Nicéville, 1889 of <iAncistroides</i Butler, 1874; <iCravera</i de Jong, 1983 of <iXeniades</i Godman, 1900; <iCobaloides</i Hayward, 1939 of <iOligoria</i Scudder, 1872; <iSaniba</i O. Mielke and Casagrande, 2003 of <iPsoralis</i Mabille, 1904; <iQuinta</i Evans, 1955 of <iCynea</i Evans, 1955; <iStyriodes</i Schaus, 1913 and <iRemella</i Hemming, 1939 of <iMnasicles</i Godman, 1901; <iRepens</i Evans, 1955 of <iEprius</i Godman, 1901; <iMorys</i Godman, 1900 of <iLerema</i Scudder, 1872; <iEnosis</i Mabille, 1889 of <iLychnuchus</i Hübner, [1831]; <iPenicula</i Evans, 1955 of <iVistigma</i Hayward, 1939; <iMnasinous</i Godman, 1900 of <iMethionopsis</i Godman, 1901; and <iMoeros</i Evans, 1955, <iArgon</i Evans, 1955, and <iSynale</i Mabille, 1904 of <iCarystus</i Hübner, [1819]. The following 20 genera are treated as junior subjective synonyms: <iLeucochitonea</i Wallengren, 1857 of <iAbantis</i Hopffer, 1855; <iSapaea</i Plötz, 1879 and <iNetrobalane</i Mabille, 1903 of <iCaprona</i Wallengren, 1857; <iParasovia</i Devyatkin, 1996 of <iSebastonyma</i Watson, 1893; <iPemara</i Eliot, 1978 of <iOerane</i Elwes and Edwards, 1897; <iAnkola</i Evans, 1937 of <iPardaleodes</i Butler, 1870; <iArotis</i Mabille, 1904 of <iMnaseas</i Godman, 1901; <iChalcone</i Evans, 1955, <iHansa</i Evans, 1955, and <iPropertius</i Evans, 1955 of <iMetrocles</i Godman, 1900; <iJongiana</i O. Mielke and Casagrande, 2002 of <iCobaloides</i Hayward, 1939; <iPamba</i Evans, 1955 of <iPsoralis</i Mabille, 1904; <iBrownus</i Grishin, 2019 of <iStyriodes</i Schaus, 1913; <iMnasilus</i Godman, 1900 of <iPapias</i Godman, 1900; <iSucova</i Evans, 1955 of <iMnasitheus</i Godman, 1900; <iPyrrhocalles</i Mabille, 1904 and <iAsbolis</i Mabille, 1904 of <iChoranthus</i Scudder, 1872; <iMiltomiges</i Mabille, 1903 of <iMethionopsis</i Godman, 1901; <iSacrator</i Evans, 1955 of <iThracides</i Hübner, [1819]; and <iLychnuchoides</i Godman, 1901 of <iPerichares</i Scudder, 1872. <iArunena</i Swinhoe, 1919 is a <bjunior subjective synonym</b of <iStimula</i de Nicéville, 1898 (not of <iKoruthaialos</i Watson, 1893). The following 27 names are species-level taxa (some in new combinations) <breinstated from synonymy</b: <iSalantoia gildo</i (Mabille, 1888) (not <iSalatis cebrenus</i (Cramer, 1777)), <iBungalotis corentinus</i (Plötz, 1882) (not <iBungalotis midas</i (Cramer, 1775)), <iTelegonus cretellus</i (Herrich-Schäffer, 1869) (not <iTelegonus cassander</i (Fabricius, 1793)), <iSanta palica</i (Mabille, 1888) (not <iChiothion asychis</i (Stoll, 1780)), <iCamptopleura cincta</i Mabille and Boullet, 1917 (not <iCamptopleura auxo</i (Möschler, 1879)), <iCamptopleura orsus</i (Mabille, 1889) (not <iNisoniades mimas</i (Cramer, 1775)), <iMetron voranus</i (Mabille, 1891) and <iMetron fasciata</i (Möschler, 1877) (not <iMetron zimra</i (Hewitson, 1877)), <iLimochores catahorma</i (Dyar, 1916) (not <iLimochores pupillus</i (Plötz, 1882)), <iPares viridiceps</i (Mabille, 1889) (not <iThoon modius</i (Mabille, 1889)), <iTigasis wellingi</i (Freeman, 1969) (not <iTigasis arita</i (Schaus, 1902)), <iRectava sobrinus</i (Schaus, 1902) (not <iPapias phainis</i Godman, 1900), <iNastra subsordida</i (Mabille, 1891) (not <iAdlerodea asema</i (Mabille, 1891), previously in <iEutychide</i Godman, 1900), <iLerema pattenii</i Scudder, 1872 (not <iLerema accius</i (J. E. Smith, 1797)), <iLerema (Morys) ancus</i (Möschler, 1879) (not <iCymaenes tripunctus theogenis</i (Capronnier, 1874)), <iCobalopsis zetus</i (Bell, 1942) (not <iCobalopsis nero</i (Herrich-Schäffer, 1869)), <iLerema (Geia) etelka</i (Schaus, 1902) (not <iLerema (Geia) geisa</i (Möschler, 1879), previously in <iMorys</i Godman, 1900), <iCymaenes isus</i (Godman, 1900) (not <iCymaenes trebius</i (Mabille, 1891)), <iVehilius labdacus</i (Godman, 1900) (not <iVehilius inca</i (Scudder, 1872)), <iPapias amyrna</i (Mabille, 1891) (not <iPapias allubita</i (Butler, 1877), previously in <iMnasilus</i Godman, 1900), <iPapias integra</i (Mabille, 1891) (not <iPapias subcostulata</i (Herrich-Schäffer, 1870)), <iMetiscus atheas</i Godman, 1900 (not <iHesperia achelous</i Plötz, 1882), <iDion agassus</i (Mabille, 1891) (not <iDion uza</i (Hewitson, 1877), previously in <iEnosis</i Mabille, 1889), <iPicova incompta</i (Hayward, 1942) (not <iLerema (Morys) micythus</i (Godman, 1900), previously in <iMorys</i Godman, 1900), <iLucida melitaea</i (Draudt, 1923) (not <iLucida lucia</i (Capronnier, 1874)), <iMethionopsis modestus</i Godman, 1901 (not <iMethionopsis ina</i (Plötz, 1882)), and <iThargella (Volus) volasus</i (Godman, 1901) (not <iEutocus facilis</i (Plötz, 1884)). The following 57 taxa are elevated from subspecies to species, <bnew status</b (some in <bnew combinations</b): <iDyscophellus doriscus</i (Hewitson, 1867) (not <iDyscophellus porcius</i (C. Felder and R. Felder, 1862), <iPhocides vida</i (A. Butler, 1872) (not <iPhocides urania</i (Westwood, 1852)), <iTagiades (Daimio) ceylonica</i Evans, 1932 (not <iTagiades litigiosa</i Möschler, 1878), <iTagiades (Daimio) tubulus</i Fruhstorfer, 1910 (not <iTagiades sambavana</i Elwes and Edwards, 1897), <iTagiades (Daimio) kina</i Evans, 1934, <iTagiades (Daimio) sheba</i Evans, 1934, <iTagiades (Daimio) martinus</i Plötz, 1884, <iTagiades (Daimio) sem</i Mabille, 1883, and <iTagiades (Daimio) neira</i Plötz, 1885 (not <iTagiades trebellius</i (Hopffer, 1874)), <iTagiades (Daimio) korela</i Mabille, 1891 and <iTagiades (Daimio) presbyter</i Butler, 1882 (not <iTagiades nestus</i (C. Felder, 1860)), <iTagiades obscurus</i Mabille, 1876, <iTagiades ravi</i (Moore, [1866]), <iTagiades atticus</i (Fabricius, 1793), <iTagiades titus</i Plötz, 1884, <iTagiades janetta</i Butler, 1870, <iTagiades inconspicua</i Rothschild, 1915, and <iTagiades hovia</i Swinhoe, 1904 (not <iTagiades japetus</i (Stoll, [1781])), <iTagiades silvia</i Evans, 1934 and <iTagiades elegans</i Mabille, 1877 (not <iTagiades gana</i (Moore, [1866])), <iTapena bornea</i Evans, 1941 and <iTapena minuscula</i Elwes and Edwards, 1897 (not <iTapena thwaitesi</i Moore, [1881]), <iDarpa dealbata</i (Distant, 1886) (not <iDarpa pteria</i (Hewitson, 1868)), <iPerus manx</i (Evans, 1953) (not <iPerus minor</i (Schaus, 1902)), <iCanesia pallida</i (Röber, 1925) (not <iCarrhenes canescens</i (R. Felder, 1869)), <iCarrhenes conia</i Evans, 1953 (not <iCarrhenes fuscescens</i (Mabille, 1891)), <iAnisochoria extincta</i Hayward, 1933 and <iAnisochoria polysticta</i Mabille, 1876 (not <iAnisochoria pedaliodina</i (Butler, 1870)), <iAnisochoria verda</i Evans, 1953 (not <iAnisochoria minorella</i Mabille, 1898), <iBralus alco</i (Evans, 1953) (not <iBralus albida</i (Mabille, 1888)), <iEphyriades jamaicensis</i (Möschler, 1879) (not <iEphyriades brunnea</i (Herrich-Schäffer, 1865)), <iKoruthaialos (Stimula) frena</i Evans, 1949 (not <iKoruthaialos focula</i (Plötz, 1882)), <iEuphyes kiowah</i (Reakirt, 1866) (not <iEuphyes vestris</i (Boisduval, 1852)), <iMnaseas inca</i Bell, 1930 (not <iMnaseas bicolor</i (Mabille, 1889)), <iMetron hypochlora</i (Draudt, 1923) (not <iMetrocles schrottkyi</i (Giacomelli, 1911), previously in <iMetron</i Godman, 1900), <iDecinea huasteca</i (H. Freeman, 1969), <iDecinea denta</i Evans, 1955, and <iDecinea antus</i (Mabille, 1895) (not <iDecinea decinea</i (Hewitson, 1876)), <iXeniades pteras</i Godman, 1900 (not <iXeniades chalestra</i (Hewitson, 1866)), <iXeniades difficilis</i Draudt, 1923 (not <iXeniades orchamus</i (Cramer, 1777)), <iXeniades hermoda</i (Hewitson, 1870) (not <iTisias quadrata</i (Herrich-Schäffer, 1869)), <iHermio vina</i (Evans, 1955) (not <iHermio hermione</i (Schaus, 1913), previously in <iLento</i Evans, 1955), <iCymaenes loxa</i Evans, 1955, (not <iCymaenes laureolus</i (Schaus, 1913)), <iNiconiades peri</i (Evans, 1955) (not <iRhinthon bajula</i (Schaus, 1902), previously in <iNeoxeniades</i Hayward, 1938), <iGallio danius</i (Bell, 1941) (not <iVehilius seriatus</i (Mabille, 1891)), <iGallio massarus</i (E. Bell, 1940) (not <iGallio garima</i (Schaus, 1902) previously in <iTigasis</i Godman, 1900), <iCymaenes edata</i (Plötz, 1882), <iCymaenes miqua</i (Dyar, 1913) and <iCymaenes aequatoria</i (Hayward, 1940) (not <iCymaenes odilia</i (Burmeister, 1878)), <iLychnuchus (Enosis) demon</i (Evans, 1955) (not <iLychnuchus (Enosis) immaculata</i (Hewitson, 1868), previously in <iEnosis</i Mabille, 1889), <iNaevolus naevus</i Evans, 1955 (not <iNaevolus orius</i (Mabille, 1883)), <iLucida scopas</i (Mabille, 1891), <iLucida oebasus</i (Godman, 1900), and <iLucida leopardus</i (Weeks, 1901) (not <iLucida lucia</i (Capronnier, 1874)), <iCorticea schwarzi</i (E. Bell, 1941) and <iCorticea sylva</i (Hayward, 1942) (not <iCorticea mendica</i (Mabille, 1898)), and <iChoranthus orientis</i (Skinner, 1920) (not <iChoranthus antiqua</i (Herrich-Schäffer, 1863), previously in <iPyrrhocalles</i Mabille, 1904). <iBorbo impar bipunctata</i (Elwes and J. Edwards, 1897) is a valid subspecies, not a synonym of <iBorbo impar tetragraphus</i (Mabille, 1891), here placed in synonymy with <iLotongus calathus</i (Hewitson, 1876), <bnew synonym</b. We confirm the species status of <iTelegonus cassius</i (Evans, 1952) and <iLerema (Morys) valda</i Evans, 1955. <iEuphyes chamuli</i Freeman, 1969 is placed as a subspecies of <iEuphyes kiowah</i (Reakirt, 1866), <bnew status</b. The following 41 taxa are <bjunior subjective synonyms</b, either newly proposed or transferred from synonymy with other species or subspecies: <iTelegonus mutius</i Plötz, 1882 of <iEuriphellus phraxanor</i (Hewitson, 1876), <iTelegonus erythras</i Mabille, 1888 of <iDyscophellus damias</i (Plötz, 1882), <iAethilla jaira</i Butler, 1870 of <iTelegonus cretellus</i (Herrich-Schäffer, 1869), <iPaches era</i Evans, 1953 of <iSanta palica</i (Mabille, 1888), <iAntigonus alburnea</i Plötz, 1884 of <iTolius tolimus robigus</i (Plötz, 1884) (not of <iEchelatus sempiternus simplicior</i (Möschler, 1877)), <iEchelatus depenicillus</i Strand, 1921 of <iE. sempiternus simplicior</i (not of <iT. tolimus robigus</i), <iAntigonus aura</i Plötz, 1884 of <iTheagenes dichrous</i (Mabille, 1878) (not of <iHelias phalaenoides palpalis</i (Latreille, [1824])), <iAchlyodes impressus</i Mabille, 1889 of <iCamptopleura orsus</i (Mabille, 1889), <iAugiades tania</i Schaus, 1902 of <iMetron voranus</i (Mabille, 1891), <iPamphila verdanta</i Weeks, 1906 of <iMetron fasciata</i (Möschler, 1877), <iNiconiades viridis vista</i Evans, 1955 of <iNiconiades derisor</i (Mabille, 1891), <iPamphila binaria</i Mabille, 1891 of <iConga chydaea</i (A. Butler, 1877) (not of <iCynea cynea</i (Hewitson, 1876)), <iPsoralis concolor</i Nicolay, 1980 of <iRalis immaculatus</i (Hayward, 1940), <iHesperia dido</i Plötz, 1882 of <iCynea (Quinta) cannae</i (Herrich-Schäffer, 1869) (not of <iLerema lochius</i (Plötz, 1882)), <iProteides osembo</i Möschler, 1883 of <iCynea (Cynea) diluta</i (Herrich-Schäffer, 1869) (not of <iCynea (Quinta) cannae</i (Herrich-Schäffer, 1869)), <iCobalopsis brema</i E. Bell, 1959 of <iEutus rastaca</i (Schaus, 1902), <iPsoralis panamensis</i Anderson and Nakamura, 2019 of <iRhomba gertschi</i (Bell, 1937), <iCobalus asella</i Herrich-Schäffer, 1869 of <iAmblyscirtes alternata</i (Grote and Robinson, 1867) (not of <iAmblyscirtes vialis</i (W. H. Edwards, 1862)), <iPapias trimacula</i Nicolay, 1973 of <iNastra subsordida</i (Mabille, 1891), <iPamphila bipunctata</i Mabille, 1889 and <iSarega staurus</i Mabille, 1904 of <iLerema pattenii</i Scudder, 1872 (not of <iCymaenes lumina</i (Herrich-Schäffer, 1869), previously in <iLerema</i Scudder, 1872), <iHesperia aethra</i Plötz, 1886 of <iLerema lineosa</i (Herrich-Schäffer, 1865) (not of <iLerema (Morys) compta</i Butler, 1877), <iMegistias miaba</i Schaus, 1902 of <iCobalopsis valerius</i (Möschler, 1879), <iPhanis sylvia</i Kaye, 1914 of <iLerema etelka</i (Schaus, 1902) (not of <iLerema (Geia) geisa</i (Möschler, 1879), previously in <iMorys</i Godman, 1900), <iCarystus odilia</i Burmeister, 1878, <iPamphila trebius</i Mabille, 1891 and <iMegistias corescene</i Schaus, 1902 of <iCymaenes lumina</i (Herrich-Schäffer, 1869), <iHesperia phocylides</i Plötz, 1882 of <iCymaenes edata</i (Plötz, 1882) (not of <iLerema accius</i (J. E. Smith, 1797)), <iPamphila xenos</i Mabille, 1898 of <iVehilius inca</i (Scudder, 1872), <iMnasilus guianae</i Lindsey, 1925 of <iPapias amyrna</i (Mabille, 1891), <iPamphila nubila</i Mabille, 1891 of <iPapias integra</i (Mabille, 1891) (not of <iCynea corisana</i (Plötz, 1882)), <iEnosis matheri</i H. Freeman, 1969 of <iMetiscus atheas</i Godman, 1900 (previously in <iEnosis</i Mabille, 1889), <iHesperia infuscata</i Plötz, 1882 of <iMnaseas derasa derasa</i (Herrich-Schäffer, 1870) (previously <iArotis</i Mabille, 1904), (not of <iPapias subcostulata</i (Herrich-Schäffer, 1870)), <iPamphila astur</i Mabille, 1891 of <iMetiscus angularis</i (Möschler, 1877) (not of <iCymaenes tripunctus theogenis</i (Capronnier, 1874)), <iAnthoptus macalpinei</i H. Freeman, 1969 of <iAnthoptus inculta</i (Dyar, 1918), <iMethionopsis typhon</i Godman, 1901 of <iMethionopsis ina</i (Plötz, 1882), <iMethionopsis dolor</i Evans, 1955 of <iThargella volasus</i (Godman, 1901), <iHesperia cinica</i Plötz, 1882 of <iDubiella dubius</i (Stoll, 1781), <iCobalus disjuncta</i Herrich-Schäffer, 1869 of <iDubiella dubius</i (Stoll, 1781) (not of <iVettius lafrenaye</i (Latreille, [1824])), and <iSaliana vixen</i Evans, 1955 of <iNeoxeniades parna</i (Evans, 1955). The following are <bnew and revised genus-species combinations</b: <iEuriphellus cebrenus</i (Cramer, 1777) (not <iSalatis</i Evans, 1952), <iGorgopas extensa</i (Mabille, 1891) (not <iPolyctor</i Evans, 1953), <iClytius shola</i (Evans, 1953) (not <iStaphylus</i Godman and Salvin, 1896), <iPerus narycus</i (Mabille, 1889) (not <iOuleus</i Lindsey, 1925), <iPerus parvus</i (Steinhauser and Austin, 1993) (not <iStaphylus</i Godman and Salvin, 1896), <iPholisora litus</i (Dyar, 1912) (not <iBolla</i Mabille, 1903), <iCarrhenes decens</i (A. Butler, 1874) (not <iAntigonus</i Hübner, [1819]), <iSanta palica</i (Mabille, 1888) (not <iChiothion</i Grishin, 2019), <iBralus nadia</i (Nicolay, 1980) (not <iAnisochoria</i Mabille, 1876), <iAcerbas sarala</i (de Nicéville, 1889) (not <iLotongus</i Distant, 1886), <iCaenides sophia</i (Evans, 1937) (not <iHypoleucis</i Mabille, 1891), <iHypoleucis dacena</i (Hewitson, 1876) (not <iCaenides</i Holland, 1896), <iDotta tura</i (Evans, 1951) (not <iAstictopterus</i C. Felder and R. Felder, 1860), <iNervia wallengrenii</i (Trimen, 1883) (not <iKedestes</i Watson, 1893), <iTestia mammaea</i (Hewitson, 1876) (not <iDecinea</i Evans, 1955), <iOxynthes trinka</i (Evans, 1955) (not <iOrthos</i Evans, 1955), <iMetrocles argentea</i (Weeks, 1901) (not <iParatrytone</i Godman, 1900), <iMetrocles scitula</i (Hayward, 1951) (not <iMucia</i Godman, 1900), <iMetrocles schrottkyi</i (Giacomelli, 1911) (not <iMetron</i Godman, 1900), <iNiconiades derisor</i (Mabille, 1891) (not <iDecinea</i Evans, 1955), <iParatrytone samenta</i (Dyar, 1914) (not <iOchlodes</i Scudder, 1872), <iOligoria (Cobaloides) locutia</i (Hewitson, 1876) (not <iQuinta</i Evans, 1955), <iPsoralis (Saniba) laska</i (Evans, 1955) (not <iVidius</i Evans, 1955), <iPsoralis (Saniba) arva</i (Evans, 1955) and <iPsoralis (Saniba) umbrata</i (Erschoff, 1876) (not <iVettius</i Godman, 1901), <iPsoralis (Saniba) calcarea</i (Schaus, 1902) and <iPsoralis (Saniba) visendus</i (E. Bell, 1942) (not <iMolo</i Godman, 1900), <iAlychna gota</i (Evans, 1955) (not <iPsoralis</i Mabille, 1904), <iAdlerodea asema</i (Mabille, 1891) and <iAdlerodea subpunctata</i (Hayward, 1940) (not <iEutychide</i Godman, 1900), <iRalis immaculatus</i (Hayward, 1940) (not <iMucia</i Godman, 1900), <iRhinthon braesia</i (Hewitson, 1867) and <iRhinthon bajula</i (Schaus, 1902) (not <iNeoxeniades</i Hayward, 1938), <iCymaenes lochius</i Plötz, 1882 (not <iLerema</i Scudder, 1872), <iParacarystus ranka</i (Evans, 1955) (not <iThoon</i Godman, 1900), <iTricrista aethus</i (Hayward, 1951), <iTricrista canta</i (Evans, 1955), <iTricrista slopa</i (Evans, 1955), <iTricrista circellata</i (Plötz, 1882), and <iTricrista taxes</i (Godman, 1900) (not <iThoon</i Godman, 1900), <iGallio madius</i (E. Bell, 1941) and <iGallio seriatus</i (Mabille, 1891) (not <iVehilius</i Godman, 1900), <iGallio garima</i (Schaus, 1902) (not <iTigasis</i Godman, 1900), <iTigasis corope</i (Herrich-Schäffer, 1869) (not <iCynea</i Evans, 1955), <iTigasis perloides</i (Plötz, 1882) (not <iCymaenes</i Scudder, 1872), <iAmblyscirtes (Flor) florus</i (Godman, 1900) (not <iRepens</i Evans, 1955), <iVidius fraus</i (Godman, 1900) (not <iCymaenes</i Scudder, 1872), <iNastra celeus</i (Mabille, 1891) (not <iVehilius</i Godman, 1900), <iNastra nappa</i (Evans, 1955) (not <iVidius</i Evans, 1955), <iVehilius warreni</i (Weeks, 1901) and <iVehilius limae</i (Lindsey, 1925) (not <iCymaenes</i Scudder, 1872), <iCymaenes lumina</i (Herrich-Schäffer, 1869) (not <iLerema</i Scudder, 1872), <iCobalopsis valerius</i (Möschler, 1879) (not <iCobalopsis</i Godman, 1900), <iCobalopsis dictys</i (Godman, 1900) (not <iPapias</i Godman, 1900), <iLerema (Morys) venias</i (Bell, 1942) (not <iCobalopsis</i Godman, 1900), <iPapias latonia</i (Schaus, 1913) (not <iCobalopsis</i Godman, 1900), <iDion iccius</i (Evans, 1955) and <iDion uza</i (Hewitson, 1877) (not <iEnosis</i Mabille, 1889), <iVistigma (Vistigma) opus</i (Steinhauser, 2008) (not <iThoon</i Godman, 1900), <iSaturnus fartuga</i (Schaus, 1902) (not <iParphorus</i Godman, 1900), <iPhlebodes fuldai</i (E. Bell, 1930) (not <iVettius</i Godman, 1901), <iMnasitheus padus</i (Evans, 1955) (not <iMoeris</i Godman, 1900), <iNaevolus brunnescens</i (Hayward, 1939) (not <iPsoralis</i Mabille, 1904), <iLamponia ploetzii</i (Capronnier, 1874) (not <iVettius</i Godman, 1901), <iMnestheus silvaticus</i Hayward, 1940 (not <iLudens</i Evans, 1955), <iRigga spangla</i (Evans, 1955) (not <iSodalia</i Evans, 1955), <iCorticea vicinus</i (Plötz, 1884) (not <iLento</i Evans, 1955), <iMnasalcas thymoetes</i (Hayward, 1942) (not <iMnasicles</i Godman, 1901), <iMnasalcas boyaca</i (Nicolay, 1973) (not <iPamba</i Evans, 1955), <iVertica brasta</i (Evans, 1955) (not <iLychnuchus</i Hübner, [1831]), <iCarystina discors</i Plötz, 1882 (not <iCobalus</i Hübner, [1819]), <iZetka irena</i (Evans, 1955) (not <iNeoxeniades</i Hayward, 1938), and <iNeoxeniades parna</i (Evans, 1955) (not <iNiconiades</i Hübner, [1821]). The following are <bnew or revised species-subspecies combinations</b: <iTagiades neira moti</i Evans, 1934, <iTagiades neira canonicus</i Fruhstorfer, 1910, <iTagiades sheba vella</i Evans, 1934, <iTagiades sheba lola</i Evans, 1945, <iTagiades korela biakana</i Evans, 1934, <iTagiades korela mefora</i Evans, 1934, <iTagiades korela suffusus</i Rothschild, 1915, <iTagiades korela brunta</i Evans, 1949, <iTagiades ravi ravina</i Fruhstorfer, 1910, <iTagiades atticus carnica</i Evans, 1934, <iTagiades atticus nankowra</i Evans, 1934, <iTagiades atticus helferi</i C. Felder, 1862, <iTagiades atticus balana</i Fruhstorfer, 1910, <iTagiades inconspicua mathias</i Evans, 1934, <iTagiades hovia kazana</i Evans, 1934, <iTagiades elegans fuscata</i de Jong and Treadaway, 2007, <iTagiades elegans semperi</i Fruhstorfer, 1910, <iMetron hypochlora tomba</i Evans, 1955, <iDecinea denta pruda</i Evans, 1955, and <iChoranthus orientis eleutherae</i (Bates, 1934) (previously in <iPyrrhocalles</i Mabille, 1904). In addition to the abovementioned changes, the following <bnew combinations</b involve newly proposed genus group names: <iFulvatis fulvius</i (Plötz, 1882) and <iFulvatis scyrus</i (E. Bell, 1934) (not <iSalatis</i Evans, 1952); <iAdina adrastor</i (Mabille and Boullet, 1912) (not <iBungalotis</i Watson, 1893); <iNascus (Praxa) prax</i Evans, 1952<i, Nascus (Bron) broteas</i (Cramer, 1780), and <iNascus (Bron) solon</i (Plötz, 1882) (not <iPseudonascus</i Austin, 2008); <iChirgus (Turis) veturius</i (Plötz, 1884); <iPaches (Tiges) liborius</i (Plötz, 1884), and <iPaches (Tiges) mutilatus</i (Hopffer, 1874) (not <iAntigonus</i Hübner, [1819]); <iPaches (Tiges) exosa</i (A. Butler, 1877); <iTolius tolimus</i (Plötz, 1884) and <iTolius luctuosus</i (Godman &amp; Salvin, 1894) (not <iEchelatus</i Godman and Salvin, 1894); <iAncistroides (Ocrypta) caerulea</i (Evans, 1928), <iAncistroides (Ocrypta) renardi</i (Oberthür, 1878), <iAncistroides (Ocrypta) waigensis</i (Plötz, 1882)<i, Ancistroides (Ocrypta) aluensis</i (Swinhoe, 1907)<i, Ancistroides (Ocrypta) flavipes</i (Janson, 1886), and <iAncistroides (Ocrypta) maria</i (Evans, 1949) (not <iNotocrypta</i de Nicéville, 1889); <iLennia lena</i (Evans, 1937)<i, Lennia binoevatus</i (Mabille, 1891)<i, Lennia maracanda</i (Hewitson, 1876), and <iLennia lota</i (Evans, 1937) (not <iLeona</i Evans, 1937); <iTrida barberae</i (Trimen, 1873) and <iTrida sarahae</i (Henning and Henning, 1998) (not <iKedestes</i Watson, 1893); <iNoxys viricuculla</i (Hayward, 1951) (not <iOxynthes</i Godman, 1900); <iXeniades (Tixe) quadrata</i (Herrich-Schäffer, 1869)<i, Xeniades (Tixe) rinda</i (Evans, 1955)<i, Xeniades (Tixe) putumayo</i (Constantino and Salazar, 2013) (not <iTisias</i Godman, 1901); <iGracilata quadrinotata</i (Mabille, 1889) (not <iStyriodes</i Schaus, 1913); <iHermio hermione</i (Schaus, 1913) (not <iLento</i Evans, 1955); <iCynea (Nycea) hycsos</i (Mabille, 1891)<i, Cynea (Nycea) corisana</i (Plötz, 1882)<i, Cynea (Nycea) popla</i Evans, 1955<i, Cynea (Nycea) iquita</i (E. Bell, 1941)<i, Cynea (Nycea) robba</i Evans, 1955<i, Cynea (Nycea) melius</i (Geyer, 1832), and <iCynea (Nycea) irma</i (Möschler, 1879); <iEutus rastaca</i (Schaus, 1902) (not <iEutychide</i Godman, 1900); <iEutus yesta</i (Evans, 1955) (not <iThoon</i Godman, 1900); <iEutus mubevensis</i (E. Bell, 1932) (not <iTigasis</i Godman, 1900); <iGufa gulala</i (Schaus, 1902) (not <iMucia</i Godman, 1900); <iGufa fusca</i (Hayward, 1940) (not <iTigasis</i Godman, 1900); <iGodmia chlorocephala</i (Godman, 1900) (not <iOnophas</i Godman, 1900); <iRhomba gertschi</i (E. Bell, 1937) (not <iJustinia</i Evans, 1955); <iMnasicles (Nausia) nausiphanes</i (Schaus, 1913) (not <iTigasis</i Godman, 1900); <iAmblyscirtes (Flor) florus</i (Godman, 1900) (not <iRepens</i Evans, 1955); <iRectava ignarus</i (E. Bell, 1932) (not <iPapias</i Godman, 1900); <iRectava vorgia</i (Schaus, 1902) (not <iCobalopsis</i Godman, 1900); <iRectava nostra</i (Evans, 1955) (not not <iVidius</i Evans, 1955); <iLerema (Geia) geisa</i (Möschler, 1879) and <iLerema (Geia) lyde</i (Godman, 1900) (not <iMorys</i Godman, 1900); <iContrastia distigma</i (Plötz, 1882) (not <iCymaenes</i Scudder, 1872); <iMit (Mit) badius</i (E. Bell, 1930) (not <iStyriodes</i Schaus, 1913); <iMit (Mit) gemignanii</i (Hayward, 1940), (not <iMnasitheus</i Godman, 1900); <iMit (Rotundia) schausi</i (Mielke and Casagrande, 2002), (not <iEnosis</i Mabille, 1889); <iPicova steinbachi</i (E. Bell, 1930) (not <iSaturnus</i Evans, 1955); <iLattus arabupuana</i (E. Bell, 1932) (not <iEutocus</i Godman, 1901); <iGubrus lugubris</i (Lindsey, 1925) (not <iVehilius</i Godman, 1900); <iThargella (Pseudopapias) tristissimus</i (Schaus, 1902) (not <iPapias</i Godman, 1900); <iKoria kora</i (Hewitson, 1877) (not <iJustinia</i Evans, 1955); <iJustinia (Septia) septa</i Evans, 1955; <iCorta lycortas</i (Godman, 1900) (not <iOrthos</i Evans, 1955); <iVertica (Brasta) brasta</i (Evans, 1955) (not <iLychnuchus</i Hübner, [1831]); <iCalvetta calvina</i (Hewitson, 1866) (not <iCobalus</i Hübner, [1819]); <iNeoxeniades (Bina) gabina</i (Godman, 1900) (not <iOrthos</i Evans, 1955); <iOz ozias</i (Hewitson, 1878) and <iOz sebastiani</i Salazar and Constantino, 2013 (not <iLychnuchoides</i Godman, 1901); and <iCarystoides (Balma) balza</i Evans, 1955 and <iCarystoides (Balma) maroma</i (Möschler, 1877). Finally, unless stated otherwise, all subgenera, species, subspecies and synonyms of mentioned genera and species are transferred together with their parent taxa, and taxa not mentioned in this work remain as previously classified.

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Everything included in this overview is a list of facts without analyses, which makes this a purely factual overview. The circumstances of the preparation for the foundation of the Croatian Dermatovenereological Society - the Croatian Medical Association (hereafter CDS-CMA) and the journal Acta Dermatovenerologica Croatica (hereafter ADC) Geopolitical changes in former Yugoslavia following 1990 and the Homeland War (1991-1995) led to new circumstances in almost all areas of social activity and the need for a restructuring and further development of professional physicians associations in our Homeland. In such new conditions, it was necessary to appropriately organize the professional work of our dermatovenerologists with the aim of founding and maintaining their professional ties to each other and to our colleagues abroad. The aforementioned appropriate organization primarily meant the founding of the Croatian Dermatological Society and the journal for Croatian dermatovenerologists, the first professional journal in the history of dermatology and venerology in our Homeland. Legal regulations for the founding of CDS-CMA and the journal ADC The legal regulations resulted from the conclusions and decisions of the 99th annual assembly of the Association of Croatian Physicians (hereafter ACP) that took place on the 26th of February 1991 (1), at which, at the suggestion of Prof. Mirko Gjurašin, PhD, the president of CMA, it was renamed to the Croatian Medical Association (CMA). Furthermore, on the basis of article 12 of the Statute of CMA, the creation and activity of professional societies of CMA was enabled, which replaced the Sections of ACP (1), and soon there appeared the Regulation of the work of the professional society of CMA. Finally, on the 30th of September 1991, CMA left the Alliance of Yugoslav Medical Societies (1). More detailed information on the aforementioned events can be found in reference 1, and the data on historical, political, national, and military aspects of the war against our Homeland can be found in the article of the esteemed member of CMA, Prof. Eduard Klain, PhD (2) and in the message by Prof. Vladimir Čajkovac, PhD (3). Preparations for the founding of CDS-CMA and ADC Ideas concerning a new founding of the Croatian Dermatological Society - CMA (hereafter CDS-CMA) and the first journal in the history of Croatian dermatovenerologists developed during 1990 and 1991. These suggestions were discussed in the meetings of the Professional college of the Department of Dermatology and Venerology at the Clinical Hospital Centre Zagreb (hereafter CHC Zagreb), and were formed at the meeting of the Professional college of the Department on the 27th of January 1992, when the Professional college provided the following suggestions, which the secretary of the Dermatovenerological Section of CMA (Primarius D. Paljan, MD, MSc) gave to the president of the Dermatovenerological section of CMA, Prof. V. Čajkovac, PhD. The suggestions were as follows: 1) for the Dermatovenerological section of CMA to leave the Association of Yugoslav dermatologists; 2) to found a Croatian Dermatological Society; 3) to found a Croatian Journal of Dermatology; and 4) to inform colleagues from clinics abroad with the state in Croatia. Of course, Prof. Čajkovac immediately agreed with all of these suggestions. Afterwards, on the 9th of October 1991, I presented the members of the Professional college of the Department of Dermatology and Venerology of CHC Zagreb and the members of the Chair of Dermatovenerology at the School of Medicine, University of Zagreb (hereafter SM Univ. of Zagreb), with the suggestions regarding the founding of the Croatian Dermatological Society - CMA and the founding of a Journal of Croatian Dermatologists (4,5). Both suggestions were accepted unanimously (4). After accepting the abovementioned suggestions, my colleagues and I undertook a number of consultations, and from the Department of Dermatology and Venerology of CHC Zagreb I sent out invitations to all the members of the Dermatovenerological Section of ACP (hereafter Section) to a meeting in the lecture room of the Clinic on Šalata, scheduled for the 29th of May 1992 (6). At that meeting, I notified the members of the Section of the decisions made at the 99th annual assembly of CMA on the 26th of February 1991, as well as of the fact that the CMA had left the Alliance of Yugoslav Physicians Societies on the 30th of September 1991 (6). Also, following the example of many other medical professions, I told the members of the Section about my suggestion regarding the founding of CDS-CMA. Therefore, on the 29th of May 1992, CDS-CMA was founded again* (6). On that occasion, a temporary Board of directors of CDS-CMA was also chosen, and Prof. Vladimir Čajkovac, who was the president of the former Dermatovenerological Section of ACP, was chosen as the president of the Board (6), while the following were chosen as members of the Board (6): Primarius Zlatka Čabrijan, MD (Rijeka), Adalbert Stašić, MSc, MD (Rijeka), Assist. Prof. Vjekoslav Stipić, PhD (Split), Primarius Boris Petričić, MD (Zadar), Prof. Ivan Dobrić, PhD (Zagreb), Assist. Prof. Teodora Gregurek-Novak,PhD (Zagreb), Primarius Jasna Lesić, PhD (Zagreb), and Primarius Aida Pašić, MD (Zagreb). Titles according to the state in 1992. *Why was CDS-CMA founded again? To understand this question, it is important to know the following: a) On the 22nd of November 1920, the Dermatological Section of the Physicians Association (7) was founded in the Hospital Sestre milosrdnice, Zagreb, Croatia (quotation from reference 7); b) this Section acted until the 19th of January 1941, when a formal session was held in the lecture room of the Clinic on Šalata under the title of the 1st (jubilee) meeting of the Croatian Dermatovenerological Society of the Croatian Medical Association, which was opened by its president, Prof. Kogoj (7); c) therefore, it is apparent that the Croatian Dermatovenerological Society of the Croatian Medical Association was founded on the 19th of January 1941, and the forerunner of the Society was the former Dermatological Section of the Physicians Association (7); the name Croatian Dermatovenerological Society of CMA has been used in professional publications since then (8); d) at the extraordinary session of the Croatian Physicians Society (probably a reference to ACP) held on the 30th of September 1945, the name of the Association of Croatian Physicians was changed to the name Croatian Medical Association, and since then the Croatian Dermatovenerological Society has appeared in professional publications under the name of the Dermatovenerological Society of the Croatian Medical Association (9); e) later the name Dermatovenerological Society - CMA was replaced with the name Dermatovenerological Section of ACP, but I am not familiar with the exact date of this change; f) the name Dermatovenerological Section of ACP existed until the 29th of May 1992, when, as it was stated above, the CDS-CMA was founded (6). NOTE: The original name of the Society founded on the 29th of May 1992 was the Croatian Dermatological Society of the Croatian Medical Association (CDS-CMA), and later this name was changed to the Croatian Dermatovenerological Society of the Croatian Medical Association (CDVS-CMA), which is the name used by the Society nowadays. The election of the Assembly and the regular Board of Directors of CDS-CMA On the 10th of July 1992, in the same lecture room in which the meeting was held on the 29th of May 1992, there was a meeting on the newly founded CDS-CMA (6). According to the book of regulations of the CMA, which was established over time, the Assembly of CDS-CMA was elected, and at the suggestion of the Assembly the following attending colleagues were elected to the regular Board of Directors of CDS-CMA, along with Prof. Vladimir Čajkovac as the president (6): Primarius Zlatka Čabrijan, MD (Rijeka), Adalbert Stašić, MD, MSc (Rijeka), Assist. Prof. Vjekoslav Stipić, PhD (Split), Primarius Boris Petričić, MD (Zadar), Prof. Ivan Dobrić, PhD (Zagreb), Assist. Prof. Teodora Gregurek-Novak, PhD (Zagreb), Primarius Jasna Lesić, PhD (Zagreb), and Primarius Aida Pašić, MD (Zagreb). Titles according to the state in 1992. Branches of CDS-CMA As we can see, colleagues from all university centers existing at the time (Osijek, Rijeka, Split, and Zagreb) were elected to the Board of Directors, in which Branches of CDS-CMA were later founded. Therefore, from the beginning of the creation of CDS-CMA, it has been our goal to found CDS-CMA with four Branches (Osijek, Rijeka, Split, and Zagreb), which is how the Society is structured even today. NOTE: Since there were no representatives from Osijek at the meeting held on the 10th of September 1992, the Assembly suggested that the president of CDS-CMA-Osijek Branch enter the Board of Directors after the Branch is founded (6). The election of the president, vice president, secretary, and treasurer of CDS-CMA Through a secret ballot, the members of the Assembly elected the following from among the members of the Board of Directors to a term of four years (6): Prof. Vladimir Čajkovac, PhD as the president of the Board of Directors of CDS-CMA (on the basis of the accepted work program), Prof. Ivan Dobrić, PhD and Assist. Prof. Vjekoslav Stipić, PhD as the vice president of the Board, Primarius Zlatka Čabrijan, MD and Assist. Prof. Teodora Gregurek-Novak, PhD as secretaries, and Primarius Aida Pašić, MD as the treasurer of the Board of Directors of CDS-CMA. The founding of the ADC and its organizational overview from Vol 1, No 1 to Vol 4, No 2 At the aforementioned meeting of CDS-CMA held on the 10th of July 1992 (6), I presented my suggestions from the 9th of October 1990 (4), which were accepted by the members of the Professional college of the Clinical Hospital Centre Zagreb and the members of the Department of Dermatovenerology of the School of Medicine, University of Zagreb, regarding the need for founding a Journal of Croatian Dermatovenerologists, i.e. a journal of CDS entitled Acta Dermatovenerologica Croatica (ADC) (4). I remind the reader that the need for founding a "professional publication" (quotation from reference 7) was expressed as early as 1920, at the founding of the Dermatological Section of ACP (7). The election of the management of the Journal Acta Dermatovenerologica Croatica At the meeting held on the 10th of July 1992, the following were elected to the management of Acta Dermatovenerologica Croatica (with no titles): Vladimir Čajkovac as the chief editor (with the instruction that he should choose his own co-workers) (6). Several days after the meeting of the 10th of July 1992, the following colleagues were appointed to certain positions in the journal: Ivan Dobrić as the deputy to the chief editor, Dragomir Budimčić as the technical editor, and Branko Baričević as the secretary of the journal. However, Dr. Budimčić resigned, so Branka Marinović was appointed to his position from Vol 1, No 4. After Dr. Baričević left for a position in diplomacy, Branka Marinović was elected to his position in the journal from Vol 4, No 2, while Mirna Šitum was elected to fill in the former position of Branka Marinović from Vol 4, No 2. Following the election of the journal's management and after certain consultations in the country and abroad were completed, members of the Editorial board* and the Editorial council** were also elected, as well as the language consultant and the translator for the English language***. *, **, ***: names and surnames of the elected colleagues are visible in the imprint of the listed volumes and issues of the journal. The titles of the particular colleagues are not included, with only the names and surnames stated (according to the statements in the journal's imprint) Addresses and the journal's office Addresses: - for Vol 1, No 1: Acta Dermatovenerologica Croatica, Department of Skin and Venereal Diseases of the Hospital Sestre milosrdnice, Vinogradska cesta 29, Zagreb, Croatia; - from Vol 1, No 2: Acta Dermatovenerologica Croatica, Department of Dermatology and Venerology, Clinical Hospital Centre Zagreb and School of Medicine, University of Zagreb, Šalata 4, Zagreb, Croatia* (see detailed information in the imprint of the listed volume and issues of the journal). The journal office Until Vol 3, No 1-2, the journal office was located on the abovementioned addresses. From Vol 3, No 1-2, a special journal office was founded, and the office manager was Ivan Dobrić, the former deputy of the chief editor, with Aleksandra Basta-Juzbašić being elected to take over Dr. Dobrić's former position from Vol 4, No 1. I. Dobrić performed the duties of the office manager until Vol 3, No 4, when this position was removed, and from Vol 4, No 1 the journal's office is yet again listed with the abovementioned address of the journal*. With the removal of the duties of the manager of the journal office, i.e. since Vol 3, No 4 (end of 1995), Prof. Dobrić no longer performed any duties in the journal, and this remains so to this day. The reason for the founding of the abovementioned office of the journal: chief editor Prof. Vladimir Čajkovac, PhD was also the head of the Department of Dermatology and Venerology of the School of Dental Medicine, University of Zagreb, and also worked in the Hospital Sestre milosrdnice, Vinogradska cesta 29, Zagreb. However, all the duties connected to the journal (preparation, correspondence, fax, requesting article reviews, sending notifications, contacting the School of Medicine, University of Zagreb, contacting Clinical Hospital Centre Zagreb, contacting the printing office) were performed by the head office of the Department of Dermatology and Venerology at the Clinical Hospital Centre Zagreb and the School of Medicine, University of Zagreb, which was, of course, tied to the expenses. Those expenses were charged to the Clinical Hospital Centre Zagreb, but for the purposes of booking the expenses, an agreement was reached with the Directorate of Clinical Hospital Centre Zagreb, according to which the expenses were booked to the journal's office and approved by the manager of the journal's office, who was then also the head of the Department, in accordance with the powers of the head of the Department according to the Temporary decision regarding the organization of Clinical Hospital Centre Zagreb from 1991. To conclude, the existence of the journal's office and its manager was of a purely pragmatic nature at the time. (For the purposes of verifying the accuracy of the abovementioned information see the imprint of the listed volumes and issues of the journal.) The first issue of ADC (Vol 1, No 1) The first issue of the journal was published at Christmas time in 1992 (10), and It was printed in Zagrebačka tiskara (which was later renamed to Grafoplast), Preradovićeva 21-23, Zagreb. The journal's expenses were covered from the following: a) membership fees for CDS-CMA; b) donations, or subscriptions to the journal of pharmaceutical companies; c) financial support of the Ministry of Science (for the year 1994); d) the help of the Directorate of Clinical Hospital Centre Zagreb; and e) financial assets from the research task "Lyme borreliosis" (leader: Prof. Dobrić). All financial business of the journal was performed through the account of the School of Medicine, University of Zagreb. Indexing the journal Thanks to all the authors who sent in their articles to our journal as well as the reviewers from our country and abroad, from January 1994 Acta Dermatovenerologica Croatica is included in the Excerpta Medica Embase database. In April 1993, the journal was already a candidate for the inclusion in Current Contents. See the letter from the institute for Scientific Information, Philadelphia, USA, dated 8th of April 1993, Mrs. Helen Szigeti, Publication Selection (Figure 2). Special thanks In the name of former associates, I extend a special thank you for the preparation for the founding of CDS-CMA to the following: a) All members of the Department and Clinic for Dermatology and Venerology of Clinical Hospital Centre Zagreb and the School of Medicine, University of Zagreb (who are listed in reference 5), as well as all colleagues from the former Dermatovenerological Section of ACP who accepted the invitation to the meeting held on the 29th of May 1992. Of course, I hereby also extend my gratitude to all those colleagues who did not attend that meeting, but explained their absence in a way that was then appropriate; b) Prof. Klaus Wolff, MD, the president of the Executive Board of the International League of Dermatological Societies, who allowed me to follow the work of the Assembly of Delegates of the International League of Dermatological Societies as a delegate of CDS-CMA (on the basis of a previously signed agreement) (New York, the 15th of July 1992); c) Prof. Stuart Maddin, MD, the general secretary of the Executive Board of the International League of Dermatological Societies, who I met with in New York some time before the beginning of the abovementioned Assembly. On that occasion, Prof. Maddin gave me many useful pieces of advice on the work of CDS-CMA and ADC (11). NOTE: Prof. Mario Gligora, PhD (an active participant at the 18th World Congress of Dermatology, New York, 1992, 12-18 June) also visited New York at that time, with whom I discussed at length, as I had done on numerous occasions prior to that, the future work of CDS-CMA and ADC, and his advice on the founding of CDS-CPA and ADC, which I presented on preparatory meetings to my colleagues, were very useful for my co-workers and myself when founding the Society and the journal; d) For everything stated above, I extend a special thank you to Prof. Mario Gligora, PhD Of course, certain pleasant events come at the very end, in order that we remember them for as long as possible. I wish here to extend special gratitude for the founding of CDS-CMA to Prof. Vladimir Čajkovac, PhD, the president of the former Dermatovenerological Section of ACP, who, after the renaming of ACP to CPA, which created the conditions for the founding of CDS-CMA and the journal ADC, always helped us with useful advice and eagerly supported each of our abovementioned initiatives. All collaboration with Prof. Čajkovac was very pleasant and useful. We repaid his favor by nominating him and electing him to the position of the first president of CDS-CMA and the first chief editor of ADC. To conclude, this article gives an overview of the important data on the founding of CDS-CMA (later CDVS-CMA) as well as the important information on ADC (until Vol 4, No 2). On my behalf and on the behalf of all my co-workers, I extend my congratulations for their achievements to everyone who continued working in CDS-CPA (later CDVS-CMA) and the journal ADC (after Vol 4, No 2), which is nowadays indexed in Science Citation Index Expanded (SCIE), Index Medicus/Medline, Embase/Excerpta Medica, Chemical Abstracts Service, Biomedicina Croatica (see ADC Vol 21, No 3, 2013). I hope the current president of the CDVS-CMA, Prof. Mirna Šitum, PhD, as well as the current chief editor of ADC, Prof. Branka Marinović, PhD, who is also the general secretary of the European Academy of Dermatology and Venerology, will enjoy many new achievements in our CDVS-CMA and the journal ADC. It is unnecessary to emphasize the importance of the fact that we have such a respectable journal in our Homeland. NOTE: The honorable duty of preparing this text was entrusted to me by the president of the CDVS-CMA, Prof. Mirna Šitum, PhD, at the meeting of the Executive Board of CDVS-CMA held on the 16th of April 2012 (for the purposes of an oral presentation of this data at the 3rd Croatian Congress of Psychodermatology with international participation, Split, 4-7 October, 2012, and again at the meeting of the Executive Board of CDVS-CMA, held on the 7th of June 2013 for the purposes of the web page of CDVS-CMA).

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The NASA/ESA Mars Sample Return (MSR) Campaign seeks to establish whether life on Mars existed where and when environmental conditions allowed. Laboratory measurements on the returned samples are useful if what is measured is evidence of phenomena on Mars rather than of the effects of sterilization conditions. This report establishes that there are categories of measurements that can be fruitful despite sample sterilization and other categories that cannot. Sterilization kills living microorganisms and inactivates complex biological structures by breaking chemical bonds. Sterilization has similar effects on chemical bonds in non-biological compounds, including abiotic or pre-biotic reduced carbon compounds, hydrous minerals, and hydrous amorphous solids. We considered the sterilization effects of applying dry heat under two specific temperature-time regimes and the effects of γ-irradiation. Many measurements of volatile-rich materials are sterilization sensitive-they will be compromised by either dehydration or radiolysis upon sterilization. Dry-heat sterilization and γ-irradiation differ somewhat in their effects but affect the same chemical elements. Sterilization-sensitive measurements include the abundances and oxidation-reduction (redox) states of redox-sensitive elements, and isotope abundances and ratios of most of them. All organic molecules, and most minerals and naturally occurring amorphous materials that formed under habitable conditions, contain at least one redox-sensitive element. Thus, sterilization-sensitive evidence about ancient life on Mars and its relationship to its ancient environment will be severely compromised if the samples collected by Mars 2020 rover Perseverance cannot be analyzed in an unsterilized condition. To ensure that sterilization-sensitive measurements can be made even on samples deemed unsafe for unsterilized release from containment, contingency instruments in addition to those required for curation, time-sensitive science, and the Sample Safety Assessment Protocol would need to be added to the Sample Receiving Facility (SRF). Targeted investigations using analogs of MSR Campaign-relevant returned-sample types should be undertaken to fill knowledge gaps about sterilization effects on important scientific measurements, especially if the sterilization regimens eventually chosen are different from those considered in this report. Executive Summary A high priority of the planned NASA/ESA Mars Sample Return Campaign is to establish whether life on Mars exists or existed where and when allowed by paleoenvironmental conditions. To answer these questions from analyses of the returned samples would require measurement of many different properties and characteristics by multiple and diverse instruments. Planetary Protection requirements may determine that unsterilized subsamples cannot be safely released to non-Biosafety Level-4 (BSL-4) terrestrial laboratories. Consequently, it is necessary to determine what, if any, are the negative effects that sterilization might have on sample integrity, specifically the fidelity of the subsample properties that are to be measured. Sample properties that do not survive sterilization intact should be measured on unsterilized subsamples, and the Sample Receiving Facility (SRF) should support such measurements. This report considers the effects that sterilization of subsamples might have on the science goals of the MSR Campaign. It assesses how the consequences of sterilization affect the scientific usefulness of the subsamples and hence our ability to conduct high-quality science investigations. We consider the sterilization effects of (a) the application of dry heat under two temperature-time regimes (180°C for 3 hours; 250°C for 30 min) and (b) γ-irradiation (1 MGy), as provided to us by the NASA and ESA Planetary Protection Officers (PPOs). Measurements of many properties of volatile-rich materials are sterilization sensitive-they would be compromised by application of either sterilization mode to the subsample. Such materials include organic molecules, hydrous minerals (crystalline solids), and hydrous amorphous (non-crystalline) solids. Either proposed sterilization method would modify the abundances, isotopes, or oxidation-reduction (redox) states of the six most abundant chemical elements in biological molecules (<ii.e.,</i carbon, hydrogen, nitrogen, oxygen, phosphorus, and sulphur, CHNOPS), and of other key redox-sensitive elements that include iron (Fe), other first-row transition elements (FRTE), and cerium (Ce). As a result of these modifications, such evidence of Mars' life, paleoenvironmental history, potential habitability, and potential biosignatures would be corrupted or destroyed. Modifications of the abundances of some noble gases in samples heated during sterilization would also reset scientifically important radioisotope geochronometers and atmospheric-evolution measurements. Sterilization is designed to render terminally inactive (kill) all living microorganisms and inactivate complex biological structures (including bacterial spores, viruses, and prions). Sterilization processes do so by breaking certain pre-sterilization chemical bonds (including strong C-C, C-O, C-N, and C-H bonds of predominantly covalent character, as well as weaker hydrogen and van der Waals bonds) and forming different bonds and compounds, disabling the biological function of the pre-sterilization chemical compound. The group finds the following: No sterilization process could destroy the viability of cells whilst still retaining molecular structures completely intact. This applies not only to the organic molecules of living organisms, but also to most organic molecular biosignatures of former life (molecular fossils). As a matter of biological principle, any sterilization process would result in the loss of biological and paleobiological information, because this is the mechanism by which sterilization is achieved. Thus, almost all life science investigations would be compromised by sterilizing the subsample by either mode. Sterilization by <b<idry heat</i</b at the proposed temperatures would lead to changes in many of the minerals and amorphous solids that are most significant for the study of paleoenvironments, habitability, potential biosignatures, and the geologic context of life-science observations. <b<iGamma-(γ-)irradiation</i</b at even sub-MGy doses induces radiolysis of water. The radiolysis products (<ie.g.,</i free radicals) react with redox-sensitive chemical species of interest for the study of paleoenvironments, habitability, and potential biosignatures, thereby adversely affecting measurements of those species. Heat sterilization and radiation also have a negative effect on CHNOPS and redox-sensitive elements. MSPG2 was unable to identify with confidence any measurement of abundances or oxidation-reduction states of CHNOPS elements, other redox-sensitive elements (<ie.g.,</i Fe and other FRTE; Ce), or their isotopes that would be affected by only one, but not both, of the considered sterilization methods. Measurements of many attributes of volatile-rich subsamples are sterilization sensitive to both heat and γ-irradiation. Such a measurement is not useful to Mars science if what remains in the subsample is evidence of sterilization conditions and effects instead of evidence of conditions on Mars. Most measurements relating to the detection of evidence for extant or extinct life are sterilization sensitive. Many measurements other than those for life-science seek to retrieve Mars' paleoenvironmental information from the abundances or oxidation-reduction states of CHNOPS elements, other redox-sensitive elements, or their isotopes (and some noble gases) in returned samples. Such measurements inform scientific interpretations of (paleo)atmosphere composition and evolution, (paleo)surface water origin and chemical evolution, potential (paleo)habitability, (paleo)groundwater-porewater solute chemistry, origin and evolution, potential biosignature preservation, metabolic element or isotope fractionation, and the geologic, geochronological, and geomorphic context of life-sciences observations. Most such measurements are also sterilization sensitive. The sterilization-sensitive attributes cannot be meaningfully measured in any such subsample that has been sterilized by heat or γ-irradiation. Unless such subsamples are deemed biohazard-safe for release to external laboratories in unsterilized form, all such measurements must be made on unsterilized samples in biocontainment. An SRF should have the capability to carry out scientific investigations that are sterilization-sensitive to both PPO-provided sterilization methods (Figure SE1). The following findings have been recognized in the Report. Full explanations of the background, scope, and justification precede the presentation of each Finding in the Section identified for that Finding. One or more Findings follow our assessment of previous work on the effects of each provided sterilization method on each of three broad categories of measurement types-biosignatures of extant or ancient life, geological evidence of paleoenvironmental conditions, and gases. Findings are designated Major if they explicitly refer to both PPO-provided sterilization methods or have specific implications for the functionalities that need to be supported within an SRF. <bFINDING SS-1:</b More than half of the measurements described by iMOST for investigation into the presence of (mostly molecular) biosignatures (iMOST Objectives 2.1, 2.2 and 2.3) in returned martian samples are sterilization-sensitive and therefore <bcannot</b be performed with acceptable analytical precision or sensitivity on subsamples sterilized either by heat or by γ-irradiation <iat the sterilization parameters supplied to MSPG2</i. That proportion rises to 86% of the measurements specific to the investigation of extant or recent life (iMOST Objective 2.3) (see Section 2.5). <uThis Finding supersedes Finding #4 of the MSPG <iScience in Containment</i report (MSPG, 2019).</u <bFINDING SS-2:</b Almost three quarters (115 out of 160; 72%) of the measurements described by iMOST for science investigations <unot associated with Objective 2</u but associated with Objectives concerning geological phenomena that include past interactions with the hydrosphere (Objectives 1 and 3) and the atmosphere (Objective 4) are sterilization-tolerant and therefore <bcan</b (generally) be performed with acceptable analytical precision or sensitivity on subsamples sterilized either by heat or by γ-irradiation <iat the sterilization parameters supplied to MSPG2</i (see Section 2.5). <uThis Finding supports Finding #6 of the MSPG <iScience in Containment</i report (MSPG, 2019).</u <iMSPG2 endorses the previously proposed strategy of conducting as many measurements as possible outside the SRF where the option exists</i. <bFINDING SS-3:</b Suggested strategies for investigating the potential for extant life in returned martian samples lie in understanding biosignatures and, more importantly, the presence of nucleic acid structures (DNA/RNA) and possible agnostic functionally similar information-bearing polymers. A crucial observation is that <iexposure of microorganisms to temperatures associated with sterilization above those typical of a habitable surface or subsurface environment results in a loss of biological information</i. If extant life is a target for subsample analysis, sterilization of material <ivia</i dry heat would likely compromise any such analysis (see Section 3.2). <bFINDING SS-4:</b Suggested strategies for investigating the potential for extant life in returned martian samples lie in understanding biosignatures, including the presence of nucleic acid structures (DNA/RNA) and possible agnostic functionally similar information-bearing polymers. A crucial observation is that <iexposure of microorganisms to γ-radiation results in a loss of biological information through molecular damage and/or destruction</i. If extant life is a target for subsample analysis, sterilization of material <ivia</i γ-radiation would likely compromise any such analysis (see Section 3.3). <bFINDING SS-5:</b Suggested strategies for investigating biomolecules in returned martian samples lie in detection of a variety of complex molecules, including peptides, proteins, DNA (deoxyribonucleic acid) and RNA (ribonucleic acid), as well as compounds associated with cell membranes such as lipids, sterols, and fatty acids and their geologically stable reaction products (hopanes, steranes, etc.) and possible agnostic functionally similar information-bearing polymers. <iExposure to temperatures above MSR Campaign-Level Requirements for sample temperature, up to and including sterilization temperatures, results in a loss of biological information</i. If the presence of biosignatures is a target for subsample analysis, sterilization of material <ivia</i dry heat would likely compromise any such analysis (see Section 4.2). <bFINDING SS-6:</b Suggested strategies for investigating biomolecules in returned martian samples lie in detection of a variety of complex molecules, including peptides, proteins, DNA (deoxyribonucleic acid) and RNA (ribonucleic acid), and compounds associated with cell membranes such as lipids, sterols and fatty acids and their geologically stable reaction products (hopanes, steranes, etc.) and possible agnostic functionally similar information-bearing polymers. <iExposure to radiation results in a loss of biological information</i. If the presence of biosignatures is a target for subsample analysis, sterilization of material <ivia</i γ-irradiation would likely compromise any such analysis (see Section 4.3). [Figure: see text] <bMAJOR FINDING SS-7:</b The use of <iheat or γ-irradiation</i sterilization should be avoided for subsamples intended to be used for organic biosignature investigations (for extinct or extant life). Studies of organic molecules from extinct or extant life (either indigenous or contaminants, viable or dead cells) or even some organic molecules derived from abiotic chemistry cannot credibly be done on subsamples that have been sterilized by any means. The concentrations of amino acids and other reduced organic biosignatures in the returned martian samples may also be so low that additional heat and/or γ-irradiation sterilization would reduce their concentrations to undetectable levels. It is a very high priority that these experiments be done on unsterilized subsamples inside containment (see Section 4.4). <bFINDING SS-8:</b Solvent extraction and acid hydrolysis at ∼100°C of unsterilized martian samples will inactivate any biopolymers in the extract and would not require additional heat or radiation treatment for the subsamples to be rendered sterile. Hydrolyzed extracts should be safe for analysis of soluble free organic molecules outside containment and may provide useful information about their origin for biohazard assessments; this type of approach, if approved, is strongly preferred and endorsed (see Section 4.4). <bFINDING SS-9:</b Minerals and amorphous materials formed by low temperature processes on Mars are highly sensitive to thermal alteration, which leads to irreversible changes in composition and/or structure when heated. <iExposure to temperatures above MSR Campaign-Level Requirements for sample temperature, up to and including sterilization temperatures, has the potential to alter them from their as-received state</i. Sterilization by dry heat at the proposed sterilization temperatures would lead to changes in many of the minerals that are most significant for the study of paleoenvironments, habitability, and potential biosignatures or biosignature hosts. It is crucial that the returned samples are not heated to temperatures above which mineral transitions occur (see Section 5.3). <bFINDING SS-10:</b Crystal structure, major and non-volatile minor element abundances, and stoichiometric compositions of minerals are unaffected by γ-irradiation of up to 0.3-1 MGy, but crystal structures are completely destroyed at 130 MGy. Measurements of these specific properties cannot be acquired from subsamples γ-irradiated at the notional 1 MGy dose-they are sterilization-sensitive (see Section 5.4). <bFINDING SS-11:</b Sterilization by γ-irradiation (even at sub-MGy doses) results in significant changes to the redox state of elements bound within a mineral lattice. Redox-sensitive elements include Fe and other first-row transition elements (FRTE) as well as C, H, N, O, P and S. Almost all minerals and naturally occurring amorphous materials that formed under habitable conditions, including the ambient paleotemperatures of Mars' surface or shallow subsurface, contain at least one of these redox-sensitive elements. Therefore, measurements and investigations of the listed properties of such geological materials are sterilization sensitive and <ishould not be performed on γ-irradiated subsamples</i (see Section 5.4). <bFINDING SS-12:</b A significant fraction of investigations that focus on high-temperature magmatic and impact-related processes, their chronology, and the chronology of Mars' geophysical evolution are sterilization-tolerant. While there may be a few analyses involved in such investigations that could be affected to some degree by heat sterilization, most of these analyses would not be affected by sterilization involving γ-irradiation (see Section 5.6). <bMAJOR FINDING SS-13:</b Scientific investigations of materials containing hydrous or otherwise volatile-rich minerals and/or X-ray amorphous materials that formed or were naturally modified at low (Mars surface-/near-surface) temperature are sterilization-sensitive in that they would be compromised by changes in the abundances, redox states, and isotopes of CHNOPS and other volatiles (<ie.g.,</i noble gases for chronometry), FRTE, and Ce, and cannot be performed on subsamples that have been sterilized by either dry heat or γ-irradiation (see Section 5.7). <bMAJOR FINDING SS-14:</b It would be far preferable to work on sterilized gas samples outside of containment, if the technical issues can all be worked out, than to build and operate a large gas chemistry laboratory inside containment. Depending on their reactivity (or inertness), gases extracted from sample tubes could be sterilized by dry heat or γ-irradiation and analyzed outside containment. Alternatively, gas samples could be filtered through an inert grid and the filtered gas analyzed outside containment (see Section 6.5). <bMAJOR FINDING SS-15:</b It is fundamental to the campaign-level science objectives of the Mars Sample Return Campaign that the SRF support characterization of samples returned from Mars that contain organic matter and/or minerals formed under habitable conditions that include the ambient paleotemperatures of Mars' surface or subsurface (&lt;∼200°C)-such as most clays, sulfates, and carbonates-in laboratories on Earth <iin their as-received-at-the-SRF condition</i (see Section 7.1). <bMAJOR FINDING SS-16:</b The search for any category of potential biosignature would be adversely affected by either of the proposed sterilization methods (see Section 7.1). <bMAJOR FINDING SS-17:</b Carbon, hydrogen, nitrogen, oxygen, sulfur, phosphorus, and other volatiles would be released from a subsample during the sterilization step. The heat and γ-ray sterilization chambers should be able to monitor weight loss from the subsample during sterilization. Any gases produced in the sample headspace and sterilization chamber during sterilization should be captured and contained for future analyses of the chemical and stable isotopic compositions of the evolved elements and compounds for <iall</i sterilized subsamples to characterize and document fully any sterilization-induced alteration and thereby recover some important information that would otherwise be lost (see Section 7.2). This report shows that <imost of the sterilization-sensitive iMOST measurement types are among either the iMOST objectives for life detection and life characterization (half or more of the measurements for life-science sub-objectives are critically sterilization sensitive) or the iMOST objectives for inferring paleoenvironments, habitability, preservation of potential biosignatures, and the geologic context of life-science observations (nearly half of the measurements for sub-objectives involving geological environments, habitability, potential biosignature preservation, and gases/volatiles are critically sterilization sensitive)</i (Table 2; see Beaty <iet al.,</i 2019 for the full lists of iMOST objectives, goals, investigations, and sample measurement types). <b<uSterilization-sensitive science about ancient life on Mars and its relationship to its ancient environment will be severely impaired or lost if the samples collected by Perseverance cannot be analyzed in an unsterilized condition</u.</b <bSummary</b: ○The SRF should have the capability to carry out or otherwise support scientific investigations that are sensitive to both PPO-provided sterilization methods. ○Measurements of most life-sciences and habitability-related (paleoenvironmental) phenomena are sensitive to both PPO-provided sterilization modes. (Major Finding SS-7, SS-15, SS-16 and Finding SS-1, SS-3, SS-4, SS-5, SS-6, SS-9, SS-11, SS-13) If subsamples for sterilization-sensitive measurement cannot be deemed safe for release, then additional contingency analytical capabilities are needed in the SRF to complete MSR Campaign measurements of sterilization-sensitive sample properties on unsterilized samples in containment (Figure SE1, below). ○Measurements of high-temperature (low-volatile) phenomena are tolerant of both PPO-provided sterilization modes (Finding SS-12). Subsamples for such measurements may be sterilized and released to laboratories outside containment without compromising the scientific value of the measurements. ○Capturing, transporting, and analyzing gases is important and will require careful design of apparatus. Doing so for volatiles present as headspace gases and a dedicated atmosphere sample will enable important atmospheric science (Major Finding SS-14). Similarly, capturing and analyzing gases evolved during subsample sterilization (<ii.e.,</i gas from the sterilization chamber) would compensate for some sterilization-induced loss of science data from volatile-rich solid (geological) subsamples (Finding SS-14, SS-17; other options incl. SS-8).

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Dibutyl phthalate is a phthalate ester with extensive use in industry in such products as plastic (PVC) piping, various varnishes and lacquers, safety glass, nail polishes, paper coatings, dental materials, pharmaceuticals, and plastic food wrap. Concomitant with this extensive worldwide use is the high potential for human exposure to dibutyl phthalate in the workplace and the home environment through direct sources as well as indirectly, through contamination of water, air, and foodstuffs. Because existing toxicity information was considered inadequate, the effects of exposure to dibutyl phthalate were examined in male and female F344/N rats and B6C3F1 mice in 13-week feed studies. Furthermore, due to concern over the potential for pervasive exposure of humans to dibutyl phthalate, additional perinatal studies examined rats and mice exposed as pups in utero, for the 4 weeks of lactation, and for an additional 4 weeks postweaning. Additional studies examined the effects on rats of combining perinatal and adult subchronic exposure. Due to the recognized biologic activity of this and other phthalates, hepatic peroxisome proliferation during the in utero and lactational phases and testicular toxicity during the perinatal period were also examined. Finally, reproductive assessment by continuous breeding (including crossover mating trials and offspring assessment) and genetic toxicity studies were also conducted. In the maximum perinatal exposure (MPE) determination study in rats, dibutyl phthalate was administered in the diet to dams during gestation and lactation, and to the pups postweaning for four additional weeks, at concentrations of 0, 1,250, 2,500, 5,000, 7,500, 10,000, and 20,000 ppm. Decreased weight gains were noted in dams exposed to 20,000 ppm during gestation and to dams exposed to 10,000 ppm during lactation. The gestation index (number of live pups per breeding female) was significantly lower in the 20,000 ppm group than in the controls, and pup mortality in this group was marked (100% by Day 1 of lactation); however, survival was 89% or greater in all other treatment groups. The mean body weight of pups in the 10,000 ppm group at Day 28 of lactation was approximately 90% of the mean weight of control pups. Pups were weaned onto diets containing dibutyl phthalate at the same concentrations fed to dams. After an additional 4 weeks of dietary administration, final mean body weights of pups in the 10,000 ppm groups were 92% of the control value for males and 95% of the control value for females. Hepatomegaly (increased relative liver weight) was observed in males in all exposed groups and in females receiving 2,500 ppm or greater. No gross lesions were observed at necropsy. Moderate hypospermia of the epididymis was diagnosed in all male rats in the 7,500 and 10,000 ppm groups; mild hypospermia of the epididymis was diagnosed in 2 of 10 males in the 5,000 ppm group. No degeneration of the germinal epithelium was detected in the testis of these rats. Thus, although toxicologically important, the epididymal hypospermia was not considered to be life threatening, and 10,000 ppm was recommended as the MPE concentration for male and female rats. In the subsequent subchronic toxicity study of dibutyl phthalate with perinatal exposure, dams were administered diets containing 0 or the MPE concentration (10,000 ppm) during gestation and lactation, and weaned pups were administered the same diets as their dams received for an additional 4 weeks, until the beginning of the 13-week exposure phase. Male and female rats then received diets containing dibutyl phthalate at concentrations of 0, 2,500, 5,000, 10,000, 20,000, and 40,000 ppm for 13 weeks. No mortality or toxicity was observed in dams during the perinatal phase of the study; however, before pups were culled at 4 days postpartum, the percentage of live pups per litter was 86% to 93% that of the controls. Through weaning, litter weights of exposed pups ranged from 89% to 92% of the control values. Ten control and ten exposed pups per sex were examined at the time of trol and ten exposed pups per sex were examined at the time of weaning; hepatomegaly and markedly increased peroxisomal enzyme activities (approximately 9-fold greater than the control values) were observed in exposed pups. Body weights of the perinatally exposed pups remained lower than those of the controls throughout the 4-week period before the 13-week adult exposures began. During the 13-week adult exposure phase, the final mean body weight of males in the MPE: 0 ppm control group (MPE rats, returned to the base diet for 13 weeks), was 95&amp;percnt; that of the controls. The body weight gain of females in the MPE:0 ppm group was greater than that of the unexposed controls, and the final body weights of these two groups were similar. Body weight gains of rats treated with dibutyl phthalate as adults decreased with increasing exposure concentration; for rats that received the MPE concentration followed by 40,000 ppm for 13 weeks, final body weights were 51&amp;percnt; of the control value for males and 74&amp;percnt; of the control value for females. Hepatomegaly apparently regressed in rats in the MPE:0 ppm groups but was observed in male rats receiving 5,000 ppm or greater and in females receiving 2,500 ppm or greater. In males that received 20,000 ppm as adults, testis and epididymal weights were less than in the controls; males in the 40,000 ppm group also had a lower testis weight than the controls. Results of hematologic analyses conducted at the end of the 13-week exposure period suggested a mild anemia in male rats administered 10,000 ppm or greater as adults and female rats administered 40,000 ppm as adults. Hypocholesterolemia and hypotriglyceridemia were observed in male and female rats at the higher exposure concentrations. Hypotriglyceridemia was detected in females receiving 20,000 or 40,000 ppm and in males receiving 10,000 ppm or greater. Elevations in alkaline phosphatase activities and bile acid concentrations in male and female rats receiving 20,000 or 40,000 ppm as adults were indicative of cholestasis. Microscopic examination revealed hepatocellular cytoplasmic alteration, consistent with glycogen depletion, in male and female rats receiving a concentration of 10,000 ppm or greater. In the liver of rats receiving 40,000 ppm, small, fine, eosinophilic granules were also observed in the cytoplasm of hepatocytes. Ultrastructural examination suggested the presence of increased numbers of peroxisomes. Lipofuscin accumulation was detected in rats that received 10,000 ppm or greater. Consistent with the regression of the hepatomegaly in rats in the MPE:0 and MPE:2,500 ppm groups, peroxisomal enzyme activity was not elevated in these groups. Marked elevations of peroxisomal enzyme activity were detected, however, in males receiving 5,000 ppm or greater and in females receiving 10,000 ppm or greater; at the 40,000 ppm concentration, the highest concentration tested, enzyme activities were approximately 20 fold greater than the control values. Histopathologic examination of the testes revealed degeneration of the germinal epithelium, a mild to moderate focal lesion in rats in the 10,000 and 20,000 ppm groups and a marked, diffuse lesion in all males receiving 40,000 ppm; at 40,000 ppm, an almost complete loss of the germinal epithelium resulted. Testicular zinc concentrations were lower in the 40,000 ppm group than in the controls, a finding consistent with the marked loss of germinal epithelium at this exposure concentration. Spermatogenesis was evaluated in rats in the 0, 2,500, 10,000, and 20,000 ppm groups; rats administered 20,000 ppm had fewer spermatid heads per testis than the unexposed controls, and epididymal spermatozoal concentration was less than that in the MPE:0 ppm group. For comparison with the perinatal subchronic study, a standard 13-week evaluation of the toxicity of dibutyl phthalate in male and female rats was also conducted. In this study, rats received dibutyl phthalate at the same dietary concentrations used in the 13-week exposure phase of the study with perinatal exposure: 0, 2,500, 5,000, 10,000, 20,000, and 40,000 ppm. No deaths occurred in the standard study. Markedly reduced final mean body weights were observed in males and females in the 40,000 ppm groups (45&amp;percnt; and 73&amp;percnt; of control body weights, respectively); final mean body weights of males receiving 10,000 ppm or greater and females receiving 20,000 ppm or greater were lower than those of the controls. Hepatomegaly was observed in males that received 5,000 ppm or greater and in females that received 10,000 ppm or greater. Testis and epididymal weights of males in the 20,000 and 40,000 ppm groups were lower than those of the controls. A minimal anemia was detected in male rats receiving 5,000 ppm or greater. Hypocholesterolemia was observed in male and female rats receiving 20,000 or 40,000 ppm, and hypotriglyceridemia was detected in males in all exposed groups and in females receiving 10,000 ppm or greater. Elevations in alkaline phosphatase activity and bile acid concentration in male and female rats were considered indicative of cholestasis. Morphologic evaluation again confirmed the toxicity of dibutyl phthalate to the liver and testes of rats. Microscopic examination of the liver revealed hepatocellular cytoplasmic alterations, consistent with glycogen depletion, in male and female rats receiving 10,000 ppm or greater. In the liver of rats in the 40,000 ppm groups, small, fine, eosinophilic granules were also observed in the cytoplasm of hepatocytes. Ultrastructural examination suggested the presence of increased numbers of peroxisomes, and peroxisomal enzyme activity was elevated in the livers of male and female rats administered 5,000 ppm or greater; the enzyme activities in the 40,000 ppm groups were approximately 13-fold greater than the control value for males and 32-fold greater than the control value for females. Lipofuscin accumulation was detected in rats receiving 10,000 ppm or greater. Histopathologic examination of the testes revealed degeneration of the germinal epithelium, a mild to marked focal lesion in the 10,000 and 20,000 ppm groups and a marked, diffuse lesion in all males in the 40,000 ppm group; at 40,000 ppm, an almost complete loss of the germinal epithelium resulted. Testicular zinc concentrations were lower in the 20,000 and 40,000 ppm groups than in the controls. Serum testosterone values were also lower at these concentrations than in the controls. Spermatogenesis was evaluated in males in the 0, 2,500, 10,000, and 20,000 ppm groups; at 20,000 ppm, spermatid heads per testis and per gram testis, epididymal spermatozoal motility, and the number of epididymal spermatozoa per gram epididymis were lower than in the controls. All of these findings are consistent with the marked loss of germinal epithelium at these exposure concentrations. In the continuous breeding study, Sprague-Dawley rats received 0, 1,000, 5,000, or 10,000 ppm dibutyl phthalate in feed. Mean body weights of exposed dams at delivery and during lactation generally decreased with increasing exposure concentration. The mean pup weight at birth in the 10,000 ppm group was significantly lower than the control pup weight. The average number of live pups per litter in all exposed groups was lower than in the controls. Crossover mating trials in the F(0) generation revealed no effects on the fertility of male or female rats receiving 10,000 ppm. In contrast to the F(0) rats, mating, pregnancy, and fertility indices of F(1) rats were lower in the 10,000 ppm group than in the controls. Germinal epithelial degeneration of the testes and absence or under development of the epididymides were noted in F(1) males in the 10,000 ppm group. Interstitial cell hyperplasia was noted in 7 of 10 males in the 10,000 ppm group. These effects document the male and female reproductive toxicity of dibutyl phthalate in F(1) rats receiving 10,000 ppm and do not exclude the possibility of developmental toxicity to F2 offspring. In the MPE determination study in mice, dams received 0, 1,250, 2,500, 5,000, 7,500, 10,000, or 20,000 ppm dibutyl phthalate in feed during gestation and lactation; pups were weaned onto the same diets as the dams received and were exposed for an additional 4 weeks. The gestation period was longer in dams that received 2,500 ppm or greater than in the controls, and gestational body weight gain depressions were noted in dams receiving 7,500 ppm or greater. Only 5 of 20 females in the 10,000 ppm group delivered live pups, and none of the 20 females receiving 20,000 ppm delivered live pups. Only one pup in the 10,000 ppm group survived past Lactation Day 1; the number of live pups per litter in the 7,500 ppm group also remained low throughout lactation. No deaths of either male or female pups occurred after weaning. Initial (postweaning) and final body weights of male pups receiving 2,500 ppm or greater were significantly less than those of the control group. The mean body weights of exposed female pups were similar to the control body weight at weaning and remained similar throughout the 4 weeks postweaning. Hepatomegaly was present in male mice in all exposed groups, and the absolute liver weight of males administered 7,500 ppm was greater than that of the controls; although a similar change was apparent in females, no statistical differences between the liver weights of exposed and control females were detected. No treatment-related gross lesions were identified at necropsy, and no histopathologic lesions definitively associated with treatment were observed in male or female mice in the 7,500 ppm groups. The one surviving male pup in the 10,000 ppm group had cytoplasmic alteration in the liver, consistent with peroxisome proliferation. Developmental toxicity and fetal and pup mortality were suggested at concentrations as low as 7,500 ppm. No subchronic toxicity study with prior MPE exposure was conducted with mice, although an MPE concentration of 5,000 ppm was suggested by the data. In a standard 13-week toxicity study, mice received 0, 1,250, 2,500, 5,000, 10,000, or 20,000 ppm dibutyl phthalate in feed. No deaths occurred during this study. Mean body weights and weight gains of male and female mice decreased with increasing exposure concentration, and the decreases were significant for males and females that received 5,000 ppm or greater. Relative liver weights were greater in males and females receiving 5,000 ppm or greater than in the controls. A minimal anemia was suggested in female mice in the 20,000 ppm group. Although no gross lesions were observed at necropsy, microscopic examination revealed hepatocellular cytoplasmic alterations, consistent with glycogen depletion, in male mice receiving 10,000 or 20,000 ppm and female mice receiving 20,000 ppm. Small, fine, eosinophilic granules, consistent with peroxisome proliferation, were also observed in the cytoplasm of hepatocytes in males and females in the 20,000 ppm groups. Lipofuscin accumulation in the liver was detected in mice receiving 10,000 ppm or greater. In a continuous breeding study using Swiss (CD-1&amp;reg;) mice, animals received 0, 300, 3,000, or 10,000 ppm dibutyl phthalate in feed. The fertility index, average number of litters per breeding pair, and average number of live pups per litter in the 10,000 ppm group were lower than in the controls. Crossover mating trials of mice receiving 10,000 ppm revealed effects on dams in the F(0) generation, with a lower fertility index, number of live pups per litter, and pup weight than in the controls. Liver weights were greater in males and females, and the uterine weight was less in exposed dams than in the controls. No other changes were observed at necropsy or on histopathologic examination. These data document the female reproductive toxicity of dibutyl phthalate in F(0) mice. Dibutyl phthalate was not mutagenic in Salmonella typhimurium strain TA98, TA100, TA1535, or TA1537 with or without exogenous metabolic activation but did induce mutations in L5178Y mouse lymphoma cells treated without metabolic activation. In peripheral blood samples obtained from male and female mice at the end of the 13-week study, frequencies of micronucleated normochromatic erythrocytes were similar between exposed and control mice. Together, the studies in rodents suggest that young rodents (in utero and perinatal) respond in a manner qualitatively similar to that of adult rats and mice. Dibutyl phthalate induced toxic effects in rodents as pups in utero and during the lactational phases of development and also affected young adults, as evidenced by fetotoxicity and lethality, body weight gain decrements, increased liver weights, hepatic peroxisome proliferation, testicular toxicity, and female reproductive toxicity. Dibutyl phthalate was lethal to rat fetuses and rat and mouse neonates at dietary concentrations that were not toxic to dams. Otherwise, there was no teratogenic or morphologic evidence that rodent young were uniquely sensitive to the effects of short-term dibutyl phthalate treatment. Synonyms: 1,2-Benzenedicarboxylic acid dibutyl ester; benzene-o-dicarboxylic acid di-n-butyl ester; o-benzenedicarboxylic acid dibutyl ester; butyl phthalate; n-butyl phthalate; DBP; dibutyl 1,2-benzene dicarboxylate; dibutylphthalate; di-n-butylphthalate; di(n-butyl) phthalate; dibutyl-o-phthalate; phthalic acid dibutyl ester. Trade Names: Celluflex DBP; Elaol; Ergoplast FDB; Ersoplast FDA; Genoplast B; Hexaplas M/B; Palatinol C; Polycizer DBP; PX 104; RC Plasticizer DBP; Staflex DBP; Uniflex DBP; Unimoll DB; Witcizer 300; Witicizer 300. (NOTE: These studies were supported in part by funds from the Comprehensive Environmental Response, Compensation, and Liability Act trust fund (Superfund) by an interagency agreement with the Agency for Toxic Substances and Disease Registry, U.S. Public Health Service.)

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An erratum was issued for: Preparation of Poly(pentafluorophenyl acrylate) Functionalized SiO2 Beads for Protein Purification.  Throughout the article, the term "3-aminopropyltriethoxysilane" has been replaced with "3-aminopropyltrimethoxysilane", and "APTES" with "APTMS". The Keywords were updated from: Poly(pentafluorophenyl acrylate), 3-aminopropyltriethoxysilane, reactive polymer brush, post-polymerization functionalization, antibody immobilization, immunoprecipitation to: Poly(pentafluorophenyl acrylate), 3-aminopropyltrimethoxysilane, reactive polymer brush, post-polymerization functionalization, antibody immobilization, immunoprecipitation The Abstract was updated from: We demonstrate a simple method to prepare poly(pentafluorophenyl acrylate) (poly(PFPA)) grafted silica beads for antibody immobilization and subsequent immunoprecipitation (IP) application. The poly(PFPA) grafted surface is prepared via a simple two-step process. In the first step, 3-aminopropyltriethoxysilane (APTES) is deposited as a linker molecule onto the silica surface. In the second step, poly(PFPA) homopolymer, synthesized via the reversible addition and fragmentation chain transfer (RAFT) polymerization, is grafted to the linker molecule through the exchange reaction between the pentafluorophenyl (PFP) units on the polymer and the amine groups on APTES. The deposition of APTES and poly(PFPA) on the silica particles are confirmed by X-ray photoelectron spectroscopy (XPS), as well as monitored by the particle size change measured via dynamic light scattering (DLS). To improve the surface hydrophilicity of the beads, partial substitution of poly(PFPA) with amine-functionalized poly(ethylene glycol) (amino-PEG) is also performed. The PEG-substituted poly(PFPA) grafted silica beads are then immobilized with antibodies for IP application. For demonstration, an antibody against protein kinase RNA-activated (PKR) is employed, and IP efficiency is determined by Western blotting. The analysis results show that the antibody immobilized beads can indeed be used to enrich PKR while non-specific protein interactions are minimal. to: We demonstrate a simple method to prepare poly(pentafluorophenyl acrylate) (poly(PFPA)) grafted silica beads for antibody immobilization and subsequent immunoprecipitation (IP) application. The poly(PFPA) grafted surface is prepared via a simple two-step process. In the first step, 3-aminopropyltrimethoxysilane (APTMS) is deposited as a linker molecule onto the silica surface. In the second step, poly(PFPA) homopolymer, synthesized via the reversible addition and fragmentation chain transfer (RAFT) polymerization, is grafted to the linker molecule through the exchange reaction between the pentafluorophenyl (PFP) units on the polymer and the amine groups on APTMS. The deposition of APTMS and poly(PFPA) on the silica particles are confirmed by X-ray photoelectron spectroscopy (XPS), as well as monitored by the particle size change measured via dynamic light scattering (DLS). To improve the surface hydrophilicity of the beads, partial substitution of poly(PFPA) with amine-functionalized poly(ethylene glycol) (amino-PEG) is also performed. The PEG-substituted poly(PFPA) grafted silica beads are then immobilized with antibodies for IP application. For demonstration, an antibody against protein kinase RNA-activated (PKR) is employed, and IP efficiency is determined by Western blotting. The analysis results show that the antibody immobilized beads can indeed be used to enrich PKR while non-specific protein interactions are minimal. The fourth paragraph of the Introduction was updated from: In this contribution, we report an alternative method to prepare poly(PFPA) grafted surface for antibody immobilization and IP application. In a simple two-step process, as illustrated in Figure 1, an APTES linker molecule is first deposited onto the silica surface, then the poly(PFPA) polymer is covalently attached to the linker molecule through the reaction between the PFP units on the polymer and the amine functions on APTES. This preparation method allows for the permanent crosslinking of poly(PFPA) to a substrate surface, but avoids the many complications associated with SI-CTA synthesis and SI-RAFT polymerization of poly(PFPA) brushes. Partial substitution of the PFP units with amino-PEG can still be performed, allowing fine-tuning of the polymer brush surface properties. We show the poly(PFPA) grafted silica beads thus prepared can be immobilized with antibodies and used for protein enrichment via IP. The detailed bead preparation procedure, antibody immobilization, and IP testing are documented in this article, for readers interested in seeking an alternative to conventional Protein A/G based IP. to: In this contribution, we report an alternative method to prepare poly(PFPA) grafted surface for antibody immobilization and IP application. In a simple two-step process, as illustrated in Figure 1, an APTMS linker molecule is first deposited onto the silica surface, then the poly(PFPA) polymer is covalently attached to the linker molecule through the reaction between the PFP units on the polymer and the amine functions on APTMS. This preparation method allows for the permanent crosslinking of poly(PFPA) to a substrate surface, but avoids the many complications associated with SI-CTA synthesis and SI-RAFT polymerization of poly(PFPA) brushes. Partial substitution of the PFP units with amino-PEG can still be performed, allowing fine-tuning of the polymer brush surface properties. We show the poly(PFPA) grafted silica beads thus prepared can be immobilized with antibodies and used for protein enrichment via IP. The detailed bead preparation procedure, antibody immobilization, and IP testing are documented in this article, for readers interested in seeking an alternative to conventional Protein A/G based IP. Step 2.1 of the Protocol was updated from: Treatment of SiO2 beads with APTES to: Treatment of SiO2 beads with APTMS Step 2.1.1 of the Protocol was updated from: SiO2 particles are available in the form of a 5% (w/v) aqueous suspension. Combine 0.8 mL of SiO2 suspension with 40 mg of APTES and 8 mL of methanol in a 20 mL scintillation vial equipped with a stir bar. to: SiO2 particles are available in the form of a 5% (w/v) aqueous suspension. Combine 0.8 mL of SiO2 suspension with 40 mg of APTMS and 8 mL of methanol in a 20 mL scintillation vial equipped with a stir bar. Step 2.1.3 of the Protocol was updated from: Transfer the solution to a conical tube. To isolate the APTES functionalized SiO2 beads, centrifuge the solution at 10,000 x g for 5 min, then remove the supernatant. Wash the beads by re-dispersing them in 3 mL of fresh methanol. Shake the tube by hand for mixing, but if necessary, improve the dispersion by sonication in a water bath for a few seconds. Centrifuge the beads at 10,000 x g for 5 min. Remove the supernatant and repeat the wash step one more time. to: Transfer the solution to a conical tube. To isolate the APTMS functionalized SiO2 beads, centrifuge the solution at 10,000 x g for 5 min, then remove the supernatant. Wash the beads by re-dispersing them in 3 mL of fresh methanol. Shake the tube by hand for mixing, but if necessary, improve the dispersion by sonication in a water bath for a few seconds. Centrifuge the beads at 10,000 x g for 5 min. Remove the supernatant and repeat the wash step one more time. Step 2.1.4 of the Protocol was updated from: Combine the methanol washed SiO2 beads with 3 mL of dimethyl sulfoxide (DMSO). Shake the mixture by hand, or if necessary sonicate for a few seconds, until the beads are fully dispersed in DMSO. Centrifuge the beads at 10,000 x g for 5 min, then remove the supernatant. Repeat the step to ensure complete solvent exchange from methanol to DMSO. NOTE: The final suspension contains the APTES functionalized SiO2 beads dispersed in 4 mL of DMSO. to: Combine the methanol washed SiO2 beads with 3 mL of dimethyl sulfoxide (DMSO). Shake the mixture by hand, or if necessary sonicate for a few seconds, until the beads are fully dispersed in DMSO. Centrifuge the beads at 10,000 x g for 5 min, then remove the supernatant. Repeat the step to ensure complete solvent exchange from methanol to DMSO. NOTE: The final suspension contains the APTMS functionalized SiO2 beads dispersed in 4 mL of DMSO. Step 2.2 of the Protocol was updated from: Grafting poly(PFPA) to APTES functionalized SiO2 beads to: Grafting poly(PFPA) to APTMS functionalized SiO2 beads Step 2.2.2 of the Protocol was updated from: Add 1 mL of APTES functionalized SiO2 beads suspended in DMSO (from Step 2.1.4) to the poly(PFPA) solution. React at RT for 1 h with vigorous stirring. to: Add 1 mL of APTMS functionalized SiO2 beads suspended in DMSO (from Step 2.1.4) to the poly(PFPA) solution. React at RT for 1 h with vigorous stirring. Step 3.4 of the Protocol was updated from: To prepare APTES functionalized SiO2 beads suspended in DMSO, follow the same steps shown in Step 2.1. Transfer 1 mL of the bead suspension into the PEG-substituted poly(PFPA) solution prepared in Step 3.3. Allow the grafting between poly(PFPA) and APTES functionalized SiO2 beads to proceed at RT for 1 h with vigorous stirring. to: To prepare APTMS functionalized SiO2 beads suspended in DMSO, follow the same steps shown in Step 2.1. Transfer 1 mL of the bead suspension into the PEG-substituted poly(PFPA) solution prepared in Step 3.3. Allow the grafting between poly(PFPA) and APTMS functionalized SiO2 beads to proceed at RT for 1 h with vigorous stirring. The first paragraph of the Representative Results was updated from: A schematic for the preparation of poly(PFPA) grafted SiO2 beads, with or without PEG substitution is shown in Figure 1. To monitor the APTES and poly(PFPA) grafting process, bare SiO2 beads, APTES functionalized SiO2 beads, and poly(PFPA) grafted SiO2 beads are characterized by both DLS (Figure 2) and XPS (Figure 3). IP efficiencies of the beads are determined by Western blotting. Figure 4 shows the Western blotting results for IP using 1% PEG-substituted poly(PFPA) grafted beads, where the beads are incubated with no antibody, a non-specific antibody, or anti-PKR antibody. Figure 5 shows the Western blotting results for IP using 0% PEG-substituted poly(PFPA) grafted beads and 1% PEG-substituted poly(PFPA) grafted beads, both incubated with anti-PKR antibodies. to: A schematic for the preparation of poly(PFPA) grafted SiO2 beads, with or without PEG substitution is shown in Figure 1. To monitor the APTMS and poly(PFPA) grafting process, bare SiO2 beads, APTMS functionalized SiO2 beads, and poly(PFPA) grafted SiO2 beads are characterized by both DLS (Figure 2) and XPS (Figure 3). IP efficiencies of the beads are determined by Western blotting. Figure 4 shows the Western blotting results for IP using 1% PEG-substituted poly(PFPA) grafted beads, where the beads are incubated with no antibody, a non-specific antibody, or anti-PKR antibody. Figure 5 shows the Western blotting results for IP using 0% PEG-substituted poly(PFPA) grafted beads and 1% PEG-substituted poly(PFPA) grafted beads, both incubated with anti-PKR antibodies. Figure 1 was updated from: Figure 1: Schematic for the preparation of poly(PFPA) grafted SiO2 beads using APTES as a linker molecule. (a) Poly(PFPA) grafted beads. (b) Partially PEG-substituted poly(PFPA) grafted beads. to: Figure 1: Schematic for the preparation of poly(PFPA) grafted SiO2 beads using APTMS as a linker molecule. (a) Poly(PFPA) grafted beads. (b) Partially PEG-substituted poly(PFPA) grafted beads. Figure 2 was updated from: Figure 2: DLS measurements for (a) bare SiO2 beads (SiO2), (b) APTES functionalized SiO2 beads (APTES-SiO2), and (c) poly(PFPA) grafted SiO2 beads (poly(PFPA)-SiO2), dispersed in DMSO. The Z-average diameter (d) and polydispersity index (PDI) of each sample are reported. to: Figure 2: DLS measurements for (a) bare SiO2 beads (SiO2), (b) APTMS functionalized SiO2 beads (APTMS-SiO2), and (c) poly(PFPA) grafted SiO2 beads (poly(PFPA)-SiO2), dispersed in DMSO. The Z-average diameter (d) and polydispersity index (PDI) of each sample are reported. Figure 3 was updated from: Figure 3: XPS spectra for bare SiO2 beads (SiO2), APTES functionalized SiO2 beads (APTES-SiO2), and poly(PFPA) grafted SiO2 beads (poly(PFPA)-SiO2). The peaks examined correspond to (a) Si 2p, (b) O 1s, (c) N 1s, and (d) F 1s. to: Figure 3: XPS spectra for bare SiO2 beads (SiO2), APTMS functionalized SiO2 beads (APTMS-SiO2), and poly(PFPA) grafted SiO2 beads (poly(PFPA)-SiO2). The peaks examined correspond to (a) Si 2p, (b) O 1s, (c) N 1s, and (d) F 1s. The first and second paragraphs of the Discussion were updated from: The synthesis of poly(PFPA) grafted SiO2 beads is illustrated in Figure 1. By employing APTES as a linker molecule, poly(PFPA) brushes covalently grafted to SiO2 substrate can be prepared via a simple two-step process. Although some of the PFP units are sacrificed for the reaction with APTES, a large number of the PFP units are expected to remain available for later reaction with either amino-PEG or antibodies. The PFP groups are known to form low energy surfaces so poly(PFPA) brushes do not solvate well in water<sup28</sup. For IP application, the antibodies need to be immobilized on the poly(PFPA) brushes, and this exchange reaction is done in aqueous buffer solution in order to preserve the activity of the antibodies. As reported in our previous publication, partial substitution of the PFP units with hydrophilic molecules such as amine-functionalized PEG can improve surface hydrophilicity, leading to increased antibody immobilization efficiency<sup18</sup. In this study, partially PEG substituted poly(PFPA) is also prepared, then grafted to the SiO2 surface using the same APTES linker molecule. Overall, the methods illustrated in Figure 1 allow the preparation of poly(PFPA) grafted surfaces with different degrees of PEG substitution. These polymer brushes with tunable surface properties provide an ideal platform for antibody immobilization and subsequent IP application. The bead preparation process is monitored by both DLS and XPS. The DLS results for various functionalized SiO2 beads in DMSO are summarized in Figure 2. The bare SiO2 beads exhibit hydrodynamic diameter of 666 nm, in agreement with the manufacturer reported bead size (0.676 μm; SD = 0.03 μm). After APTES treatment, the bead diameter increases to 740 nm; and with poly(PFPA) treatment, the bead diameter further increases to 1889 nm. It is important to point out that the polydispersity index (PDI) for the poly(PFPA) grafted beads is rather large (PDI = 0.76), which is indicative of poor quality sample containing large aggregates. Although the DLS curve only shows one nano-sized peak, small amount of aggregates may be present in the suspension. The functionalized SiO2 beads are also examined by XPS to determine surface composition (Figure 3). Following APTES treatment, N 1s peak associated with the amine groups on APTES is detected. And, following poly(PFPA) treatment, F 1s peak associated with the PFP units on the polymer is detected. Together these data show the successful functionalization of the SiO2 surface, first with APTES, then with poly(PFPA). to: The synthesis of poly(PFPA) grafted SiO2 beads is illustrated in Figure 1. By employing APTMS as a linker molecule, poly(PFPA) brushes covalently grafted to SiO2 substrate can be prepared via a simple two-step process. Although some of the PFP units are sacrificed for the reaction with APTMS, a large number of the PFP units are expected to remain available for later reaction with either amino-PEG or antibodies. The PFP groups are known to form low energy surfaces so poly(PFPA) brushes do not solvate well in water<sup28</sup. For IP application, the antibodies need to be immobilized on the poly(PFPA) brushes, and this exchange reaction is done in aqueous buffer solution in order to preserve the activity of the antibodies. As reported in our previous publication, partial substitution of the PFP units with hydrophilic molecules such as amine-functionalized PEG can improve surface hydrophilicity, leading to increased antibody immobilization efficiency<sup18</sup. In this study, partially PEG substituted poly(PFPA) is also prepared, then grafted to the SiO2 surface using the same APTMS linker molecule. Overall, the methods illustrated in Figure 1 allow the preparation of poly(PFPA) grafted surfaces with different degrees of PEG substitution. These polymer brushes with tunable surface properties provide an ideal platform for antibody immobilization and subsequent IP application. The bead preparation process is monitored by both DLS and XPS. The DLS results for various functionalized SiO2 beads in DMSO are summarized in Figure 2. The bare SiO2 beads exhibit hydrodynamic diameter of 666 nm, in agreement with the manufacturer reported bead size (0.676 μm; SD = 0.03 μm). After APTMS treatment, the bead diameter increases to 740 nm; and with poly(PFPA) treatment, the bead diameter further increases to 1889 nm. It is important to point out that the polydispersity index (PDI) for the poly(PFPA) grafted beads is rather large (PDI = 0.76), which is indicative of poor quality sample containing large aggregates. Although the DLS curve only shows one nano-sized peak, small amount of aggregates may be present in the suspension. The functionalized SiO2 beads are also examined by XPS to determine surface composition (Figure 3). Following APTMS treatment, N 1s peak associated with the amine groups on APTMS is detected. And, following poly(PFPA) treatment, F 1s peak associated with the PFP units on the polymer is detected. Together these data show the successful functionalization of the SiO2 surface, first with APTMS, then with poly(PFPA).

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Tetrafluoroethylene is used in the production of polytetrafluoroethylene (Teflon(R)) and other polymers. Tetrafluoroethylene was nominated by the National Cancer Institute for toxicity and carcinogenicity studies based on the potential for human exposure to the chemical due to the large production volume and on the lack of adequate data for tetrafluoroethylene in the literature. Male and female F344/N rats and B6C3F1 mice were exposed to tetrafluoroethylene (98% to 99% pure) by whole body inhalation exposure for 16 days, 13 weeks, or 2 years. Genetic toxicity studies were conducted in mouse peripheral blood erythrocytes. 16-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were exposed to 0, 312, 625, 1,250, 2,500, or 5,000 ppm tetrafluoroethylene by inhalation for 6 hours per day, 5 days per week for a total of 12 exposures during a 16-day period. All rats survived to the end of the study. The final mean body weights and body weight gains of males and females exposed to 5,000 ppm were significantly less than those of the controls. The mean body weight gain of females exposed to 2,500 ppm was also significantly less than that of the controls. There were no exposure-related clinical findings in male or female rats. There were no significant differences in hematology parameters that were considered to be related to tetrafluoroethylene exposure. Absolute and relative kidney weights of all exposed groups of males were significantly greater than those of the controls, as were those of females in the 2,500 and 5,000 ppm groups. The absolute kidney weight of females exposed to 1,250 ppm was also significantly greater than that of the controls. The relative liver weights of all exposed groups of males and the absolute liver weights of males in the 625 and 2,500 ppm groups were significantly greater than those of the controls. Increased incidences of renal tubule degeneration occurred in males and females exposed to 625 ppm or greater; this lesion was located predominantly at the corticomedullary junction. The severity of degeneration increased with increasing exposure concentration and was slightly greater in males than females. 16-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were exposed to 0, 312, 625, 1,250, 2,500, or 5,000 ppm tetrafluoroethylene by inhalation for 6 hours per day, 5 days per week for a total of 12 exposures during a 16-day period. All mice survived to the end of the study. Final mean body weights and body weight gains of all exposed groups of mice were similar to those of the controls. There were no exposure-related clinical findings in male or female mice. There were no significant differences in hematology parameters that were considered to be related to tetrafluoroethylene exposure. The absolute and relative liver weights of females exposed to 5,000 ppm were significantly greater than those of the controls, as was the absolute kidney weight of females in that group and the absolute liver weight of females in the 2,500 ppm group. Renal tubule karyomegaly was observed in male and female mice in the 1,250, 2,500, and 5,000 ppm groups, and the severity of this lesion increased with increasing exposure concentration. Karyomegaly was located predominantly in the inner renal cortex. 13-WEEK STUDY IN RATS: Groups of 10 male and 9 or 10 female F344/N rats were exposed to 0, 312, 625, 1,250, 2,500, or 5,000 ppm tetrafluoroethylene by inhalation for 6 hours per day, 5 days per week, for 13 weeks. All rats survived to the end of the study. The final mean body weight and body weight gain of males exposed to 5,000 ppm were significantly less than those of the controls, as was the mean body weight gain of females in this exposure group. There were no clinical findings attributed to exposure to tetrafluoroethylene. Exposure of rats to tetrafluoroethylene resulted in a concentration-dependent normocytic, normochromic, nonresponsive anemia consistent with a secondary hypoproliferative anemia. An exposure concentration-dependent proteinuria also occurred, consistent with renal tubule th renal tubule degeneration observed histopathologically. The absolute and relative liver weights of all exposed groups of males and of females in the 5,000 ppm group were significantly greater than those of the controls. The absolute and relative right kidney weights of males and females exposed to 1,250 ppm or greater and of females in the 625 ppm group were also significantly greater than those of the controls. There were no differences in sperm morphology or vaginal cytology parameters between control and exposed groups of rats. Incidences of renal tubule degeneration in males exposed to 625 ppm or greater and in females exposed to 2,500 or 5,000 ppm were significantly greater than those in the controls. Renal lesions were similar to those observed in the 16-day study and were located predominantly at the corticomedullary junction. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were exposed to 0, 312, 625, 1,250, 2,500, or 5,000 ppm tetrafluoroethylene by inhalation for 6 hours per day, 5 days per week, for 13 weeks. All mice survived to the end of the study. Final mean body weights and body weight gains of all exposed groups of male and female mice were generally similar to those of the controls. There were no clinical findings that were considered to be related to tetrafluoroethylene exposure. Exposure of mice to tetrafluoroethylene resulted in a concentration-dependent normocytic, normochromic, nonresponsive anemia, consistent with a secondary hypoproliferative anemia, and in polyuria. Differences in sperm morphology parameters and estrous cycle lengths were not considered to be exposure related. Incidences of karyomegaly of the renal tubule epithelial cells in male and female mice exposed to 1,250 ppm or greater were significantly greater than those in the controls. Karyomegaly was similar to that observed in the 16-day study and was observed primarily in the inner renal cortex. 2-YEAR STUDY IN RATS: Groups of 60 male rats were exposed to 156, 312, or 625 ppm and groups of 60 female rats were exposed to 312, 625, or 1,250 ppm tetrafluoroethylene by inhalation for 6 hours per day, 5 days per week, for 104 weeks, with an observation period of 11 days following the final exposure. Ten male and ten female rats from each exposure group were evaluated at 15 months for organ weights and clinical pathology. Survival, Body Weights, and Clinical Findings: Survival rates of males in the 625 ppm group and of all exposed groups of females were significantly less than those of the controls. Mean body weights of males exposed to 625 ppm were lower than those of the controls from week 81 until the end of the study, and the mean body weight of 1,250 ppm females was slightly lower than that of the controls at the end of the study. The only clinical finding associated with exposure to tetrafluoroethylene was opacity of the eyes in exposed groups of female rats; this change was observed microscopically as cataracts. Hematology, Clinical Chemistry, and Urinalysis: At the 15-month interim evaluation, there were no differences in hematology, clinical chemistry, or urinalysis parameters that were considered to be related to tetrafluoroethylene exposure. Pathology Findings: The absolute and relative kidney weights of males exposed to 625 ppm and females exposed to 1,250 ppm and the absolute kidney weight of females exposed to 625 ppm were significantly greater than those of the controls at the 15-month interim evaluation. At 15 months, renal tubule hyperplasia was observed in one male exposed to 312 ppm and one male and one female exposed to 625 ppm; oncocytic hyperplasia was observed in one female exposed to 1,250 ppm. At the end of the study, incidences of renal tubule adenoma were greater in males and females exposed to 312 ppm or greater than those in the controls. This exposure-related increase was confirmed by examination of step sections (extended evaluations). At the end of the study, the incidences of renal tubule hyperplasia in males exposed to 625 ppm and females exposed to 1,250 ppm were significantly greater than those in the controls. The incidences of renal tubule adenoma and renal tubule adenoma or carcinoma (combined) in the extended evaluations and in the standard and extended evaluations (combined) in the 1,250 ppm female group and the 625 ppm male group were significantly greater than those in the controls, and the incidences occurred with significant positive trends. Oncocytic hyperplasia was observed at the end of the study in one male exposed to 312 ppm and in three females exposed to 1,250 ppm. At 15 months and at the end of the study, the incidences of renal tubule degeneration in all exposed groups of males and in females in the 625 and 1,250 ppm groups were greater than those in the controls. Renal tubule degeneration was similar to that observed in the 13-week study and was located predominantly at the corticomedullary junction. The severity of nephropathy generally increased with increasing exposure concentration in male rats at 15 months and 2 years. The absolute and relative liver weights of females in the 1,250 ppm group and the absolute liver weight of females exposed to 625 ppm were significantly greater than those of the controls at the 15-month interim evaluation. At 2 years, the incidences of hepatocellular carcinoma and hepatocellular adenoma or carcinoma (combined) in males exposed to 312 ppm, the incidences of hepatocellular adenoma and adenoma or carcinoma (combined) in females in all exposed groups, and the incidences of hepatocellular carcinoma in females exposed to 312 or 625 ppm were significantly greater than those in the controls. Also at 2 years, the incidence of hemangiosarcoma in females exposed to 625 ppm was significantly greater than that in the controls. In all exposed groups of males, the incidences of clear cell foci at 15 months were greater than those in the controls; at 2 years, the incidences of eosinophilic foci in all exposed groups of males and the incidences of basophilic and mixed cell foci in males in the 312 and 625 ppm groups were greater than those in the controls. The incidences of mixed cell foci at 15 months in females exposed to 625 or 1,250 ppm and at 2 years in females exposed to 1,250 ppm were also significantly greater than those in the controls. At the end of the 2-year study, increased incidences of cystic degeneration occurred in the liver of all exposed groups of males, and increased incidences of hepatic angiectasis were observed in exposed groups of females. Incidences of mononuclear cell leukemia in males exposed to 156 ppm and in all exposed groups of females were significantly greater than those in the controls. Incidences of cataracts in females exposed to 1,250 ppm were greater than those in the controls at the end of the 2-year study. At the end of the study, there were slight increases in the incidences of testicular interstitial cell adenoma in rats exposed to 312 or 625 ppm. 2-YEAR STUDY IN MICE: Groups of 58 male and 58 female B6C3F1 mice were exposed to 0, 312, 625, or 1,250 ppm tetrafluoroethylene by inhalation for 6 hours per day, 5 days per week, for 95 to 96 weeks. Ten male and ten female mice from each exposure group were evaluated at 15 months for organ weights. Survival, Body Weights, and Clinical Findings: The survival rates of all exposed groups of males and females were significantly less than those of the controls. Because of the reduced survival due to exposure-related liver neoplasms, the study was terminated during week 96. Mean body weights of exposed groups of males and females were generally similar to those of the controls, except at the end of the study, when they were somewhat less than those of the controls. There were no clinical findings related to tetrafluoroethylene exposure. Pathology Findings: At the 15-month interim evaluation, there were no differences in absolute or relative kidney, liver, or lung weights between exposed and control groups of mice. At the end of the study, the incidences of multifocal coagulative necrosis of the liver were increased in males in the 625 and 1,250 ppm groups. Also at the end of the study, females in all exposed groups had greater incidences of hematopoietic cell proliferation in the liver than the controls. Angiectasis occurred in all exposed groups of males and females at 15 months and at the end of the study. At the 15-month interim evaluation, hemangiosarcomas were observed in three males exposed to 1,250 ppm and in one female exposed to 312 ppm. The incidences of hemangiosarcoma in all exposed groups of males and females at the end of the study were significantly greater than those in the controls and exceeded the historical chamber control ranges. Also at the end of the study, the incidences of hemangioma in males and females exposed to 312 ppm and in males exposed to 625 ppm were also significantly greater than those in the controls and exceeded the range in historical chamber controls. At 15 months, hepatocellular adenomas and carcinomas occurred in control males and all exposed groups of males and females. Females exposed to 625 or 1,250 ppm had significantly greater incidences of eosinophilic foci than the controls at the 15-month interim evaluation. At the end of the study, the incidences of eosinophilic foci in males exposed to 625 or 1,250 ppm and in females exposed to 312 or 625 ppm were significantly greater than those in the controls. In male and female mice, increased incidences of a variety of hepatocellular neoplasms, including adenomas, multiple adenomas, carcinomas, and multiple carcinomas, were considered related to tetrafluoroethylene exposure. At the end of the study, the incidences of histiocytic sarcoma (all organs) in all exposed groups of males and females were significantly greater than those in the controls and exceeded the historical control ranges for all organs. The greatest incidences of histiocytic sarcomas were observed in the liver and lung, but these neoplasms were also observed in the spleen, lymph nodes, bone marrow, and kidney. Significantly increased incidences of renal tubule dilatation (males) and karyomegaly (males and females), located predominantly in the inner cortex, were observed in mice exposed to 625 or 1,250 ppm at 15 months. At the end of the study, the increased incidences of dilatation and karyomegaly in all exposed groups of males and of karyomegaly in 1,250 ppm females were generally significant. Incidences of hematopoietic cell proliferation in the spleen of all exposed groups of males and females were significantly greater than those in the controls at the end of the study. Additionally, the severity of this lesion increased with increasing exposure concentration. GENETIC TOXICOLOGY: No increases in the frequency of micronucleated erythrocytes were observed in peripheral blood samples obtained from male and female mice at the end of the 13-week inhalation study of tetrafluoroethylene. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was clear evidence of carcinogenic activity of tetrafluoroethylene in male F344/N rats based on increased incidences of renal tubule neoplasms (mainly adenomas) and hepatocellular neoplasms. There was clear evidence of carcinogenic activity of tetrafluoroethylene in female F344/N rats based on increased incidences of renal tubule neoplasms, liver hemangiosarcomas, hepatocellular neoplasms, and mononuclear cell leukemia. There was clear evidence of carcinogenic activity of tetrafluoroethylene in male and female B6C3F1 mice based on increased incidences of liver hemangiomas and hemangiosarcomas, hepatocellular neoplasms, and histiocytic sarcomas. Slight increases in the incidences of mononuclear cell leukemia and testicular interstitial cell adenomas in male rats may have been related to exposure to tetrafluoroethylene. Exposure of rats to tetrafluoroethylene resulted in increased incidences of renal tubule hyperplasia and degeneration in males and females, increased severity of kidney nephropathy in males, and increased incidences of liver angiectasis and cataracts in females. Exposure of mice to tetrafluoroethylene resulted in increased incidences of hematopoietic cell proliferation of the liver in females, liver angiectasis in males and females, renal tubule dilatation in males, renal tubule karyomegaly in males and females, and splenic hematopoietic cell proliferation in males and females. Synonyms: Perfluoroethylene; tetrafluoroethene; 1,1,2,2-tetrafluoroethylene; TFE

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More than 60 years of biochemical and biophysical studies have accustomed us to think of proteins as highly purified entities that act in isolation, more or less freely diffusing until they find their cognate partner to bind to. While in vitro experiments that reproduce these conditions largely remain the only way to investigate the intrinsic properties of molecules, this approach ignores an important factor: in their natural milieu , proteins are surrounded by several other molecules of different chemical nature, and this crowded environment can considerably modify their behaviour. About 40% of the cellular volume on average is occupied by all sorts of molecules. Furthermore, biological macromolecules live and operate in an extremely structured and complex environment within the cell (endoplasmic reticulum, Golgi apparatus, cytoskeletal structures, etc). Hence, to further complicate the picture, the interior of the cell is by no means a simply crowded medium, rather, a most crowded and confining one. In recent times, several approaches have been developed in the attempt to take into account important factors such as the ones mentioned above, at both theoretical and experimental levels, so that this field of research is now emerging as one of the most thriving in molecular and cell biology (see figure 1). [Formula: see text] Figure 1. Left: number of articles containing the word 'crowding' as a keyword limited to the biological and chemical science domains (source: ISI Web of Science). The arrow flags the 2003 'EMBO Workshop on Biological Implications of Macromolecular Crowding' (Embo, 2012). Right: number of citations to articles containing the word 'crowding' limited to the same domains (bars) and an exponential regression curve (source: Elsevier Scopus). To promote the importance of molecular crowding and confinement and provide researchers active in this field an interdisciplinary forum for meeting and exchanging ideas, we recently organized an international conference held in Ascona from 10 to 14 June 2012. In the unique scenario of the Maggiore lake and absorbed in the magic atmosphere of the Centro Stefano Franscini (CSF) at Monte Verità, we enjoyed three-and-a-half days of intense and inspiring activity, where not only many of the most prominent scientists working on macromolecular crowding, but also experts in closely related fields such as colloids and soft matter presented their work. The meeting was intended and has been organized to bring theoreticians and experimentalists together in the attempt to promote an active dialogue. Moreover, we wanted different disciplines to be represented, notably physics and chemistry, besides biology, as cross-fertilization is proving an increasingly fundamental source of inspiration and advancement. This issue of Physical Biology (PB) features a selection of the oral contributions presented at the conference, expanded in the form of research or review articles. PB, one of the scientific journals of the Institute of Physics (IOP), is one of the most dynamic and lively forums active at the interface between biology on one side, and physics and mathematics on the other. As its mission is stated by IOP, PB 'focuses on research in which physics-based approaches lead to new insights into biological systems at all scales of space and time, and all levels of complexity'. For these reasons, and also in view of its high reputation and broad readership, PB appears to be the ideal place for disseminating the thriving pieces of research presented at the conference. We are extremely grateful to PB and its kind and efficient editorial staff who helped make this issue a great scientific follow-up to the conference. The opening lecture of the conference, the first of four day-opening keynote lectures, was given by Allen P Minton from NIH (USA), possibly the most influential among the pioneers in the field. He provided a lucid and well-thought-out overview of the concept of macromolecular crowding through an exhaustive chronological account of the major milestones. It is clear that the concept of excluded volume as a key factor remains central to the concept of molecular crowding. As a consequence, simple descriptive paradigms borrowed essentially from colloid physics may still provide useful tools to understand the subtle effects of crowding and confinement in living matter. The contiguity between crowding, colloids and soft matter further emerged as an important concept in the course of the conference in several theoretical lectures and a few experimental ones. Dave Thirumalai, from the University of Maryland (USA), one of the most active theoreticians in the field of theoretical biophysics, outlined scaling theories, concepts from colloid literature and different simulation techniques to describe scenarios for crowding-induced changes in the structure and dynamics of proteins and RNA. In particular, he showed the importance of the shape of crowding particles in affecting folding oligomerization of amyloidogenic peptides. Johannes Schöneberg, from IMPRS, Mathematics Institute (Germany), illustrated ReaDDy , a newly developed particle-based simulation software tool for reaction-diffusion dynamics, developed in the group of Frank Noe at EMPRS. He showed that ReaDDy makes it possible to bridge the gap between soft matter and molecular dynamics (MD) simulations on the one hand and particle-based stochastic reaction-diffusion simulations on the other. We asked Johannes to organize a tutorial session to lead interested participants into the package and 'get their hands wet' under the guidance of the developers. The tutorial session was indeed successful and the broad possibilities offered by the simulation toolkit appeared to be clear to the participants. Paolo De Los Rios, from the Ecole Polytechnique Fédérale de Lausanne (EPFL, Switzerland), examined the complexity of the effects caused by crowding conditions from the point of view of statistical physics. Starting from a modification of the well-known Smoluchowski approach to calculate the encounter rate of diffusion-limited reactions, he showed how more realistic situations accounting for crowding effects could be treated equally well on the same theoretical grounds. This talk marked an important point in the conference as it reinforced the idea that simple models of theoretical physics still have the power to provide inspiring results in spite of the intrinsic simplifications of such theoretical approaches. Along the same lines, Nicolas Dorsaz, from the University of Cambridge (UK), proposed an extension of the Smoluchowski framework that incorporates repulsive and attracting interactions between the reactants. This approach was illustrated by reaction rates obtained from event-driven Brownian dynamics and dynamical Monte Carlo simulations. Another striking example of the physical subtleties associated with modelling crowding effects was provided by Jeffrey Skolnick, from the Georgia Institute of Technology (USA). He examined the role of hydrodynamic interactions in the self-organization of biological assemblies in the presence of crowding. His results strongly suggest that hydrodynamic interactions greatly affect the kinetics of self-assembly reactions, so that including them in the picture appears crucial for understanding the dynamics of biological systems in vivo . Margareth Cheung, from the University of Houston (USA), emphasized that how the crowded environment inside a cell affects the structural conformation of a protein with a spherical shape is a vital question because the geometry of proteins and protein-protein complexes are far from globules in vivo . Her work demonstrates the malleability of 'native' proteins and implies that crowding-induced shape changes may be important for protein function and malfunction in vivo . Huan-Xiang Zhou, from the Florida State University (USA), focused on atomistic simulations of protein folding and binding under crowding conditions. His lab has developed a post-processing method that allows the atomistic representation of proteins in folding and binding processes under crowding. A comparison with experimental results was also presented. Other lecturers pointed out that there are still aspects not entirely explored in the effects of both crowding and confinement. As suggested in the talk by Gary Pielak, from the University of North Carolina (USA), the currently used synthetic crowding agents are far from being satisfactory in replicating naturally occurring effects associated with crowded environments. For example, non-specific binding seems to play a subtle role in the cell, as natural macromolecules can induce both stabilization and destabilization when used as crowders. It is indeed possible to fine-tune the effect of proteins, as crowders, on the stability of other proteins. Another aspect that became clear is that new, more powerful methods need to be developed to study the effect of crowding, but even more to compare crowding and confinement. Indeed, it appeared clear from the lecture by Pierandrea Temussi, from the University of Naples (Italy), that a reliable comparison of the effects of crowding and confinement on the stability of proteins can only be based on the measurement of the whole stability curve of the same protein. Controversial aspects do not pertain only to the influence of crowding on protein stability, but also to aggregation phenomena in natural fluids. Domenico Sanfelice, from NIMR (London, UK), reported an interesting case of the apparent influence of crowding on aggregation. Hen egg white, a possible natural medium to study macromolecules in crowded conditions can dramatically increase the aggregation kinetics of proteins with an inbuilt tendency to associate. By carefully dissecting the phenomenology, it was shown that only part of this effect is due to crowding, while another factor playing an important role is the interaction with proteins from the milieu . In other words, high-molecular-weight glycoproteins can act as efficient molecular seeds for aggregation. A special topic of great relevance in the conference appeared to be the direct study of crowding in living systems. Alan Verkman, from the University of California, San Francisco (USA), one of the world's leading scientific personalities in the field of experimental investigation of crowding and confinement, was invited to give the second plenary lecture devoted to the experimental study of crowding effects in vivo . In his keynote lecture, Dr Verkman led us on a wide and compelling tour, exploring the main experimental approaches to study molecular crowding in and around cells. After a thorough examination of methods such as fluorescence recovery after photo-bleaching, fluorescence correlation spectroscopy, photo-activation localization microscopy and stochastic reconstruction microscopy, he concluded that the general consensus emerging from experimental studies is that the notion of universally anomalous diffusion in and around cells as a consequence of molecular crowding may not be correct, and that the slowing of diffusion in cells is less marked than has been widely assumed and can be simply described through a five- to sixfold reduction of the normal diffusion coefficient. A Soranno, from the University of Zürich (Switzerland), described how, by employing FRET measurements, it is possible to quantify the effect of molecular crowding on the dimensions of the highly charged, intrinsically disordered protein human prothymosin alpha. For a large variety of polymeric crowders (PEG, PVP, Ficoll, Dextran, PVA, PAA), a collapse of the polypeptide chain is observed with increasing polymer size and polymer concentration. The largest extent of collapse is observed for polymer radii comparable to the dimensions of the protein, in agreement with theoretical considerations. For his contribution, A Soranno was awarded the CSF Award for the best contributed talk. In his most inspiring talk, Clifford Brangwynne, from Princeton University (USA), drew attention to very important objects, namely Ribonucleoprotein (RNP) bodies. These are non-membrane-bound macromolecular assemblies that form from the dynamic interactions of RNA and proteins. The assembly of RNP bodies may sensitively depend on the biophysical features of the surrounding cytoplasm, including the degree of crowding, transport coefficients and mechanical properties. This dependency may have important implications for the RNA processing reactions involved in fundamental biological processes such as developmental cell growth. Remarkably, Brangwynne showed how RNPs behave in the cell as liquid droplets, pointing to a possible entirely new means that the cell could use to control and fine-tune its internal processes, in fact, more than that, a completely unexplored, new state of organization of living matter, and a functional one. Giuseppe Zaccai, from Institut Laue Langevin, Grenoble (France), showed that protein dynamics is more sensitive than structure to environmental factors such as crowding, solvent, temperature or pressure. Furthermore, he convincingly explained how neutron scattering provides unique experimental data to underpin MD calculations in this context. Following up on environment-induced modulations of protein functional dynamics, Ruth Nussinov, from Tel Aviv University (Israel), addressed the important problem of whether cellular signals can travel long distances in a crowded environment. She proposed a model based on the evolution of at least three properties: a modular functional organization of the cellular network, sequences in some key regions of proteins, such as linkers or loops, and compact interactions between proteins, possibly favoured by a crowded environment. The workshop ended on a keynote lecture by Jean-Marie Lehn, from the Université de Strasbourg (France). Lehn, 1987 Nobel Laureate in chemistry, offered a 'supramolecular view' of the field of molecular interactions. Supramolecular chemistry explores the design of systems undergoing self-organization , i.e. systems capable of generating well-defined functional supramolecular architectures by self-assembling from their components, thus behaving as programmed chemical systems . Chemistry may therefore be considered an information science , the science of informed matter. Supramolecular chemistry is intrinsically a dynamic chemistry in view of the ability of the interactions connecting the molecular components of a supramolecular entity and the resulting ability of supramolecular species to exchange their constituents. The same holds for molecular chemistry when the molecular entity contains covalent bonds that may form and break reversibly, so as to allow a continuous change in constitution by the reorganization and exchange of building blocks. These features define a constitutional dynamic chemistry (CDC) on both the molecular and supramolecular levels. CDC takes advantage of dynamic constitutional diversity to allow variation and selection in response to either internal or external factors to achieve adaptation . The merging of the features-information and programmability, dynamics and reversibility, constitution and structural diversity-points towards the emergence of adaptive and evolutive chemistry . The whole workshop could have not taken place without the help of the Centro Stefano Franscini. The CSF is the congress centre of the Swiss Federal Institute of Technology of Zurich (ETH Zurich) and has been situated at Monte Verità since 1989. It is an ideal meeting point for all members of the international scientific community who wish to discuss the state-of-the-art and new challenges of any field of research. The CSF supports 20-25 international conferences every year and, since 2010, up to ten winter doctoral schools<sup1</sup. The competence and professionalism of the staff were at the same level of beauty and inspiring character as that of Monte Verità. A meeting of this sort, if successful, leaves the audience with more open questions than settled answers, and this was definitely the case for Crowding 2012. Excluded volume is clearly a fundamental concept that has allowed crowding, a very familiar concept in soft matter, to enter into the domain of biological sciences. However, the complexity of the biological milieu calls for more refined descriptions. What is the role of electrostatic and electrodynamic interactions? What is the role of hydrodynamics interactions? To what extent does the strong spatial inhomogeneity (clustering of molecules, cellular compartmentalization, etc) have to be taken into account? Or, more generally, what are the minimal elements that prove crucial to describe reactions within a cell? How does the diffusion proceed (diffusion, slow diffusion, sub-diffusion) given that the experimental evidences are still controversial? In conclusion, we knew that allowing scientists with very different backgrounds and ideas to mingle was a hazardous attempt. Despite that, the workshop turned out to be a very successful experiment, which was highly enjoyed both by the participants and the organizers. Discussions sparked regularly among ever-changing groups, comprising senior scientists and students, despite the rather tight schedule, adding to the sense of fulfilment ignited by the outstanding level of the presentations. Given the success of the meeting Crowding 2012, a new event has been organized and will take place on the same themes during fall 2013, this time in the beautiful scenery of the Loire valley in France. The workshop 'Macromolecular crowding effects in cell biology: models and experiments' will be held on the CNRS campus in Orléans, France, on 24-25 October 2013. More information can be found on the workshop website: http://dirac.cnrs-orleans.fr/∼piazza/. <sup1</supSource: www.csf.ethz.ch/

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1-Amino-2,4-dibromoanthraquinone is an anthraquinone-derived vat dye, a member of a class of insoluble dyes that are impregnated into textile fibers. Five anthraquinone-derived dyes with representative and diverse structures, as well as the parent chemical, anthraquinone, were selected for NTP Toxicology and Carcinogenesis evaluation. Similar to the benzidine dye initiative, the rationale for selecting these vat dyes was to generate sufficient toxicologic data to permit more reliable predictions of carcinogenicity to be made on other chemicals in this class, thereby eliminating or reducing the need to study every anthraquinone dye. 1-Amino-2,4-dibromoanthraquinone is the last anthraquinone-derived dye in this group to be studied. Groups of male and female F344/N rats and B6C3F1 mice were exposed to 1-amino-2,4-dibromoanthraquinone (87% to 97% pure) for 13 weeks or for 9, 15, or 24 months. Because 1-amino-2,4-dibromoanthraquinone was predicted to be carcinogenic, these studies were designed to evaluate the potential for tumor progression and regression. Absorption and excretion studies were carried out in male F344/N rats. Genetic toxicity was determined in vitro using Salmonella typhimurium and cultured Chinese hamster ovary cells. Extensive chemical analyses were performed to identify and characterize impurities of the 1-amino-2,4-dibromoanthraquinone used in these studies. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were given 0, 2,500, 5,000, 10,000, 25,000, or 50,000 ppm 1-amino-2,4-dibromoanthraquinone in feed for 13 weeks. These levels correspond to approximately 150 to 3,200 mg 1-amino-2,4-dibromoanthraquinone/kg body weight per day for males and to approximately 170 to 3,200 mg/kg for females. Chemical-related mortality was limited to one male and one female in the 50,000 ppm groups. Final mean body weights and body weight gains of all exposed groups of rats were significantly lower than those of the controls. Feed consumption by all exposed groups was less than that by the controls throughout the study and generally decreased with increasing exposure concentration. Pink-red staining of the fur and tail was observed in all exposed groups. Absolute and relative liver weights of all exposed groups were generally significantly greater than those of the controls. Chemical-related lesions were present in the liver, kidney, and spleen of male and female rats. Nonneoplastic lesions in the liver included foci of hepatocellular alteration, diffuse hepatocellular hypertrophy (cytomegaly), hepatocellular cytoplasmic vacuolation, bile duct hyperplasia, inflammation, and pigmentation. These differences were observed primarily in the 25,000 and 50,000 ppm groups of males and females; the spectrum of proliferative lesions of the bile ducts (hyperplasia, fibrosis, and necrotizing cholangitis) in the 25,000 and 50,000 ppm groups was morphologically consistent with the lesion described as cholangiofibrosis. Pigmentation was present in the renal tubule epithelium of all groups of exposed rats; nuclear enlargement (karyomegaly) was also present in the renal tubule epithelium in some of the exposed rats. Accumulation of hyaline droplets in the cytoplasm of the renal tubule epithelium and tubule lumina was present in 2,500, 5,000, 10,000, and 25,000 ppm males. Incidences of hematopoiesis of the spleen in exposed groups of males and females were increased compared to those in the controls. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were given 0, 2,500, 5,000, 10,000, 25,000, or 50,000 ppm 1-amino-2,4-dibromoanthraquinone in feed for 13 weeks. These levels correspond to approximately 500 to 10,600 mg 1-amino-2,4-dibromoanthraquinone/kg body weight per day for males and approximately 660 to 11,700 mg/kg per day for females. There was no chemical-related mortality. Feed consumption and final mean body weights of exposed groups were similar to those of the controls. Red staining of the fur was observed in all exposed groups. Absolute and relative liver weights of the exposed groups were greater than those er than those of the controls except for the absolute liver weight of 2,500 ppm males. Absolute and relative kidney weights of 25,000 and 50,000 ppm males were lower than those of the controls. Chemical-related lesions were limited to the livers of males and consisted of pigmentation of hepatocytes at all exposure concentrations and centrilobular hepatocellular hypertrophy at 10,000, 25,000, and 50,000 ppm. Minimal pigment was present in the liver of one female in the 25,000 ppm group and in one female in the 50,000 ppm group. 2-YEAR STUDY IN RATS: Groups of 70 male and 70 female rats were given 0, 5,000, or 10,000 ppm 1-amino-2,4-dibromoanthraquinone in feed for 103 weeks. In addition, groups of 50 male and 50 female rats were given 2,000 ppm 1-amino-2,4-dibromoanthraquinone in feed for 104 weeks. These exposure concentrations were approximately equal to 90, 240, or 490 mg 1-amino-2,4-dibromoanthraquinone/kg body weight for males and 110, 285, or 600 mg/kg for females. Ten animals from each group were evaluated for histopathology at 9 months. Additional groups of 10 animals from the 0 and 10,000 ppm groups were evaluated for histopathology at 15 months. Survival, Body Weights, Feed Consumption, and Clinical Findings In the 2-year study, survival of the 10,000 ppm males and females was significantly lower than that of the controls. Survival of the 2,000 and 5,000 ppm groups was similar to that of the controls. During the last year of the study, the mean body weights of exposed males were 80&amp;percnt; to 91&amp;percnt; those of controls, and the mean body weights of exposed females were 67&amp;percnt; to 84&amp;percnt; those of controls. Feed consumption among exposed groups was generally similar, but was less than that by controls. The fur and urine of all exposed male and female groups were discolored. Pathology Findings In the 2-year study, 1-amino-2,4-dibromoanthraquinone was associated with significant chemical-related increases in the incidences of benign and malignant neoplasms in the liver, large intestine, kidney, and urinary bladder of males and females. Chemical-related nonneoplastic proliferative and degenerative lesions occurred in the liver, kidney, urinary bladder, and forestomach of males and females. The incidences of foci of hepatocellular alteration and pigmentation in the liver of males and females were increased at the 9-month interim evaluation, and a hepatocellular adenoma was present in one 5,000 ppm male. At the 15-month interim evaluation, hepatocellular adenoma or carcinoma (combined) occurred in all males and nine females in the 10,000 ppm groups. By the end of the 2-year study, hepatocellular adenoma, carcinoma, cholangioma, or cholangiocarcinoma were observed in males and females in the 5,000 and 10,000 ppm groups. In the 2,000 ppm groups, similar liver neoplasms were present in 63&amp;percnt; of the males and in 83&amp;percnt; of the females. Of the hepatocellular carcinomas in the 5,000 and 10,000 ppm groups of males and females, 31&amp;percnt; to 49&amp;percnt; were metastatic to the lungs or other sites. Increases in the incidences of foci of hepatocellular alteration (basophilic, eosinophilic, and clear cell) and pigmentation of the liver were also observed in exposed groups of males and females. Adenomatous polyps (adenoma) of the large intestine were present in six 10,000 ppm males at the 15-month interim evaluation. Incidences of adenomatous polyp (adenoma) and carcinoma of the large intestine were significantly increased in exposed groups of males and females after 2 years; multiple benign and malignant intestinal neoplasms were observed in many of these rats. In the kidney, incidences of renal tubule adenoma and carcinoma were significantly increased in exposed groups of males and females after 2 years. Renal tubule adenomas were present in two 10,000 ppm males at 15 months. There were also chemical-related increases in the incidences and severities of renal tubule epithelial hyperplasia, pigmentation, and transitional cell hyperplasia in the kidney of males and females. Hyaline droplet accumulation was present in all exposed male rats at 9 months. Incidences of transitional cell papilloma and carcinoma of the urinary bladder were increased at 2 years in males and females in the 10,000 ppm groups. Transitional cell hyperplasia was observed in exposed males and females at the 15-month interim evaluation. Other nonneoplastic lesions observed in the urinary bladder at 2 years included metaplasia of the transitional epithelium and submucosal stromal tissue. In the forestomach, the incidences and severities of inflammation, ulceration, hyperkeratosis, and hyperplasia of the squamous mucosa were increased in all exposed groups of males and females at 2 years, but not at the 9- or 15-month interim evaluations. In exposed males and females, the incidences of mononuclear cell leukemia were significantly decreased. The incidences of atrophy of the seminal vesicle were increased in exposed male rats in the 2-year study. Stop-Exposure Evaluation in Rats Groups of 40 male and 40 female rats were given 20,000 ppm 1-amino-2,4-dibromoanthraquinone in feed for 9 or 15 months. At 9 months, 10 males and 10 females were evaluated for histopathology (9-month interim evaluation groups). After 9 months of exposure, an additional 10 males and 10 females were fed control diet until the end of the 15-month evaluation (9-month stop-exposure groups), and 20 males and 20 females continued to receive 20,000 ppm 1-amino-2,4-dibromoanthraquinone until the end of the evaluation (15-month exposure groups). The approximate daily consumption of 1-amino-2,4-dibromoanthraquinone was 1,335 mg/kg for males and 1,790 mg/kg for females in the 9-month stop-exposure groups and 1,115 mg/kg for males and 1,435 mg/kg for females in the 15-month exposure groups. Survival was similar among groups except for the females in the 15-month exposure group; the survival of this group was lower than that of the controls. Lower mean body weights were related to increased exposure duration. The mean body weights of exposed males were 76&amp;percnt; to 82&amp;percnt; that of controls, and the mean body weights of exposed females were 73&amp;percnt; to 84&amp;percnt; that of controls. For the stop-exposure evaluation, similar chemical-related neoplasms and nonneoplastic lesions were observed in the same sites as in the 2-year study: liver, large intestine, kidney, urinary bladder, and forestomach. After 9 months of dietary exposure to a concentration of 20,000 ppm 1-amino-2,4-dibromoanthraquinone, hepatocellular adenoma and carcinoma occurred in males and females. Nonneoplastic chemical-related lesions in the liver of exposed rats included pigmentation, focal hepatocellular alteration, and bile duct hyperplasia. Neoplasms at other sites in males included one adenomatous polyp (adenoma) in the large intestine and one transitional cell papilloma in the urinary bladder. Hyaline droplet accumulation was present in the kidney of exposed males at 9 months. In the stop-exposure groups examined at 15 months, hepatocellular adenoma and carcinoma were present in most males and females. Adenomatous polyp (adenoma) of the colon, renal tubule cell adenoma, and urinary bladder transitional cell papilloma and carcinoma also occurred in males and females. Nonneoplastic chemical-related lesions included foci of hepatocellular alteration in the liver and hyperplasia of the renal tubule epithelium and urinary bladder transitional epithelium. Hyperplasia, hyperkeratosis, inflammation, and ulceration were observed in the forestomach of some male and female rats continuously exposed for 15 months. 2-YEAR STUDY IN MICE: Groups of 60 male and 60 female mice were given 0, 10,000, or 20,000 ppm 1-amino-2,4-dibromoanthraquinone in feed for 104 weeks. The daily compound consumption was approximately 1,690 or 3,470 mg 1-amino-2,4-dibromoanthraquinone/kg body weight for males and 1,950 or 4,350 mg/kg for females. Ten animals from each group were evaluated for histopathology at 15 months. Survival, Body Weights, Feed Consumption, and Clinical Findings In the 2-year study, survival of exposed males was significantly lower than that of the controls. Survival of exposed females was similar to that of the controls. The final mean body weights of exposed males were 83&amp;percnt; to 85&amp;percnt; that of controls, and the final mean body weights of exposed females were 81&amp;percnt; to 86&amp;percnt; that of controls. Feed consumption by exposed groups was generally similar to that by controls. Discoloration of the fur, urine, and feces was observed in all exposed groups. Pathology Findings In the 2-year study, 1-amino-2,4-dibromoanthraquinone was associated with significant chemical-related increases in the incidences of benign and malignant neoplasms in the liver, forestomach, and lung of males and females. Incidences of hepatocellular adenoma and carcinoma were increased in exposed groups at the 15-month interim evaluation and at 2 years. At 2 years, there were significant increases in the incidences of multiple hepatocellular adenoma and carcinoma in males and females and in the incidences of hepatoblastoma in males. Centrilobular hypertrophy of hepatocytes in males and foci of hepatocellular alteration and pigmentation in the liver of males and females were also chemical-related changes. Sqamous cell papilloma of the forestomach mucosa occurred in 10,000 ppm females and 20,000 ppm males and females at the 15-month interim evaluation, and the incidences of squamous cell papilloma and carcinoma were significantly increased in exposed groups of males and females at 2 years. Chemical-related hyperplasia of forestomach epithelium was also present at 15 months and at 2 years. Alveolar/bronchiolar adenomas were present only in the exposed groups of males and females at 15 months, and the incidences of alveolar/bronchiolar adenoma were significantly increased in exposed males and females at 2 years. The incidences of multiple alveolar/bronchiolar adenomas were also increased in exposed males. In the kidney, pigmentation was present in the renal tubules of most mice after 2 years of exposure. DISPOSITION AND METABOLISM STUDIES: Adult male F344/N rats were given [14C]-labeled 1-amino-2,4-dibromoanthraquinone as a single intravenous dose of 0.4 mg/kg body weight or as a single oral dose of 2, 23, 118, 814, or 1,473 mg/kg. A 6-hour bile cannulation study was also performed. From day 0 through day 3 after intravenous administration, about 50&amp;percnt; of the 14C was excreted in the feces, 15&amp;percnt; in the urine, and 6&amp;percnt; in expired air. Unmetabolized 1-amino-2,4-dibromoanthraquinone accounted for less than 3&amp;percnt; of the excreted 14C after intravenous administration. For oral doses administered, the amount of the dose that was absorbed fit the equation: absorbed dose = 6.6 x log(dose). After intravenous administration, the metabolites of 1-amino-2,4-dibromoanthraquinone in blood were primarily in the plasma fraction (blood:plasma ratio of approximately 0.5:1). The highest concentrations of 14C in tissues 15 minutes after intravenous dosing were in excretory organs, lung, kidney, small intestine, liver, adipose tissue, and adrenal gland. GENETIC TOXICOLOGY: 1-Amino-2,4-dibromoanthraquinone was mutagenic in Salmonella typhimurium strains TA98 and TA1537 in the absence of S9; with S9, an equivocal response was observed in TA1537. 1-Amino-2,4-dibromoanthraquinone resulted in an equivocal response in TA100 with and without S9, and no mutagenic activity was detected with strain TA1535. In cultured Chinese hamster ovary cells, 1-amino-2,4-dibromoanthraquinone induced sister chromatid exchanges with and without S9; chromosomal aberrations were induced in the absence of S9. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was clear evidence of carcinogenic activity of 1-amino-2,4-dibromoanthraquinone in male and female F344/N rats based on increased incidences of neoplasms in the liver, large intestine, kidney, and urinary bladder. There was clear evidence of carcinogenic activity of 1-amino-2,4-dibromoanthraquinone in male and female B6C3F1 mice based on increased incidences of neoplasms in the liver, forestomach, and lung. Exposure of male and female rats to 1-amino-2,4-dibromoanthraquinone for 2 years was associated with basophilic focus (males only), clear cell focus, eosinophilic focus, and pigmentation in the liver; renal tubule hyperplasia, renal tubule pigmentation, and transitional cell hyperplasia in the kidney; transitional cell hyperplasia, squamous metaplasia, and stromal metaplasia (females only) in the urinary bladder; squamous hyperplasia, hyperkeratosis, ulceration, and inflammation of the forestomach mucosa; and seminal vesicle atrophy. Exposure of male and female mice to 1-amino-2,4-dibromoanthraquinone for 2 years was associated with centrilobular hepatocellular hypertrophy (males only), basophilic focus, clear cell focus (females only), eosinophilic focus, and pigmentation in the liver; pigmentation in the kidney; and hyperplasia, basal cell hyperplasia, hyperkeratosis, and inflammation of the forestomach mucosa. Synonym: ADBAQ

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4,4'-Thiobis(6- t -butyl- m -cresol) (TBBC) is used in the rubber and plastics industries as an antioxidant. TBBC is also used as a stabilizer in polyethylene and polyolefin packaging materials for foodstuffs. Toxicology and carcinogenesis studies were conducted by administering TBBC (99% pure) in feed to groups of male and female F344/N rats and B6C3F1 mice for 15 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells. 15-DAY STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were fed diets containing 0, 1,000, 2,500, 5,000, 10,000 or 25,000 ppm TBBC for 15 days. Rats given to 1,000, 2,500, 5,000, or 10,000 ppm received approximate doses of 95, 235, 335, or 365 mg TBBC per kilogram body weight per day (males) or 85, 220, 325, or 270 mg/kg per day (females). Approximate doses for rats receiving 25,000 ppm could not be calculated due to early deaths. All 25,000 ppm rats and three male and four female 10,000 ppm rats died. Surviving rats in the 10,000 ppm groups had a significant weight loss and the final mean body weights of 5,000 and 10,000 ppm male and female rats were significantly lower than those of the controls. Male and female rats exposed to 5,000, 10,000, or 25,000 ppm TBBC consumed markedly less feed than the controls. Diarrhea occurred in 5,000, 10,000, and 25,000 ppm males and females. The principal lesions attributed to the administration of TBBC were renal papillary and tubule necroses which occurred in 10,000 ppm rats. Focal necrosis or erosions of the glandular stomach also occurred in some 10,000 ppm rats. Changes observed in the thymus and spleen were attributed to debilitation or stress; bone marrow depletion was attributed to nutrient deficiency accompanying weight loss. 15-DAY STUDY IN MICE: Groups of 10 male and 10 female B6C3F1, mice were fed diets containing 0, 1,000, 2,500, 5,000, 10,000, or 25,000 ppm TBBC for 15 days. Mice given 1,000, 2,500, or 5,000 ppm received approximate doses of 285, 585, or 475 mg TBBC per kilogram body weight per day (males) or 360, 950, or 1,030 mg/kg per day (females). Approximate doses for mice given 10,000 or 25,000 ppm could not be calculated due to early deaths. All 10,000 and 25,000 ppm mice died, as did eight males and eight females given 5,000 ppm. A significant weight loss occurred in surviving 5,000 ppm males and females and the final mean body weights of 2,500 ppm females and 5,000 ppm males and females were significantly lower than those of the controls. Feed consumption by mice given 5,000, 10,000, or 25,000 ppm was markedly reduced. Diarrhea occurred in all 25,000 ppm mice and in most male and female mice given 5,000 or 10,000 ppm. Renal tubule necrosis occurred in eight males and three females in the 5,000 ppm groups. Lymphocytic depletion of Iymphoid tissues in many 5,000 ppm males and females was attributed to debilitation and stress or to nutrient deficiency accompanying weight loss. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were fed diets containing 0, 250, 500, 1,000, 2,500, or 5,000 ppm TBBC for 13 weeks. These exposure levels delivered approximate doses of 15, 30, 60, 165, or 315 mg TBBC per kilogram body weight per day (males) or 15, 35, 70, 170, or 325 mg/kg per day (females). All rats survived to the end of the study. The final mean body weight of 5,000 ppm males was 40% lower than that of the controls; the final mean body weight of 5,000 ppm females was 27% lower than that of the controls. Feed consumption by male and female rats exposed to 5,000 ppm TBBC was markedly lower than that by the controls throughout the study. The absolute and relative liver weights of 5,000 ppm females were significantly greater than those of the controls. Serum alkaline phosphatase (ALP) levels were significantly higher in 2,500 and 5,000 ppm males and slightly higher in 5,000 ppm females. Serum alanine aminotransferase levels were significantly higher in 2,500 and 5,000 ppm males and females. Hematocrit and hemoglobin concentrations and mean erythroions and mean erythrocyte volume (MCV) values were significantly lower in 1,000, 2,500, and 5,000 ppm males than in controls; MCV values were also significantly lower in 5,000 ppm females. A dose-related significant increase in forelimb and hindlimb grip strength was observed in exposed male and female rats. Histopathologic findings in the liver of 2,500 and 5,000 ppm males and females included hypertrophy of Kupffer cells, bile duct hyperplasia, and individual cell necrosis of hepatocytes; centrilobular hepatocyte hypertrophy also occurred in males and females exposed to 5,000 ppm TBBC. Macrophages were increased in size and number in the mesenteric Iymph nodes of males and females exposed to 5,000 ppm, and to a lesser extent in 2,500 ppm male and female rats. Pigmentation and degeneration of the renal cortical tubule epithelial cells was also present in males and females in the 2,500 and 5,000 ppm groups; cortical tubule necrosis occurred in 5,000 ppm males and females. 13-WEEK STUDY IN MICE: Groups of up to 10 male and 10 female B6C3F1 mice were fed diets containing 0, 100, 250, 500, 1,000, or 2,500 ppm TBBC for 13 weeks. These exposure levels delivered approximate doses of 15, 30, 65, 145, or 345 mg TBBC per kilogram body weight per day (males) or 10, 35, 60, 165, or 340 mg/kg per day (females). All mice survived to the end of the study. The final mean body weights of 2,500 ppm males and of 500,1,000, or 2,500 ppm females were significantly lower than those of the controls. Feed consumption by 2,500 ppm males averaged 24&amp;percnt; lower than that by controls through week 3 and was similar to that by controls for the remainder of the study. Feed consumption by females receiving 2,500 ppm averaged 27&amp;percnt; less than that by the controls during most of the study. The absolute and relative liver weights of males and females exposed to 2,500 ppm TBBC were slightly but significantly greater than those of the controls. Males exposed to 500, 1,000, or 2,500 ppm and females exposed to 2,500 ppm had significantly increased absolute and relative spleen weights. No clinical findings in mice were considered chemical related. Hematocrit concentrations and erythrocyte counts of males receiving 1,000 or 2,500 ppm were significantly less than those of the controls; hemoglobin concentration in males receiving 2,500 ppm was significantly less and mean erythrocyte volume was significantly less in males receiving 2,500 ppm. Females in the 1,000 and 2,500 ppm groups had significantly decreased hematocrit concentrations and erythrocyte counts; 2,500 ppm females also had significantly decreased hemoglobin concentrations and mean erythrocyte volumes. Kupffer cell hypertrophy, bile duct hyperplasia, and an increase in size and number of macrophages in mesenteric Iymph nodes were present in 2,500 ppm male and female mice. 2-YEAR STUDY IN RATS: Doses selected for the 2-year study of TBBC were based on the lower body weights and liver and kidney toxicity observed at 5,000 ppm in the 13-week study. Groups of 115 male and 75 female F344/N rats were fed diets containing 0, 500, 1,000, or 2,500 ppm TBBC for 2 years. Based on average daily feed consumption, these exposure levels resulted in a daily ingestion of TBBC of approximately 20, 40, or 100 mg/kg body weight for males and 20, 45, or 120 mg/kg body weight for females. Hematology, clinical chemistry, and urinalysis evaluations were performed on 15 male and 15 female rats from each group at 3, 9, and 15 months. Also at 15 months, an additional 10 male and 10 female rats from each group were evaluated for histopathology, hematology, and clinical chemistry. Forty male rats per group were evaluated for neurotoxic effects. Survival, Body Weights, Feed Consumption, and Clinical Findings: Two-year survival rates and mean body weights of exposed male and female rats were generally similar to those of the controls. The mean body weights of 2,500 ppm male rats were slightly lower than those of the controls throughout the study. At week 65, the mean body weight of 2,500 ppm females was 14&amp;percnt; lower than that of the controls, but the final mean body weight of this group was 6&amp;percnt; lower than that of the control group. Feed consumption, behavior, and general health and appearance of exposed male and female rats were similar to those of the controls. Hematology and Clinical Chemistry: Results of the hematology evaluation were not uniformly consistent at 3, 9, and 15 months in one set of rats, nor were they consistent between the two sets of rats evaluated at 15 months. Slight but significant decreases in hematocrit levels, hemoglobin concentrations, and erythrocyte counts were observed in the 1,000 and 2,500 ppm groups in one set of males at 15 months. Similar significant decreases in hematocrit level and hemoglobin concentration occurred in 2,500 ppm females at 9 months. Mean erythrocyte hemoglobin and mean erythrocyte hemoglobin concentration of 2,500 ppm females were also significantly lower than those of controls at 9 months and in both sets of female rats evaluated at 15 months. Platelet counts of 2,500 ppm male and female rats were slightly but significantly higher than those of controls at 3 and 9 months. Platelet counts were also slightly but significantly increased in 2,500 ppm males of one set evaluated at 15 months, and in 2,500 ppm females of the second set evaluated at 15 months. Serum activities of alkaline phosphatase, alanine aminotransferase, and sorbitol dehydrogenase in 2,500 ppm males were significantly greater than those in the controls at 3, 9, and 15 months. Alkaline phosphatase activities in both sets of 1,000 ppm males evaluated at 15 months were also significantly greater than those of controls. Serum activities of alanine aminotransferase and sorbitol dehydrogenase in 2,500 ppm females were also significantly greater than those in controls at 3, 9, and 15 months. Neurotoxicity Findings: There were no significant inhibitory effects of TBBC on motor nerve excitability or conduction, neuromuscular transmission, or muscle contractility. There were no microscopic lesions in the sciatic nerve, quadriceps muscle, or teased nerve preparations of sciatic nerve that could be attributed to TBBC administration. Pathology Findings: At the 15-month interim evaluation, the absolute and relative liver weights of 2,500 ppm female rats were significantly greater than those of controls; at 15 months and at the end of the study, the incidences of Kupffer cell hypertrophy, hepatocyte cytoplasmic vacuolization, and mixed cell foci were also significantly increased. At the end of the study, the incidence of hepatocellular fatty change was significantly increased in 2,500 ppm females. The incidence of Kupffer cell hypertrophy was significantly increased in 2,500 ppm males at 15 months and at 2 years; the incidence of cytoplasmic vacuolization was significantly increased in all exposed males at 15 months but only moderately increased in 1,000 and 2,500 ppm males at 2 years; the incidence of basophilic foci was significantly increased in 2,500 ppm males at 15 months and the incidence of mixed cell foci was significantly increased in 1,000 and 2,500 ppm male rats at 2 years. The incidences of hepatocellular adenoma or carcinoma (combined) in exposed male rats were not significantly greater than that in the controls (0 ppm, 1/50; 500 ppm, 3/50; 1,000 ppm, 3/50; 2,500 ppm, 5/49), were within the historical control range, and were not considered chemical related. The severity of nephropathy was significantly increased in 2,500 ppm female rats. There was a significant negative trend in the incidence of mammary gland fibroadenoma, adenoma, or carcinoma (combined) in female rats (32/50, 24/50, 11/50, 16/50), and the incidences of fibroadenoma in 1,000 and 2,500 ppm females were significantly less than that of the controls. 2-YEAR STUDY IN MICE: Because of the reduction in body weights, the increase in liver and spleen weights, and the accompanying histopathologic changes in the liver of 2,500 ppm male and female mice in the 13-week study, the doses selected for the 2-year study were 250, 500, and 1,000 ppm. Groups of 80 male and 80 female mice were fed diets containing 0, 250, 500, or 1,000 ppm TBBC for 2 years. Based on average daily feed consumption, these exposure levels resulted in the daily ingestion of approximately 30, 60, or 145 mg TBBC/kg body weight for males and 45, 110, or 255 mg TBBC/kg body weight for females. Nine or 10 animals from each exposure group were evaluated at 3, 9, and 15 months. Survival, Body Weights, Feed Consumption, and Clinical Findings: Two-year survival rates of exposed male and female mice were similar to those of the controls. The final mean body weights of male and female mice exposed to 1,000 ppm were 8&amp;percnt; and 18&amp;percnt; lower than those of the controls, respectively. The final mean body weights of females exposed to 250 or 500 ppm were 8&amp;percnt; to 9&amp;percnt; lower than that of the controls. Feed consumption by exposed males was similar to that by controls, and there were no clinical findings attributed to TBBC administration. Hematology and Clinical Chemistry: Hematocrit level, hemoglobin concentration, and erythrocyte count in 1,000 ppm male mice were significantly lower than those in controls at the 15-month interim evaluation. Serum alkaline phosphatase activities in 1,000 ppm males were slightly but significantly greater than those in controls at 3 and 9 months, as was the serum alkaline phosphatase activity in 1,000 ppm females at 9 months. Serum levels of total bilirubin in all exposed groups of males were significantly greater than those in controls at 9 and 15 months. Pathology Findings: In the liver of male mice, negative trends in the incidences of fatty change, clear cell foci, and adenoma or carcinoma combined occurred at the end of the 2-year study. There were no compound-related increased incidences of neoplasms or nonneoplastic lesions in mice receiving TBBC for 2 years. A negative trend in the incidence of fatty change in the liver of male mice also occurred at 15 months. GENETIC TOXICOLOGY: 4,4'-Thiobis(6- t -butyl- m -cresol) was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 with or without exogenous metabolic activation (S9). Sister chromatid exchanges were induced in cultured Chinese hamster ovary cells treated with TBBC, with and without S9, but no increases in chromosomal aberrations were noted in cultured Chinese hamster ovary cells after treatment with TBBC. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of 4,4'-thiobis(6- t -butyl- m -cresol) in male or female F344/N rats administered 500, 1,000, or 2,500 ppm or in male or female B6C3F1, mice administered 250, 500, or 1,000 ppm. Nonneoplastic lesions associated with exposure to TBBC included: Kupffer cell hypertrophy, cytoplasmic vacuolization, and mixed cell foci in the liver of male and female rats, fatty change in the liver of female, rats, and an increase in the severity of nephropathy in the kidney of female rats. In addition, decreased incidences of fibroadenoma, adenoma, or carcinoma (combined) were observed in the mammary gland of female rats. Decreases also occurred in the incidences of fatty change, clear cell foci, and adenoma or carcinoma (combined) in the liver of male mice. Synonyms: 4,4'-Thiobis(6- t -butyl-3-cresol); bis(3- t -butyl-4-hydroxy-6-methylphenyl)sulfide

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Cochrane Neonatal was first established in 1993, as one of the original review groups of the Cochrane Collaboration. In fact, the origins of Cochrane Neonatal precede the establishment of the collaboration. In the 1980's, the National Perinatal Epidemiology Unit at Oxford, led by Dr. Iain Chalmers, established the "Oxford Database of Perinatal Trials" (ODPT), a register of virtually all randomized controlled trials in perinatal medicine to provide a resource for reviews of the safety and efficacy of interventions used in perinatal care and to foster cooperative and coordinated research efforts in the perinatal field [1]. An effort that was clearly ahead of its time, ODPT comprised four main elements: a register of published reports of trials; a register of unpublished trials; a register of ongoing and planned trials; and data derived from pooled overviews (meta-analyses) of trials. This core effort grew into the creation of the seminal books, "Effective Care in Pregnancy and Childbirth" as well as "Effective Care of the Newborn Infant" [2,3]. As these efforts in perinatal medicine grew, Iain Chalmers thought well beyond perinatal medicine into the creation of a worldwide collaboration that became Cochrane [4]. The mission of the Cochrane Collaboration is to promote evidence-informed health decision-making by producing high-quality, relevant, accessible systematic reviews and other synthesized research evidence (www.cochrane.org). Cochrane Neonatal has continued to be one of the most productive review groups, publishing between 25 tpo to 40 new or updated systematic reviews each year. The impact factor has been steadily increasing over four years and now rivals most of the elite journals in pediatric medicine. Cochrane Neonatal has been a worldwide effort. Currently, there are 404 reviews involving 1206 authors from 52 countries. What has Cochrane done for babies? Reviews from Cochrane Neonatal have informed guidelines and recommendations worldwide. From January 2018 through June 2020, 77 international guidelines cited 221 Cochrane Neonatal reviews. These recommendations have included recommendations of the use of postnatal steroids, inhaled nitric oxide, feeding guidelines for preterm infants and other core aspects of neonatal practice. In addition, Cochrane Reviews has been the impetus for important research, including the large-scale trial of prophylactic indomethacin therapy, a variety of trials of postnatal steroids, trials of emollient ointment and probiotic trials [6]. While justifiably proud of these accomplishments, one needs to examine the future contribution of Cochrane Neonatal to the neonatal community. The future of Cochrane Neonatal is inexorably linked to the future of neonatal research. Obviously, there is no synthesis of trials data if, as a community, we fail to provide the core substrate for that research. As we look at the current trials' environment, fewer randomized controlled trial related to neonates are being published in recent years. A simple search of PubMed, limiting the search to "neonates" and "randomized controlled trials" shows that in the year 2000, 321 randomized controlled trials were published. These peaked five years ago, in 2015, with close to 900 trials being published. However, in 2018, only 791 studies are identified. Does this decrease represent a meaningful change in the neonatal research environment? Quite possibly. There are shifting missions of clinical neonatology at academic medical institutions, at least in the United States, with a focus on business aspects as well as other important competing clinical activities. Quality improvement has taken over as one of the major activities at both private and academic neonatal practices. Clearly, this is a needed improvement. All units at levels need to be dedicated to improving the outcomes of the sick and fragile population we care for. However, this need not be at the expense of formal clinical trials. It is understandable that this approach would be taken. Newer interventions frequently relate to complex systems of care and not the simple single interventions. Even trials that might traditionally have been done as randomized controlled trials, such as the introduction of a new mode of ventilation, are in reality complex challenges to the ability of institutions to create systems to adapt to these new technologies. Cost of doing trials has always been a barrier. The challenging regulatory and ethical environment contributes to these problems as well [7]. Despite these barriers, how does the research agenda of the neonatal community move forward in the 21st Century? We need to reassess how we create and disseminate our research findings. Innovative trial designs will allow us to address complex issues that we may not have tackled with conventional trials. Adaptive designs may allow us to look at potentially life-saving therapies in a way that feel more efficient and more ethical [8]. Clarifying issues such as the use of inhaled nitric oxide in preterm infants would be greatly served if we even knew whether or not there are hypoxemic preterm infant who would benefit from this therapy [9]. Current trials do not suggest so, yet current practice tells us that a significant number of these babies will receive inhaled nitric oxide [10-13]. Adaptive design, such as those done with trials of extracorporeal membrane oxygenation (ECMO), would allow us to quickly assess whether, in fact, these therapies are life-saving and allow us to consider whether or not further trials are needed [14,15]. Our understanding that many interventions involve entire systems approaches does not relegate us only to doing quality improvement work. Cluster designs may allow us to test more complex interventions that have usually been under the purview of quality improvement [16-18]. Cluster trials are well suited for such investigations and can be done with the least interruption to ongoing care. Ultimately, quality improvement is the application of the best evidence available (evidence-based medicine is "what to do" and evidence-based practice is "how to do"). [19,20]. Nascent efforts, such as the statement on "embedding necessary research into culture and health" (the ENRICH statement) call for the conduct of large, efficient pragmatic trials to evaluate neonatal outcomes, as in part called for in the ALPHA Collaboration [21,22]. This statement envisions an international system to identify important research questions by consulting regularly with all stakeholders, including patients, public health professionals, researchers, providers, policy makers, regulators, funders of industry. The ENRICH statement envisions a pathway to enable individuals, educational institutions, hospitals and health-care facilities to confirm their status as research-friendly by integrating an understanding of trials, other research and critical thinking and to teaching learning and culture, as well as an engagement with funders, professional organizations and regulatory bodies and other stake holders to raise awareness of the value of efficient international research to reduce barriers to large international pragmatic trials and other collaborative studies. In the future, if trials are to be done on this scale or trials are prospectively designed to be analyzed together, core outcome measures must be identified and standardized. That clinical trials supply estimates of outcomes that are relevant to patients and their families is critical. In addition, current neonatal research evaluates many different outcomes using multiple measures. A given measure can have multiple widely used definitions. Bronchopulmonary dysplasia (or chronic lung disease just to add to the confusion) quickly comes to mind [23,24]. The use of multiple definitions when attempting to measure the same outcome prevents synthesis of trial results and meta-analysis and hinders efforts to refine our estimates of effects. Towards that end, Webbe and colleagues have set out to develop a core outcome set for neonatal research [25]. Key stakeholders in the neonatal community reviewed multiple outcomes reported in neonatal trials and qualitative studies. Based on consensus, key outcome measures were identified, including survival, sepsis, necrotizing enterocolitis, brain injury on imaging, retinopathy or prematurity, gross motor ability, general cognitive ability, quality of life, adverse events, visual impairment or blindness, hearing impairment or deafness, chronic lung disease/bronchopulmonary dysplasia. Trials registration has to be a continued focus of the neonatal community. Trials registration allows for systematic reviewers to understand whether or not reporting bias has occurred [26]. It also allows for transparent incorporation of these core outcome measures. Ultimately, trials registration should include public reporting of all of these core outcomes and, in the future, access to data on an individual level such that more sophisticated individual patient data meta-analysis could occur. Lastly, there is no reason to see clinical trials and quality improvement as separate or exclusive activities. In fact, in the first NICQ Collaborative, conducted by Vermont Oxford Network, participation in a trial of postnatal steroids was considered part of the quality improvement best practices as opposed to simply choosing an as-of-yet unproven approach to use of this potent drug [27]. What role will Cochrane Neonatal play as we move forward in the 21st Century? As the neonatal community moves forward with its' research agenda, Cochrane Neonatal must not only follow but also lead with innovative approaches to synthesizing research findings. Cochrane Neonatal must continue to work closely with guideline developers. The relationship between systematic review production and guideline development is clearly outlined in reports from the Institute of Medicine [28,29]. Both are essential to guideline development; the systematic review group culling the evidence for the benefits and harms of a given intervention and the guideline group addressing the contextual issues of cost, feasibility, implementation and the values and preferences of individuals and societies. Most national and international guidelines groups now routinely use systematic reviews as the evidence basis for their guidelines and recommendations. Examples of the partnership between Cochrane Neonatal and international guideline development can be seen in our support of the World Health Organization (WHO) guidelines on the use of vitamin A or the soon to be published recommendations from the International Liaison Committee on Resuscitation (ILCOR) on cord management in preterm and term infants [30]. In the future, we need to collaborate early in the guideline development process so that the reviews are fit for purpose and meet the needs of the guideline developers and the end users. Towards this end, all Cochrane Neonatal reviews now contain GRADE assessments of the key clinical findings reported in the systematic review [31]. Addition of these assessments addresses the critical issue of our confidence in the findings. We are most confident in evidence provided by randomized controlled trials but this assessment can be can be downgraded if the studies that reported on the outcome in question had a high risk of bias, indirectness, inconsistency of results, or imprecision, or where there is evidence of reporting bias. Information provided by GRADE assessments is seen as critical in the process of moving from the evidence to formal recommendations [32]. We need to explore complex reviews, such as network (NMA) or multiple treatment comparison (MCT) meta-analyses, to address issues not formally addressed in clinical trials [33]. In conditions where there are multiple effective interventions, it is rare for all possible interventions to have been tested against each other [34]. A solution could be provided by network meta-analysis, which allows for comparing all treatments with each other, even if randomized controlled trials are not available for some treatment comparisons [34]. Network meta-analysis uses both direct (head-to-head) randomized clinical trial (RCT) evidence as well as indirect evidence from RCTs to compare the relative effectiveness of all included interventions [35]. However, Mills and colleagues note that the methodological quality of MTCs may be difficult for clinicians to interpret because the number of interventions evaluated may be large and the methodological approaches may be complex [35]. Cochrane Neonatal must take a role in both the creation of such analyses and the education of the neonatal community regarding the pitfalls of such an approach. The availability of individual patient data will make more sophisticated analyses more available to the community. Although the current crop of individual patient data meta-analyses (including the reviews of elective high frequency ventilation, inhaled nitric oxide and oxygen targets) have not differed substantially from the findings of the trials level reviews (suggesting that, in fact, sick neonates are more alike that unalike), there still will be a large role for individual patient data meta-analysis, at least to end the unfound conclusions that these therapies are effective in various subgroups (be it issues of sex, disease severity, or clinical setting) [36-39]. Future trials should take a lesson from the NeOProM Collaborative [37,39]. Given the difficulty in generating significant sample size and creating funding in any single environment, trials with similar protocols should be conducted in a variety of healthcare settings with an eye towards both study level and individual patient level meta-analysis at the conclusion of those trials, allowing for broader contribution to the trials data, more rapid accrual of sample size, and more precise results. We need to educate the neonatal community regarding the use and abuse of diagnostic tests. Diagnostic tests are a critical component of healthcare but also contribute greatly to the cost of medical care worldwide. These costs include the cost of the tests themselves and the costs of misdiagnosis and treatment of individuals who will not benefit from those treatments. Clinicians may have a limited understanding of diagnostic test accuracy, the ability of a diagnostic test to distinguish between patients with and without the disease or target condition [41,42]. Efforts such as Choosing Wisely have tried to identify these deficiencies [40]. As Cochrane has increased the general literacy of both the medical and general population regarding the interpretation of the results of interventions on various diseases, so should Cochrane move forward and improve the understanding of diagnostic testing. We need to become more efficient at creating and maintaining our reviews. The time spent to produce systematic reviews is far too great. In average, it takes between 2½ to 6½ years to produce a systematic review, requiring intense time input for highly trained and expensive experts. Innovations in the ways in which we produce systematic reviews can make the review process more efficient by outsourcing some of the tasks or crowdsourcing to machine learning. We need to let the crowd and machine learning innovations help us sort the massive amounts of information needed to conduct systematic reviews. It can also allow for "live" updating of critical reviews where the research landscape is quickly changing [43]. Lastly, Cochrane Neonatal must focus more on users of the reviews and not necessarily authors of the reviews. Current Cochrane programming speaks of Cochrane training with an eye towards developing the skills of individuals who will conduct systematic reviews. While this is clearly needed and laudable, the fact of the matter is that most of the community will be "users" of the reviews. Individuals who need to understand how to use and interpret the findings of systematic reviews. These review users include clinicians, guideline developers, policy makers and families. Incorporation of GRADE guidelines has been a huge step in adding transparency to the level of uncertainty we have in our findings. From a family's perspective, we need to overcome the environment of mistrust or misunderstanding of scientific evidence and how we convey what we know, and our uncertainty about what we know, to parents and families.

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Coumarin is the basic structure of numerous naturally occurring compounds with important and diverse physiological activities. More than a thousand coumarin derivatives have been described, varying from simple coumarins containing alkyl and hydroxyl side chains to complex coumarins with benzoyl, furanoyl, pyranoyl, or alkylphosphorothionyl substituents. Coumarin and 3,4-dihydrocoumarin were nominated by the Food and Drug Administration and the National Cancer Institute for study because of the widespread use of coumarin in perfumes, cosmetics, and other products as a fragrance, continued interest in coumarin compounds as flavor-enhancing agents for foods, and the interest in structure-activity relationships of this important group of compounds. Coumarin is believed to be metabolized to a 3,4-epoxide intermediate, which may be responsible for its toxic effects, while 3,4-dihydrocoumarin, which lacks the 3,4-double bond, is not considered likely to form an epoxide intermediate. Toxicity and carcinogenicity studies were conducted by administering coumarin (97% pure) in corn oil by gavage to groups of male and female F344/N rats and B6C3F1 mice for 16 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, Drosophila melanogaster, and B6C3F1 mice. 16-DAY STUDY IN RATS: Groups of five male and five female rats received coumarin in corn oil by gavage at doses of 0, 25, 50, 100, 200, or 400 mg per kg body weight, 5 days a week for a total of 12 doses in a 16-day period. All female rats and four male rats receiving 400 mg/kg died. The mean body weight gains and final mean body weights of surviving dosed male and female rats were similar to those of the controls. There were no clinical signs of organ-specific toxicity, and there was no evidence of impaired blood coagulation from measurements of capillary clotting time or prothrombin and activated partial thromboplastin time. 16-DAY STUDY IN MICE: Groups of five male and five female mice received coumarin in corn oil by gavage at doses of 0, 40, 75, 150, 300, or 600 mg per kg body weight, 5 days a week for a total of 12 doses in a 16-day period. All mice receiving 600 mg/kg, two male mice receiving 300 mg/kg, and one male mouse receiving 75 mg/kg died. The mean body weight gains and final mean body weights of surviving dosed male and female mice were similar to those of the controls. Clinical findings of inactivity, excessive lacrimation, piloerection, bradypnea, ptosis, or ataxia were observed in some mice from the 300 and 600 mg/kg groups within the first several hours after dosing. Capillary clotting time and platelet counts of dosed mice were similar to those of controls. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats received coumarin in corn oil by gavage at doses of 0,19, 38, 75,150, or 300 mg per kg body weight. Three male and three female rats receiving 300 mg/kg died. The mean body weight gains and final mean body weights of male rats that received 150 and 300 mg/kg were significantly lower than those of the controls. There were no clinical signs related to specific organ toxicity. Male and female rats receiving coumarin exhibited dose-related decreases in mean erythrocyte volume and mean erythrocyte hemoglobin, and dose-related increases in erythrocyte counts. Serum levels of total bilirubin and one or more cytoplasmic enzymes including alanine aminotransferase, aspartate aminotransferase, ornithine carbamoyltransferase, and/or sorbitol dehydrogenase in males and females receiving 300 mg/kg were higher than those of controls. The absolute and relative liver weights of male and female rats that received 150 and 300 mg/kg were significantly greater than those of the controls. Centrilobular hepatocellular degeneration and necrosis, chronic active inflammation, and bile duct hyperplasia were observed in the liver of rats receiving 150 or 300 mg/kg. The high dose selected for the 2-year study was 100 mg/kg, which was just below the level at which mortality, lower final mean body weiody weights, and treatment-related liver lesions were observed in the 13-week study. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice received coumarin in corn oil by gavage at doses of 0, 19, 38, 75, 150, or 300 mg per kg body weight. Two male mice receiving 300 mg/kg died. The mean body weight gain and final mean body weight of surviving male mice that received 300 mg/kg were significantly lower than those of the controls. No clinical signs of toxicity were observed. Male and female mice receiving coumarin exhibited dose-related decreases in mean erythrocyte volume and mean erythrocyte hemoglobin. The absolute and relative liver weights of males and females that received 150 and 300 mg/kg were significantly greater than those of the controls. Centrilobular hepatocellular hypertrophy was observed in male and female mice receiving 300 mg/kg. The high dose selected for the 2-year study was 200 mg/kg, which was just below the level at which mortality and liver lesions were observed in the 13-week study. 2-YEAR STUDY IN RATS: Groups of 60 male and 60 female rats were administered coumarin in corn oil by gavage at doses of 0, 25, 50, or 100 mg per kg body weight. After 15 months, 10 animals from each group were evaluated. Survival, Body Weights, and Clinical Findings: None of the male rats receiving 100 mg/kg and only two males receiving 50 mg/kg survived until the end of the study (vehicle control, 28/50; 25 mg/kg, 9/50; 50 mg/kg, 2/51; 100 mg/kg, 0/50). Survival of dosed female rats was similar to that of the controls (29/50, 38/50, 36/50, 30/50). The reduced survival in dosed male rats was primarily attributed to chemical-related exacerbation of spontaneously occurring renal disease. Final mean body weights of female rats that received 100 mg/kg and all dosed groups of male rats were lower than those of the controls. There were no clinical signs of toxicity in rats, other than nonspecific signs relating to debilitation as a result of renal or other spontaneous disease. Hematology and Clinical Chemistry: At the 15-month interim evaluation, the values for one or more hematologic parameters including mean erythrocyte volume, mean erythrocyte hemoglobin in 50 and 100 mg/kg rats, and hematocrit or hemoglobin in 100 mg/kg rats were significantly lower than those of controls. Activated partial thromboplastin times were also significantly lower in 50 and 100 mg/kg males, while platelet counts were significantly higher. Activities of alanine aminotransferase, sorbitol dehydrogenase, or g-glutamyltransferase in 50 and 100 mg/kg male and 100 mg/kg female rats were significantly higher than those of the controls at the 15-month interim evaluation. Pathology Findings: The principal lesions associated with the administration of coumarin to rats for up to 2 years occurred in the liver, kidney, and forestomach. While the hepatic lesions were seen in all groups of males, they occurred only in the 50 and 100 mg/kg females. The lesions consisted of a spectrum of changes including hepatocellular necrosis, fibrosis, cytologic alteration, and increased severity of bile duct hyperplasia. The incidences of hepatocellular neoplasms were not increased in dosed rats. There was a chemical-related increase in the average severity of nephropathy in all groups of dosed male and female rats. There were corresponding increased incidences of parathyroid gland hyperplasia in all groups of dosed males, probably as a result of compromised renal function. In the standard evaluation of single kidney sections, a low incidence of renal adenomas was seen in all groups of males and in 100 mg/kg females (males: vehicle control, 1/49; 25 mg/kg, 2/50; 50 mg/kg, 2/51; 100 mg/kg, 1/50; females: 0/49, 0/50, 0/50, 2/49). An evaluation of step sections identified additional individuals with renal tubule focal hyperplasia (males: 2/49, 12/50, 10/51, 6/50; females: 1/49, 0/50, 4/50, 2/49) and adenoma (males: 0/49, 4/50, 5/51, 4/50; females: 0/49, 0/50, 1/50,1/49) in the dosed groups. The incidences of forestomach ulcers in all groups of dosed male rats and in 100 mg/kg female rats were significantly greater than those of the controls (males: 7/48, 24/50, 35/51, 34/50; females: 1/48, 1/49, 6/50, 9/48). STOP-EXPOSURE EVALUATION: A group of 40 male rats received 100 mg/kg coumarin in corn oil by gavage for 9 months, when 20 of the animals were necropsied and evaluated. The remainder of the male rats received only the corn oil vehicle during the 15-month recovery period. Similarly, a group of 30 male rats received 100 mg/kg coumarin in corn oil by gavage for 15 months, when 10 of the rats were necropsied and evaluated. The remaining 20 rats received only corn oil during the 9-month recovery period. A group of 20 vehicle control male rats were necropsied at 9 months, and another 10 vehicle control male rats were necropsied at 15 months. While chemical-related hepatic lesions were seen at both the 9- and 15-month interim evaluations, the incidences and severities of these lesions following the recovery period were generally similar to controls. Thus, the hepatic lesions produced by 9 or 15 months of exposure were reversible. In contrast to the liver lesions, the severity of nephropathy in male rats following the recovery period was significantly greater than that of males examined at the 9- and 15-month interim evaluations. This is not unexpected, since nephropathy is a progressive degenerative disease that naturally increases in severity with age. The incidence of renal tubule hyperplasia in the 15-month stop-exposure group (dosed for 15 months followed by the recovery period) and the incidence of renal tubule adenoma in the 9-month stop-exposure group were significantly greater than those of the control group. 2-YEAR STUDY IN MICE: Groups of 70 male and 70 female mice were administered coumarin in corn oil by gavage at doses of 0, 50, 100, or 200 mg per kg body weight for up to 2 years. After 15 months, 19 or 20 mice from each group were evaluated. Survival, Body Weights, and Clinical Findings: Survival of dosed male and female mice was similar to that of the controls (males: vehicle control, 43/50; 50 mg/kg, 47/50; 100 mg/kg, 42/50; 200 mg/kg, 37/51; females: 33/50, 40/50, 42/51, 28/51). The mean body weights of 200 mg/kg male and female mice were lower than those of controls throughout much of the study. There were no clinical findings related to chemical administration. Hematology and Clinical Chemistry: Mean erythrocyte volume, mean erythrocyte hemoglobin, and hematocrit of 200 mg/kg males and mean erythrocyte volume of 200 mg/kg females were significantly lower than those of the controls. Blood platelet counts of 200 mg/kg males and females were significantly higher than those of controls. There were no biologically significant differences in enzyme activities between dosed and control mice. Pathology Findings: The principal toxic lesions associated with the administration of coumarin to mice occurred in the liver. The incidences of centrilobular hypertrophy in 100 and 200 mg/kg males and 200 mg/kg females were significantly greater than those of controls. The incidences of syncytial alteration in all male dose groups and in 200 mg/kg females were also significantly greater than controls. The incidences of eosinophilic foci, a putative preneoplastic lesion, and of hepatocellular adenoma were significantly greater in the 50 and 100 mg/kg females. Hepatocellular carcinomas occurred with low incidences in the dosed females, but none occurred in the controls. The overall incidence of hepatocellular neoplasms (benign and malignant combined) in the 50 and 100 mg/kg females (control, 8/50; 50 mg/kg, 27/49; 100 mg/kg, 31/51; 200 mg/kg, 13/50) exceeds the range in historical controls (range 2&amp;percnt;-34&amp;percnt;; 129/898, 14.4&amp;percnt;) from recent NTP studies. The reason for a lack of liver response in 200 mg/kg female mice is not known, but may be due in part to the decrease in body weight. While the incidences of eosinophilic foci were marginally greater in dosed male mice, the incidences of hepatocellular neoplasms were similar among the dosed and control groups. The incidences of alveolar/bronchiolar adenomas were significantly greater in 200 mg/kg male and female mice than in the controls. Further, the incidence of alveolar/bronchiolar carcinoma in 200 mg/kg females was also significantly greater than in controls. The overall incidence of pulmonary neoplasms (benign and malignant combined) in the 200 mg/kg groups (males: 14/50, 9/50,15/50, 25/51; females: 2/51, 5/49, 7/49, 27/51) exceeds the range in historical controls (males: range 6&amp;percnt;-28&amp;percnt;; 166/900, 18.4&amp;percnt;; females: range 0&amp;percnt;-14&amp;percnt;; 58/899, 6.5&amp;percnt;) from recent NTP studies. The incidence of squamous cell papilloma of the forestomach in 50 mg/kg males was greater than that of the controls (2/50, 8/50, 2/50, 0/51) and also exceeds the range of this neoplasm in control male mice from recent NTP studies (range 0&amp;percnt;-14&amp;percnt;; 27/902, 3.0&amp;percnt;). The incidence of squamous cell papilloma of the forestomach in 50 mg/kg female mice was also slightly increased (1/52, 5/50, 2/51, 2/51); however, the incidence did not exceed the NTP historical range (27/901, 3&amp;percnt;; range, 0&amp;percnt;-10&amp;percnt;). GENETIC TOXICOLOGY: Coumarin induced gene mutations in Salmonella typhimurium strain TA100 in the presence, but not in the absence, of exogenous metabolic activation (S9); no mutations were induced in strains TA98, TA1535, or TA1537, with or without S9. In Chinese hamster ovary cells, coumarin induced sister chromatid exchanges in the absence of S9, and chromosomal aberrations in the presence of S9. Coumarin did not induce sex-linked recessive lethal mutations in germ cells of male Drosophila melanogaster treated either as adults by feeding or injection, or as larvae by feeding. No increase in the frequency of micronucleated erythrocytes was observed in peripheral blood of male and female B6C3F1 mice administered coumarin by gavage for 13 weeks. CONCLUSIONS: Under the conditions of these 2-year gavage studies there was some evidence of carcinogenic activity of coumarin in male F344/N rats based on increased incidences of renal tubule adenomas. There was equivocal evidence of carcinogenic activity of coumarin in female F344/N rats based on a marginally increased incidence of renal tubule adenomas. There was some evidence of carcinogenic activity of coumarin in male B6C3F1 mice based on the increased incidence of alveolar/bronchiolar adenomas. There was clear evidence of carcinogenic activity of coumarin in female B6C3F1 mice based on increased incidences of alveolar/bronchiolar adenomas, alveolar/bronchiolar carcinomas, and hepatocellular adenomas. The marginally increased incidences of squamous cell papillomas of the forestomach in male and female mice receiving 50 mg/kg may have been related to coumarin administration. The administration of coumarin to rats was also associated with an increased severity of nephropathy in the kidney and of bile duct hyperplasia in the liver, increased incidences of ulcers of the forestomach, and necrosis, fibrosis, and cytologic alteration of the liver. Administration of coumarin to mice was also associated with centrilobular hypertrophy, syncytial alteration, and eosinophilic focus in the liver. Synonyms: 5,6-benzo-alpha-pyrone, 2H-1-benzopyran-2-one, 2H-benzolblpyran-2-one, 1,2-oxo-1,2-benzopyran, 1,2-benzopyrone, cis-o-coumarinic acid lactone, coumarinic anhydride, cumarin, o-hydroxycinnamic acid lactone, kumarin, [2-propenoic acid, 3-(-2-hydroxyphenyl)-delta-lactone], Rattex, tonka bean camphor

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Atrial fibrillation (AF) is an irregular heart rhythm, characterised by chaotic atrial activation, which is promoted by remodelling. Once initiated, AF can also propagate the progression of itself in the so-called ''AF begets AF''. Several lines of investigation have shown that signalling molecules, including reactive oxygen species, angiotensin II, and phosphoinositide 3-kinases (PI3Ks), in presence or absence of cardiovascular disease risk factors, stabilise and promote AF maintenance. In particular, reduced cardiac-specific PI3K activity that is not associated with oncology is cardiotoxic and increases susceptibility to AF. Atrial-specific PI3K(p110α) transgene can cause pathological atrial enlargement. Highlighting the crucial importance of the p110α protein in a clinical problem that currently challenges the professional health care practice, in over forty (40) transgenic mouse models of AF (Table1), currently existing, of which some of the models are models of human genetic disorders, including PI3K(p110α) transgenic mouse model, over 70% of them reporting atrial size showed enlarged, greater atrial size. Individuals with minimal to severely dilated atria develop AF more likely. Left atrial diameter and volume stratification are an assessment for follow-up surveillance to detect AF. Gene therapy to reduce atrial size will be associated with a reduction in AF burden. In this overview, PI3K(p110α), a master regulator of organ size, was investigated in atrial enlargement and in physiological determinants that promote AF. Table 1 Transgenic and Knockout Mouse Models of AF Gene Alteration Atrial enlargement Fibrosis Thrombus Ventricular dysfunction based on echo and/or catheter Conduction abnormalities by ECG APD Alteration AF pattern/other major cellular and molecular mechanisms References Rho GDIα TG Cardiac-specific overexpression of Rho GDP dissociation inhibitor (GDI)α with α-myosin heavy chain (α-MHC) promoter Atrial weight 0.6-fold increase vs NTg at 4 months but no changes at 4 weeks ✔ no significant increase in atrial and ventricle Not reported  ↔  Sinus bradycardia, varying degrees of AV block, prolongation of P-wave duration, and PR interval at 7 months Not reported Spontaneous Other mechanisms oreduced Connexin 40 expression oincreased expression of RhoA, Rac1, and Cdc42 [58] RhoA Cardiac-specific overexpression of RhoA with α-MHC promoter Atrial weight threefold increase vs NTg ✔ in ventricle Not reported ✔ Bradycardia and AV block Not reported Spontaneous Other mechanisms oincreased expression of hypertrophic genes oInflammation [59] Junction TG Cardiac-specific overexpression of junctin protein with α-MHC promoter Atrial weight, more than tenfold increase vs WT for right atrium ✔ in atrial and ventricle ✔ in left and right atria ✔ Bradycardia Atrial and ventricle APD<sub70,</sub phase 3 ↑ Spontaneous Other mechanisms oreduced triadin, RYR2, diastolic Ca<sup2+</sup, and Ca<sup2+</sup transient amplitude [60] Junctate 1 TG Cardiac-specific SR-located Ca<sup2+</sup-binding protein junctate 1 overexpression with α-MHC promoter Atrial weight, fourfold increase for left atrium and about fivefold increase for right atrium vs WT ↑ in atria and ventricle ✔ Intra-atrial thrombi ✔ Ventricular bigeminy, sinus pause, and bradycardia APD<sub90,</sub phase 4 ↑ Spontaneous Other mechanisms oreduced phospholamban phosphorylation, troponin I phosphorylation, Calreticulin, and RyR2 channel oreduced SR Ca<sup2+</sup content, Ca<sup2+</sup transient amplitude oincreased I<subCa,L</sub [61] AMPK TG<supN488I</sup Cardiac-specific PRKAG2 (AMPK γ2 subunit) overexpression with missense mutation Not reported Not reported Not reported ✔ Reduced PR interval, persistent sinus bradycardia without AV block Not reported Spontaneous and paroxysmal Other mechanisms ocardiac glycogen accumulation [62] A<sub1</subAR TG Cardiac-specific overexpression of A<sub1</sub adenosine receptor (A<sub1</subAR) with α-MHC No difference No fibrosis Not reported ✔ Slow AV conduction APD<sub90,</sub phase 4 ↔  APD<sub50,</sub phase 2 ↔  APD<sub70,</sub phase 2 ↔  Spontaneous [63] A<sub3</subtg TG Cardiac-specific overexpression of A<sub3</sub adenosine receptor (A<sub3</subAR) with α-MHC promoter Atrial size onefold and twofold increase at 12 weeks and 21 weeks, respectively, vs NTg Not present in atria and ventricle Not reported ✔ Absence of normal sinus rhythm, bradycardia, and intermittently complete Not reported Spontaneous Other mechanisms oreduced SERCA mRNA levels [64] RTEF1 TG Cardiac-specific overexpression of Transcription enhancer factor-1-related factor (RTEF1) with α-MHC promoter Atrial weight 4-sixfold increase vs control Not present in atria and ventricle ✔ Organised Not reported Slow conduction in working myocardium, prolonged PR interval, and QRS duration Not reported Spontaneous Mechanisms oincreased PP1β phosphatase ochronic dephosphorylation of cardiac connexin [65] ACE 8/8 TG Cardiac-restricted angiotensin-converting enzyme (ACE) Overexpression with α-MHC Ang II concentration was 4.3-fold higher in ACE mice compared to WT Atrial weight, about threefold increase vs WT ✔ in atria but not in ventricle Not reported ✔ AV block Not reported Spontaneous [66] K<subir</sub2.1 TG K<subir</sub2.1 I<subK1</sub channel subunit cardiac-specific overexpression with α-MHC promoter Atrial weight, left and right atrial to body weight 65% and 141% increase, respectively, vs control Not reported Not reported ✔ Absence of T wave and reduced QT interval APD<sub90,</sub phase 4 ↓ APD<sub50,</sub phase 2 ↔  APD<sub75,</sub phase 3 ↔  MAP90 Phase 4 ↓ MAP75 phase 3 ↓ MAP50<sub,</sub phase 2 ↔  Spontaneous [67] Kcne1<sup-/-</sup K<sup+</sup-channel KCNE1 subunit global protein deletion in mouse Normal atrial size Not present in atria and ventricle Not reported  ↔  AV block APD<sub50,</sub phase 2 ↓ APD<sub90,</sub phase 4 ↓ Spontaneous [68] hKCNE1-hKCNQ1 TG Human (h)KCNE1-hKCNQ1 Cardiac-specific overexpression with α-MHC promoter in mouse Not reported Not reported Not reported Not reported Complex atrial and irregular ventricular excitation β-AR mediated APD<sub50,</sub phase 2 ↑ APD<sub90,</sub phase 4 ↓ Spontaneous Other mechanisms oIncreased I<subKs</sub density [69] Des<sup-/-</sup Desmin global knockout Not reported Not reported Not reported Not reported Supraventricular premature beats, spontaneous ventricular premature beats, and Wenckebach periodicity Not reported Spontaneous Other mechanisms oHypokalemia, oReduced refractory period [70] CREM-IbΔC-X Human cAMP-response element modulator (CREM) heart-directed overexpression with α-MHC promoter Atrial weight, about 5-sevenfold increase vs NTg at 12-16 weeks Not present in left atrium and ventricle ✔ Organised thrombi in left and right atria ✔ Not reported Not reported Spontaneous Other mechanisms oReduced phosphorylation of CREB and of PLB oIncreased phosphorylation of SERCA2, PP1, and mRNA levels of ANP [71] CREM-IbΔC-X Human cAMP-CREM heart-directed Overexpression with α-MHC promoter Left atrial size, twofold increase vs WT at 13-17 weeks ↑ in atria Not reported Not reported Ectopic beats APD<sub25,</sub phase 1 ↑ APD<sub50,</sub phase 2 ↑ APD<sub90</sub phase 4 ↑ Spontaneous and persistent Other mechanisms oLeaky SR Ca<sup2+</sup stores oDownregulation of connexin 40 [72] CREM-IbΔC-X Human cAMP- CREM and reduced RyR<sub2</sub-S2814A phosphorylation heart-directed overexpression with germline transmission and Meox2-Cre crossing Atrial weight, sixfold increase vs WT at 3 months ↑ in atria and ventricle Not reported  ↔  Spontaneous atrial ectopy APD<sub80,</sub phase 4 ↑ Spontaneous at 3-month paroxysmal and persistent at 4-5 months Other mechanisms oincreased SR Ca<sup2+</sup leak and CaMKII activity oreduced connexin 40 [73] JDP TG Heart-restricted c-Jun dimerization protein 2 overexpression with α-MHC promoter Atrial cell diameter 1.4-fold increase vs WT Not present in the atrial and ventricle Not reported  ↔  Increased PR interval, AV block and Wenckebach periodicity Not reported Spontaneous Other mechanisms oreduced expression of connexin 40 and 43 oAng II signalling [74] RacET Heart-restricted constitutively active Rac1 Rho GTPase overexpression with α-MHC promoter Atrial weight, fourfold increase vs WT ↑ in atria and ventricle Not reported ✔ No observable conduction defects except AF Not reported Spontaneous and persistent Other mechanisms oincreased NADPH oxidase activity [75] Anxa7<sup-/-</sup Annexin global knockout Not reported Not reported Not reported  ↔ at basal AV block, ventricular tachyarrhythmia, shorter P-wave and QRS duration, and abnormal conduction velocity Not reported Spontaneous Other mechanisms oreduced protein expression of SERCA2a oincrease expression of NCX protein oβ<sub1</sub-adrenergic signalling [76] TNF1.6 TG Heart-directed overexpression of tumour necrosis factor-α with α-MHC promoter Isolated atrial area 3.6-fold increase from 6 to 9 months in female vs NTg ✔ in atria ✔ Organised thrombi in atria Not reported Episodes of second degree AV block, premature beats, and Ventricular ectopy APD<sub75</sub Phase 4 ↔  Spontaneous Other mechanisms oimpaired Ca<sup2+</sup loading oreduced intracellular Ca<sup2+</sup transients [77] MHCsTNF TG Cardiac-specific overexpression of tumour necrotic factor with α-MHC promoter Not reported Not reported Not reported ✔ AV junctional rhythm, short PR interval and wide QRS complex Not reported Spontaneous Other mechanisms oreduced connexion 40 expression oinflammation [78] MURCTG Cardiac-specific overexpression of muscle-related coiled-coil protein with α-MHC promoter Enlarged atrial compared to NTg ↑ in atria and ventricle Thrombus in the left atrial ✔ Complete AV block and prolongation of the PR interval Not reported Spontaneous Other mechanisms oreduced SERCA2, increased ANP, BNP, βMHC, TGF-β1, TGF-β2, and TGF-β3 [79] Nup155<sup±</sup Reduced nuclear envelope permeability by nucleoporin (NUP) 155 gene missense mutation on R391H Not reported Not reported Not reported Not reported Irregular RR intervals APD<sub90,</sub phase 4 ↓ Spontaneous Other mechanisms oreduced HSP70 nuclear localization [80] a1D<sup-/-</sup L-type Ca<sup2+</sup channel (Ca<subv</sub1.3) subunit global knockout Not reported Not reported Not reported Not reported SA and AV nodes conduction defects Not reported Spontaneous Other mechanisms olack of Ca<subv</sub1.3, and reduced I<subCa,L</sub [81] LTCC (α1D<sup-/-</sup) L-type Ca<sup2+</sup channel α1D subunit global knockout Smaller compared with WT Not reported Not reported Not reported Sinus bradycardia and AV block Not reported Spontaneous Other mechanisms oreduced I<subCa,L</sub, Ca<sup2+</sup transient amplitude, and SR Ca<sup2+</sup content [82] dnPI3K-DCM Cardiac-specific dominant negative phosphoinositide 3-kinase p110α (dnPI3K) DCM due to overexpression of mammalian sterile 20-like kinase 1 expression with α-MHC promoter Atrial size 3.45-fold increase vs NTg ↑ in atria and ventricle ✔ Chronic thrombi in the left atrium ✔ Prolonged PR intervals, double peak P-wave, and second and third degree AV block Not reported Spontaneous Other mechanisms oaltered expression of metabolic genes and K<sup+</sup channels oreduced HSP70 [16] Dct<sup-/-</sup Melanin synthesis enzyme dopachrome tautomerase global knockout Not reported No Not reported  ↔  No observable conduction defects except for AF APD<sub50</sub, phase 2 ↔  APD<sub90</sub, phase 4 ↔  Spontaneous Other mechanisms oplasma membrane caveolae accumulation oenlargement of mitochondria [83] RyR2<supR176Q/+</sup R176Q mutation in RYR2 gene through germline transmission and Meox2-Cre crossing Normal atrial size No fibrosis in atrial and ventricle Not reported Not reported RR interval variability, absence of P-wave APD<sub50</sub phase 2 ↔  APD<sub80</sub phase 4 ↔  Spontaneous Other mechanisms oincreased CaMKII-dependent phosphorylation of RyR2 oelevated SR Ca<sup2+</sup leak [84] Gα<subq</sub TG Overexpression of activated Gαq cardiac protein with α-MHC promoter Left atrial size, 2.5-fold increase vs WT ↑ in atria but not in ventricle ✔ Left atrial, unorganised thrombus Not reported Premature atrial contraction and irregular RR interval APD<sub80</sub, phase 4 ↑ Spontaneous [85] NppaCre<sup+</supPitx2<sup-</sup/<sup-</sup Atrial and ventricular-restricted loss of function of paired-like homeodomain transcription factor 2 (PITX2) Atrial length about 1.6-fold increase for left atrium and 1.2-fold increase for right atrium vs WT ↑ in ventricle but not in atria Not reported Not reported AV block APD<sub20</sub phase 1, ↔  APD<sub50</sub phase 2, ↔  APD<sub90</sub phase 4, ↔  Spontaneous Other mechanisms oreduced expression of Pitx2, oreduced expression of Nav1.5 oreduced expression of Kir2.1 [86] AnkB<sup±</sup Ankyrin-B (ANK2) heterologous null mutation Not reported Not reported Not reported ✔ Spontaneous bradycardia and abnormal ventricular response APD<sub90</sub phase 4, ↓ Spontaneous Other mechanisms oreduced I<subCa,L</sub oreduced Cav1.3 expression, osignalling interaction between ankyrin-B and Cav1.2 [87] D1275N-Na<subv</sub1.5 Human sodium channel Na<subv</sub1.5 global missense mutation Not reported No Not reported ✔ prolongation of P-wave and QRS duration PR interval and AV block APD<sub50</sub, phase 2 ↑ APD<sub90</sub, phase 4 ↑ Spontaneous Other mechanisms oreduced peak I<subNa</sub oincreased late I<subNa</sub [88] SLN<sup-/-</sup Sarcolipin global knockout No difference ↑ in atria but not in ventricle Not reported Not reported Small oscillatory waves APD<sub50</sub, phase 2 ↔  APD<sub90</sub, phase 4 ↑ Spontaneous Other mechanisms oSR Ca<sup2+</sup overload oDADs oincreased phosphorylation of RyR<sub2</sub [89] FKBP12.6<sup-/-</sup FK506-binding protein deficiency with reduced RYR2 phosphorylation at S2814 Not reported Not reported Not reported Not reported Absence of P-waves and irregular RR intervals APD<sub30</sub, phase 2 ↔  APD<sub50</sub, phase 2 ↔  Spontaneous Other mechanisms oLack of FK506-binding protein 12.6 oDADs oSR Ca<sup2+</sup leak oincreased I<subNCX</sub oCaMKII phosphorylation of RYR<sub2</sub and PLB [90] MHC-TGFcys<sup33</supser Cardiac-restricted constitutively active TGFβ1 overexpression with αMHC promoter Not reported ↑ in atria Not reported Not reported Activation wavefront APD<sub80</sub, phase 4 ↓ for both left and right atria Spontaneous Other mechanisms oincreased Ca<sup2+</sup transient [91] DN-MSTN TG13 TG Heart-directed overexpression of the N-terminal pro-peptide with α-MHC promoter Atrial weight 3.7-fold increase vs NTg ↑ in atria Appears present  ↔  AV block, Bradycardia Increased P-waves and QRS duration Not reported Spontaneous Other mechanisms oreduced connexin 40 expression [92] Casq2<sup-/-</sup Calsequestrin 2 global knockout Atria tissue area, about 1.8-2.0-fold increase vs WT No differences Not reported ✔ Atrial ectopic activity, bradycardia APD<sub80,</sub phase 4↑ Spontaneous [93] LKB1 knockout Cardiac-specific AMPK-activating liver kinase B1 (LKB1) knockout with α-MHC promoter Atria size, about twofold increase for paroxysmal at 4-6 weeks and threefold increase for persistent AF over 6 weeks vs WT ↑ in atria ✔ Intra-atrial thrombi  ↔  Increased PR interval and QRS duration in paroxysmal AF Not reported Paroxysmal and persistent Other mechanisms oreduced expression of AMPK oincreased in connexin 40 and 43 expression oROS and inflammation [94] F1759A-Na<subv</sub1.5-dTG Human sodium channel Na<subv</sub1.5 cardiac-specific expression with α-MHC promoter Right and left atria area increase by 52% and 54%, respectively, vs control ↑ in atria and ventricle Not reported ✔ Premature ventricular complexes and non-sustained polymorphic VT APD<sub80,</sub phase 4 ↑ for both right and left atria Spontaneous Other mechanisms oincreased late I<subNa</sub oincreased glycogen accumulation omyofibril disorganisation omitochondria injury oNCX regulation of Na<sup+</sup entry [95] LKB1/CTR LKB1/CT atrial-specific knockdown Not reported ↑ in atria Not reported  ↔  Irregularly irregular R-R intervals Not reported Spontaneous Other mechanisms oAtrial cardiomyocyte produces calcitonin oCalcitonin receptor and its ligand signalling governs fibroblast roles oParacrine signalling between atrial cardiomyocyte released calcitonin and fibroblast [96] PLK2 deficiency PLK2 Knockout Greater left atrial area ↑ in atria Not reported  ↔  ventricular tachycardia APD ↔  ERP ↔  Spontaneous Other mechanisms oPLK2/ERK/OPN is a dominant structural remodelling axis for AF generation [97] Mouse models that have been used to study the pathophysiology of AF, including atrial enlargement, electrophysiological alterations, apoptosis, functional and molecular underpinnings, and anatomical, transgenic; RYR2, ryanodine receptor 2; SR, sarcoplasmic reticulum; APD, action potential; SERCA mRNA, sarco/endoplasmic reticulum Ca<sup2+</sup-ATPase messenger ribonucleic acid; CTR, calcitonin receptor; KCNE1, potassium voltage-gated channel subfamily E member 1; AV, Atrioventricular block; MAP, monophasic action potential; PLB, phospholamban; ANP, atrial natriuretic peptide; β-AR, beta adrenergic receptor; PPβ1, protein phosphatase type 1β; NADPH, nicotinamide adenine dinucleotide phosphate; CaMKII, Ca<sup2+</sup/calmodulin-dependent protein kinase II; NCX, sodium-calcium exchanger; SERCA2a, Sarco/endoplasmic reticulum calcium (Ca<sup2+</sup) ATPase gene; TGF- β, Transforming growth factor beta; BNP, brain natriuretic peptide; HSP70, heat shock protein 70; DCM, dilated cardiomyopathy; AMPK, 5' adenosine monophosphate-activated protein kinase; PLK2, polo-like kinase 2; OPN, osteopontin; ERK1/2, extracellular signal-regulated kinase ½. ↔ unchanged in that condition; ✔ present in that condition; ↑ increased in that condition; ↓ reduced in that condition.

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C.I. Direct Blue 218 is a copper chelated dye used for cellulose, acetate, nylon, silk, wool, tissue, papers, and textile goods with a urea-formaldehyde finish. C.I. Direct Blue 218 is one of five chemicals/dyes that are part of the National Toxicology Program's Benzidine Dye Initiative, established to determine the toxicity and carcinogenicity of representative benzidine congeners, congener-derived dyes, and benzidine-derived dyes. Industrial grade C.I. Direct Blue 218 was selected for study because of its widespread use. Because of the high salt content, the dye was desalted prior to use. Toxicology and carcinogenesis studies were conducted by administering C.I. Direct Blue 218 in feed to groups of male and female F344/N rats and B6C3F1 mice for 14 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and Drosophila melanogaster. 14-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were fed diets containing 0, 1,000, 3,000, 7,000, 15,000, or 30,000 ppm C.I. Direct Blue 218. All rats survived until the end of the study. Rats receiving 30,000 ppm lost weight, and the mean body weight gain of males receiving 15,000 ppm was significantly lower than that of the controls. Feed consumption by rats receiving 30,000 ppm was lower than that by the controls. Decreased organ weights at the 30,000 ppm level were related to the decreased body weights at this exposure level. 14-DAY STUDY IN MICE: Groups of five male and five female mice were fed diets containing 0, 1,000, 3,000, 7,000, 15,000, or 30,000 ppm C.I. Direct Blue 218. All mice survived until the end of the study. The final mean body weight of males receiving 30,000 ppm was 25% lower than that of controls and that of 30,000 ppm females was 20% lower than that of controls. Feed consumption by exposed and control groups was similar except for the 15,000 and 30,000 ppm groups. Feed spillage, due to reduced palatability, precluded the accurate determination of feed consumption by these two groups. Male and female mice receiving 30,000 ppm appeared hyperactive and emaciated during the last week of the study. Decreased organ weights were noted at 30,000 ppm and were attributed to the decreased mean body weights at this exposure level. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were fed diets containing 0, 3,000, 10,000, or 20,000 ppm C.I. Direct Blue 218. All male and female rats survived until the end of the study. Rats exposed to 3,000,10,000, or 20,000 ppm C.I. Direct Blue 218 received approximate daily doses of 200, 600 or 1,300 mg dye/kg body weight (males) and 200, 800, or 1,400 mg/kg (females). The final mean body weight of male rats receiving 20,000 ppm was 24% lower than that of the controls and the final mean body weight of female rats receiving 20,000 ppm was 15% lower than that of the controls. Feed consumption by exposed and control groups was similar except in the 20,000 ppm groups where feed spillage was noted. Absolute and relative kidney weights of rats receiving 10,000 or 20,000 ppm were significantly greater than those of controls. Significantly decreased organ weights were noted, particularly in the 20,000 ppm groups, and were attributed to the lower mean body weights at this exposure level. The hematocrit, hemoglobin, mean erythrocyte volume, and mean erythrocyte hemoglobin values in male and female rats receiving 10,000 and 20,000 ppm were significantly lower than those of controls. Serum levels of alanine aminotransferase and sorbitol dehydrogenase in male and female rats receiving 20,000 ppm were significantly higher than those of controls, which is consistent with hepatocellular injury. Male rats receiving 10,000 ppm and male and female rats receiving 20,000 ppm had hepatic lesions consisting of intracytoplasmic pigment in periportal Kupffer cells, minimal to mild individual hepatocyte necrosis, increased numbers of binucleated and multinucleated hepatocytes, and minimal bile duct hyperplasia. Male and female rats receiving 20,000 ppm had ys receiving 20,000 ppm had yellow-green pigment within the cytoplasm of proximal convoluted tubules of the kidney. Microconcretions of mineral were observed along the corticomedullary junction of the kidney in most female rats, but the numbers of microconcretions in kidney sections were increased in females that received 20,000 ppm. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were fed diets containing 0, 3,000, 10,000, or 20,000 ppm C.I. Direct Blue 218. There were no deaths attributed to C.I. Direct Blue 218. Mice exposed to 3,000, 10,000, or 20,000 ppm C.I. Direct Blue 218 received approximate daily doses of 400, 1,500, or 3,600 mg dye/kg body weight (males) and 400, 1,800, or 4,000 mg/kg (females). The final mean body weight of males that received 20,000 ppm was 24&amp;percnt; lower than that of the controls, and the final mean body weight of females that received 20,000 ppm was 14&amp;percnt; lower than that of controls. Feed consumption by exposed mice was similar to that by controls except in the 20,000 ppm groups where feed spillage was noted. Significant differences in organ weights were noted at 20,000 ppm which were attributed primarily to the lower mean body weights in these exposure groups. The hematocrit, hemoglobin, mean erythrocyte volume, and mean erythrocyte volume, and mean erythrocyte hemoglobin values were significantly lower in males and females receiving 10,000 and 20,000 ppm. Serum levels of alanine aminotransferase and sorbitol dehydrogenase in male and female mice receiving 10,000 and 20,000 ppm were significantly higher than those of controls, indicating hepatic injury. Male and female mice receiving 20,000 ppm had hepatic lesions consisting of centrilobular hepatocyte hypertrophy and karyomegaly, multifocal individual hepatocyte necrosis, oval cell proliferation, and periportal Kupffer cells with intracytoplasmic pigment. Males and females receiving 20,000 ppm also had increased numbers of pigmented macrophages within the red pulp of the spleen. 2-YEAR STUDY IN RATS: The doses selected for the 2-year study of C.I. Direct Blue 218 were based on the lower final mean body weights and the occurrence of hepatic lesions in the 20,000 ppm groups in the 13-week study. Groups of 60 male and 60 female rats were fed diets containing 0, 1,000, 3,000, or 10,000 ppm C.I. Direct Blue 218 for 103 weeks. Nine or 10 rats from each group were evaluated after 15 months. Survival, Body Weights, Feed and Compound Consumption, and Clinical Findings: Survival of female rats receiving 10,000 ppm was slightly, but not significantly, lower than that of the controls. Mean body weights of male and female rats in the 10,000 ppm groups were approximately 5&amp;percnt; to 14&amp;percnt; lower than those of the controls after week 15, and the final mean body weights of male and female rats at this level were 11&amp;percnt; and 9&amp;percnt; lower than those of the controls, respectively. Feed consumption by exposed male and female rats was similar to that by the controls and was estimated to deliver daily doses of 40, 120, and 440 mg dye/kg body weight to males and 50, 140, and 470 mg/kg to females. No chemical-related clinical signs of toxicity were noted. Hematology and Clinical Chemistry: The hematocrit, hemoglobin, mean erythrocyte volume, and mean erythrocyte hemoglobin values in 10,000 ppm female rats were significantly lower than those of controls, while in males only the mean erythrocyte hemoglobin value was significantly lower. Serum levels of alanine aminotransferase and sorbitol dehydrogenase in male and female rats receiving 10,000 ppm were significantly higher than those of the controls at the 15-month interim evaluation. Pathology Findings: Squamous cell papillomas of the oral mucosa (pharynx) occurred in five males receiving 10,000 ppm but not in the lower exposure groups or in controls. A squamous cell carcinoma occurred in one 10,000 ppm male and a benign basosquamous tumor was observed in another. The incidence of oral mucosal neoplasms in the 10,000 ppm males was significantly greater than that in controls and exceeded the range observed in untreated historical controls (lO/l,253, 0.8&amp;percnt;; range 0&amp;percnt;-4&amp;percnt;). These neoplasms were considered chemical related. Administration of C.I. Direct Blue 218 to rats produced significantly increased incidences of forestomach basal cell hyperplasia in males receiving 3,000 or 10,000 ppm (0 ppm, 0/50; 1,000 ppm, 2/50; 3,000 ppm, 10/50;10,000 ppm, 19/50) and in females receiving 10,000 ppm (1/50, 1/49, 5/50, 11/49). Further, there were marginal increased incidences of focal squamous hyperplasia in the 3,000 and 10,000 ppm males (1/50,1/50, 6/50, 4/50). Squamous cell papillomas of the forestomach were seen in two 3,000 ppm males and in one 10,000 ppm male; no papillomas were observed in the controls. A squamous cell carcinoma was also seen in one 3,000 ppm male. Because of the uncommon occurrence of forestomach neoplasms in untreated control male rats (4/1,253, 0.3&amp;percnt;; range 0&amp;percnt;-2&amp;percnt;) and the slight increase in the incidence of focal hyperplasia, these neoplasms may have been chemical related. The incidence of uterine endometrial stromal polyps in each exposed group of female rats was significantly greater than that of the controls (1/50,12/50,10/50, 10/50). Because the incidences in the exposed groups did not increase in a dose-related manner and the incidence in the controls was unusually low (historical incidence: 205/1,251,16.4&amp;percnt;; range 2&amp;percnt;-30&amp;percnt;), the higher incidence of stromal polyps in the exposed groups was not considered chemical related. 2-YEAR STUDY IN MICE: The dose selection for the 2-year study was based on the lower final mean body weights and the liver lesions observed at the 20,000 ppm level in the 13-week study. Groups of 60 male and 60 female mice were fed diets containing 0, 1,000, 3,000, or 10,000 ppm C.I. Direct Blue 218 for 103 weeks. Nine or 10 mice from each exposure group were evaluated after 15 months. Survival, Body Weights, Feed and Compound Consumption, and Clinical Findings: Survival of exposed male and female mice was similar to that of the controls. Mean body weights of male and female mice receiving 10,000 ppm were 10&amp;percnt; to 29&amp;percnt; lower than those of the controls during most of the study, and the final mean body weights in these groups were 19&amp;percnt; lower than that of the controls for males and 27&amp;percnt; lower than that of the controls for females. Feed consumption by exposed mice was similar to that by controls and the diets were estimated to deliver daily doses of approximately 120, 360, and 1,520 mg of dye/kg body weight to males and 140, 470, and 2,050 mg/kg to females. No chemical-related clinical signs of toxicity were noted. Hematology and Clinical Chemistry: Hematocrit, hemoglobin, and mean erythrocyte volume values in males and females receiving 10,000 ppm were significantly lower than those of the controls. Serum levels of alanine aminotransferase and/or sorbitol dehydrogenase values in male and female mice that received 10,000 ppm were significantly higher than those of controls, which is consistent with hepatocellular damage. Pathology Findings: The administration of C.I. Direct Blue 218 to mice produced significantly increased incidences of hepatocellular adenoma (0 ppm, 16/50; 1,000 ppm, 19/50; 3,000 ppm, 17/50; 10,000 ppm, 40/50) and hepatocellular carcinoma (7/50, 3/50, 8/50,17/50) in males receiving 10,000 ppm, and a significantly increased incidence of hepatocellular adenoma in females receiving 3,000 or 10,000 ppm (7/49, 12/50, 17/49, 41/49). In females that received 10,000 ppm, the incidence of hepatocellular carcinoma was marginally increased. Consistent with these findings, the incidence of hepatocellular foci of cytologic alteration, a preneoplastic lesion, was also increased in males and females in the 10,000 ppm groups. The increased incidences of hepatocellular foci, adenomas, and carcinomas were considered chemical related. Uncommon renal tubule neoplasms also occurred at low incidences in male mice receiving C.I. Direct Blue 218, but not in controls. Renal tubule adenomas were seen in two males receiving 1,000 ppm, one male receiving 3,000 ppm, and one male receiving 10,000 ppm. A renal tubule carcinoma was also seen in one male that received 1,000 ppm. Because renal tubule neoplasms are uncommon in male mice (4/1,366, 0.3&amp;percnt;; range 0&amp;percnt;-2&amp;percnt;), these neoplasms may have been chemical related. Carcinomas of the small intestine occurred in four male mice receiving 10,000 ppm. One was observed at the 15-month interim evaluation, while the other three were observed in mice at the end of the study. One control male mouse also had a carcinoma of the small intestine. Because of the uncommon occurrence of small intestine neoplasms in untreated male mice (12/1,374, 0.9&amp;percnt;; range 0&amp;percnt;-4&amp;percnt;), the slightly higher incidence of these neoplasms in males receiving 10,000 ppm may have been chemical related. Carcinomas of the small intestine also occurred in one 3,000 ppm and one 10,000 ppm female, but the low incidences precluded drawing an association with chemical administration. GENETIC TOXICOLOGY: C.I Direct Blue 218 was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 tested with and without exogenous metabolic activation (S9). It was also tested in a modified Salmonella test protocol which employed reductive metabolism supplied by flavin mononucleotide or rat cecal bacteria, followed by oxidative metabolism; results of this test using strain TA1538 were also negative. C.I. Direct Blue 218 induced a small but significant increase in sister chromatid exchanges in Chinese hamster ovary cells at the highest dose tested without S9. No increase in chromosomal aberrations were observed in Chinese hamster ovary cells with or without S9. C.I. Direct Blue 218 did not induce sex-linked recessive lethal mutations in germ cells of male Drosophila melanogaster. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was some evidence of carcinogenic activity of C.I. Direct Blue 218 in male F344/N rats based on the occurrence of pharyngeal neoplasms. Squamous cell neoplasms of the forestomach may have been chemical related. There was no evidence of carcinogenic activity of C.I Direct Blue 218 in female F344/N rats given 1,000, 3,000, or 10,000 ppm. There was clear evidence of carcinogenic activity of C.I. Direct Blue 218 in male and female B6C3F1 mice based on increased incidences of hepatocellular adenomas and carcinomas. The occurrence of a few neoplasms of the kidney and small intestine in male mice may have been related to C.I. Direct Blue 218 treatment. The administration of C.I. Direct Blue 218 produced an increased incidence of forestomach basal cell hyperplasia in rats and hepatocellular foci of cytologic alteration in mice. Synonyms: cuprate(4-), [mu-[(3,3'-dihydroxy[1,1'-biphenyl]-4,4'-diyl)bis[5-amino-4-hydroxy- 2,7-naphthalnedisulfonato]](8-)]]di-, tetrasodium; copper, [tetrahydrogen-3,3'-[(3,3'-dihydroxy-4,4'-biphenylylene)bis(azo)]bis [5-amino-4-hdroxy-2,7-naphthalenedisulfonato](4-)]di-, tetrasodium salt; 1-naphthol-3,6-disulfonic acid, 2,2'-(3,3'-dihydroxy-4,4'-biphenylylenebisazo)bis [8-amino-, dicopper deriv., tetrasodium salt

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Nickel subsulfide is used in the manufacture of lithium batteries and is a major component in the refining of certain nickel ores. Nickel subsulfide was nominated as part of a class study of nickel compounds, for which there was little information on the toxic and carcinogenic effects of inhalation exposure. Male and female F334/N rats and B6C3F1 mice were exposed to nickel subsulfide (at least 97% pure; the mean value for the mass median aerodynamic diameter at each exposure concentration ranged from 2.0 to 2.2 mm by inhalation 6 hours per day, 5 days per week, for 16 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, and mouse peripheral blood samples were analyzed for frequency of micronucleated normochromatic erythrocytes. 16-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were exposed to atmospheres containing 0, 0.6, 1.2, 2.5, 5, or 10 mg nickel subsulfide/m(3) (equivalent to 0, 0.44, 0.88, 1.83, 3.65, and 7.33 mg nickel/m(3)) 6 hours per day, 5 days per week for a total of 12 exposure days during a 16-day period. Additionalmgroups of three male and three female rats were exposed to 0, 0.6, 2.5, or 10 mg/m(3) for tissue burden studies. One male exposed to 10 mg nickel subsulfide/m(3) in the core study died on day 14; all other rats survived until the end of the study. Final mean body weights and mean body weight gains of males exposed to 5 or 10 mg nickel subsulfide/m(3) and females exposed to 2.5, 5, or 10 mg/m(3) were significantly lower than those of the controls. Clinical findings of toxicity on day 5 of the study included labored respiration in 10 mg/m(3) males and 5 and 10 mg/m(3) females and dehydration in 5 and 10 mg/m(3) females. Absolute and relative lung weights of 2.5, 5, and 10 mg/m(3) males and all exposed groups of females were significantlymgreater than those of the controls, as was the absolute lung weight of 1.2 mg/m(3) males. Inflammation of the lung and atrophy of the nasal olfactory epithelium occurred in all exposed mgroups. The concentrations of nickel in the lungs of exposedmgroups of rats increased with exposure concentration (males, 7 to 67 mg nickel/g lung; females, 9 to 77 mg/g lung). 16-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were exposed to atmospheres containing 0, 0.6, 1.2, 2.5, 5, or 10 mg nickel subsulfide/m(3) for 6 hours per day, 5 days per week for a total of 12 exposure days during a 16-day period. Additional groups of three male and three female mice were exposed to 0, 0.6, 2.5, or 10 mg/m(3) for tissue burden studies. All male and female mice exposed to 10 mg nickel subsulfide/m(3) in the core study died before the end of the study; the death of one female was accidental. One control male, one control female, and one 1.2 mg/m(3) male also died before the end of the study. Final mean body weights and mean body weight gains of 5 mg/m(3) males were significantly lower than those of the controls. Clinical findings at day 5 included labored respiration in 10 mg/m(3) males and females. The absolute lung weight of 5 mg/m(3) males, the absolute and relative lung weights of 10 mg/m(3) males and 5 mg/m(3) females, and the relative lung weight of 10 mg/m(3) females were significantly greater than those of the controls. Inflammation of the lung occurred in 2.5, 5, and 10 mg/m(3) male and female mice, fibrosis of the lung occurred in 5 mg/m(3) males and females, and lymphoid hyperplasia of the bronchial lymph nodes and atrophy of the nasal olfactory epithelium occurred in 1.2, 2.5, 5, and 10 mg/m(3) males and females. Nickel concentrations in the lung of exposed male and female mice were greater than those of the controls (males, 10 to 20 mg nickel/g lung; females, 8 to 20 mg/g lung) 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were exposed to atmospheres containing 0, 0.15, 0.3, 0.6, 1.2, or 2.5 mg nickel subsulfide/m(3) (equivalent to 0, 0.11, 0.22, 0.44, 0.88, and 1.83 mg nickel/m(3)) 6 hours per day, 5 days per week for 13 weeks. Additional groups of 18 male and 18 female female rats were exposed to 0, 0.15, 0.6, or 2.5 mg/m(3) for tissue burden studies. All core study rats survived until the end of the study. Final mean body weights and mean body weight gains of 2.5 mg/m(3) males were significantly lower than those of the controls; final mean body weights of all other exposure groups were similar to those of the controls. Chemical-related clinical findings included labored respiration in 2.5 mg/m(3) males and females during weeks 2 through 7. In general, neutrophil and erythrocyte counts, hematocrit values, and hemoglobin concentrations were minimally increased in exposed rats. Absolute and relative lung weights of all exposed groups were significantly greater than those of the controls. Increases in the number of alveolar macrophages, interstitial infiltrates, or incidences of chronic inflammation of the lung occurred in all groups exposed to nickel subsulfide concentrations of 0.3 mg/m(3) or greater; the severity of these lesions generally increased with increasing exposure concentration. Increases in the number of alveolar macrophages were observed in 0.15 mg/m(3) males and females. Lymphoid hyperplasia of the bronchial and mediastinal lymph nodes was observed in rats exposed to 0.3 mg/m(3) or greater. Most 0.6, 1.2, and 2.5 mg/m(3) males and females had atrophy of the nasal olfactory epithelium, and the severity generally increased with increasing exposure concentration. Nickel concentrations in the lung increased with exposure concentration and were greater than those in the controls in rats exposed for 13 weeks (males, 5 to 18 mg nickel/g lung; females, 5 to 17 mg/g lung). 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were exposed to atmospheres containing 0, 0.15, 0.3, 0.6, 1.2, or 2.5 mg nickel subsulfide/m(3) for 6 hours per day, 5 days per week for 13 weeks. Additional groups of six male and six female mice were exposed to 0, 0.15, 0.6, or 2.5 mg/m(3) for tissue burden studies. Final mean body weights of all exposure groups were similar to those of the controls. No chemical-related clinical findings were observed. Lymphocyte counts in 1.2 and 2.5 mg/m(3) males were minimally greater than that of the controls. Hemoglobin concentrations and erythrocyte counts in 0.3, 0.6, 1.2, and 2.5 mg/m(3) females were minimally greater than those of the controls. Absolute and relative lung weights of 1.2 and 2.5 mg/m(3) males and females were significantly greater than those of the controls. An increase in alveolar macrophages was present in mice from the 0.3 mg/m(3) and higher exposure groups. Chronic inflammation and fibrosis were observed in the lung of 1.2 and 2.5 mg/m(3) males and females. Interstitial infiltrates of lymphocytes were observed in mice exposed to 0.6, 1.2, or 2.5 mg/m(3). Lymphoid hyperplasia of the bronchial lymph nodes was observed in groups exposed to 1.2 or 2.5 mg/m(3). Atrophy of the nasal olfactory epithelium occurred in 0.6, 1.2, and 2.5 mg/m(3) males and females, and incidences and severity generally increased with increasing exposure concentration. At 13 weeks, nickel concentrations in the lungs of exposed mice were greater than those of the controls (males, 3 to 17 g nickel/g lung; females, 6 to 23 mg/g lung), and these concentrations increased with increasing exposure concentration. 2-YEAR STUDY IN RATS: Survival, Body Weights, Clinical Findings, and Hematology: Groups of 63 male and 63 female F344/N rats were exposed to 0, 0.15, or 1 mg nickel subsulfide/m(3) (equivalent to 0, 0.11, or 0.73 mg nickel/m(3)) by inhalation for 6 hours per day, 5 days per week for 104 weeks. Survival of exposed males and female rats was similar to that of the controls. Mean body weights of males and females exposed to 0.15 mg/m(3) were similar to those of the controls. Mean body weights of rats exposed to 1 mg/m(3) were lower than those of the controls throughout the second year of the study. Chemical-related clinical findings included rapid and shallow breathing following exposure periods. Hematocrit values and hemoglobin concentrations in 1 mg/m(3) males and females and the erythrocyte count in 1 mg/m(3) males were mildly greater than those in the controls. Pathology Findings: In general, the absolute and relative lung weights of exposed males and females were significantly greater than those of the controls at 7 and 15 months. There were exposure-related increases in the incidences of alveolar/bronchiolar adenoma in males, alveolar/bronchiolar carcinoma in males and females, and alveolar/bronchiolar adenoma or carcinoma (combined) in males and females at 2 years. Nonneoplastic lung lesions generally observed in exposed males and females included fibrosis; chronic active inflammation; focal alveolar epithelial hyperplasia, macrophage hyperplasia, and proteinosis; bronchial lymphoid hyperplasia; and interstitial inflammation. At 2 years, there were significant exposure-related increases in the incidences of benign pheochromocytoma, malignant pheochromocytoma, and benign or malignant pheochromocytoma (combined) in males and of benign pheochromocytoma in females. The incidence of adrenal medulla hyperplasia in 1 mg/m(3) females was significantly greater than that of the controls At 2 years, the incidences of chronic active inflammation of the nose in 1 mg/m(3) females and of olfactory epithelial atrophy in 1 mg/m(3) males and females were significantly greater than those of the controls. The incidences of lymphoid hyperplasia of the bronchial lymph node in exposed males at 7 and 15 months and in exposed males and females at 2 years were significantly greater than those of the controls. Incidences of macrophage hyperplasia in the bronchial lymph node of exposed males at 15 months and exposed males and females at 2 years were greater than those of the controls. Tissue Burden Analyses: Nickel concentrations in the lungs of exposed rats were greater than those of the controls at 7 months (males, 6 to 9 mg nickel/g lung; females, 6 to 9 mg/g lung) and 15 months (males, 4 to 3 mg nickel/g lung; females, 4 to 7 mg/g lung). 2-YEAR STUDY IN MICE: Survival, Body Weights, Clinical Findings, and Hematology: Groups of 80 male and 80 female B6C3F1 mice were exposed to 0, 0.6, or 1.2 mg nickel subsulfide/m(3) (equivalent to 0, 0.44, or 0.88 mg nickel/m(3)) by inhalation for 6 hours per day, 5 days per week for 105 weeks. Survival of exposed male and female mice was similar to that of the controls. Mean body weights of 0.6 and 1.2 mg/m(3) males and females were less than those of the controls throughout the second year of the study. Chemical-related clinical findings in male and female mice included labored respiration following exposure periods. The hematocrit value and the segmented neutrophil, monocyte, lymphocyte, and total leukocyte counts in 1.2 mg/m(3) females were greater than those in the controls. Pathology Findings: Absolute and relative lung weights of exposed males and females were generally significantly greater than those of the controls at 7 and 15 months. The incidence of alveolar/bronchiolar carcinoma in 0.6 mg/m(3) females and the incidences of alveolar/bronchiolar adenoma or carcinoma (combined) in 0.6 mg/m(3) males and 0.6 and 1.2 mg/m(3) females were significantly less than those of the controls. In general, the incidences of chronic active inflammation; bronchialization (alveolar epithelial hyperplasia), macrophage hyperplasia and proteinosis; interstitial infiltration; and fibrosis in exposed groups of males and females were greater than those of the controls at 7 and 15 months and at 2 years. The incidences of atrophy of the nasal olfactory epithelium and inflammation of the nose in exposed mice were also generally greater than those of the controls. At 2 years, the incidences of degeneration of olfactory epithelium in exposed females were significantly less than that of the controls. The incidences of lymphoid hyperplasia of the bronchial lymph node in 1.2 mg/m(3) males at 15 months, in 0.6 and 1.2 mg/m(3) females at 15 months, and in 0.6 and 1.2 mg/m(3) males and females at 2 years were significantly greater than those of the controls. The incidences of macrophage hyperplasia in 1.2 mg/m(3) males at 7 and 15 months, in 0.6 and 1.2 mg/m(3) females at 15 months, and in 0.6 and 1.2 mg/m(3) males and females at 2 years were significantly greater than those of the controls. Tissue Burden Analyses: Nickel concentrations in the lungs of exposed mice were greater than those of the controls at 7 months (males, 10 to 11 mg nickel/g lung; females, 10 to 14 mg/g lung) and 15 months (males, 12 to 20 mg nickel/g lung; females, 15 to 26 mg/g lung). GENETIC TOXICOLOGY: Nickel subsulfide was considered to be equivocal in the Salmonella gene mutation assay overall. Sporadic weakly positive and equivocal responses were obtained in strain TA100 with and without S9 metabolic activation enzymes; all other strain/activation combinations gave negative results. No increase in the frequency of micronucleated erythrocytes was observed in peripheral blood samples from male or female mice exposed to nickel subsulfide by inhalation for 13 weeks. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was clear evidence of carcinogenic activity of nickel subsulfide in male F344/N rats based on increased incidences of alveolar/bronchiolar adenoma, carcinoma, and adenoma or carcinoma (combined) and on increased incidences of benign, malignant, and benign or malignant (combined) pheochromocytoma of the adrenal medulla. There was clear evidence of carcinogenic activity of nickel subsulfide in female F344/N rats based on increased incidences of alveolar/bronchiolar carcinoma and alveolar/bronchiolar adenoma or carcinoma (combined) and an increased incidence of benign pheochromocytoma of the adrenal medulla. There was no evidence of carcinogenic activity of nickel subsulfide in male or female B6C3F1 mice exposed to 0.6 or 1.2 mg/m(3). Exposure of male and female rats to nickel subsulfide by inhalation for 2 years resulted in inflammation, hyperplasia, and fibrosis in the lung; inflammation and atrophy of the olfactory epithelium in the nose; and hyperplasia in the adrenal medulla (females). Exposure of male and female mice to nickel subsulfide by inhalation for 2 years resulted in inflammation, bronchialization, hyperplasia, and fibrosis in the lung and inflammation and atrophy of the olfactory epithelium in the nose. Synonyms: Heazlewoodite, nickel subsulphide, nickel sulfide (3:2), a-nickel sulfide (3:2) crystalline, nickel sulphide, nickel tritadisulphide, trinickel disulfide

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Phenolphthalein is used as a laboratory reagent and acid-base indicator and in over-the-counter laxative preparations. The National Cancer Institute nominated phenolphthalein for study because of its widespread use as a component in numerous laxative preparations and the lack of adequate testing for carcinogenicity in experimental animals. Male and female F344/N rats and B6C3F1 mice were exposed to phenolphthalein (98% to 99% pure) in feed for 14 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and mouse peripheral blood. 14-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were given 0, 6,250, 12,500, 25,000, 50,000, or 100,000 ppm phenolphthalein in feed for 14 days. All rats survived to the end of the study. The final mean body weights of all exposed groups of rats were similar to those of the controls. No chemical-related gross or microscopic lesions were observed. 14-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were given 0, 6,250, 12,500, 25,000, 50,000, or 100,000 ppm phenolphthalein in feed for 14 days. All mice survived to the end of the study. The final mean body weights of all exposed groups of mice were similar to those of the controls. No chemical-related gross or microscopic lesions were observed. 13-WEEK STUDY IN RATS: Groups of 10 male and 9 or 10 female F344/N rats were given 0, 3,000, 6,000, 12,000, 25,000, or 50,000 ppm phenolphthalein (equivalent to average daily doses of approximately 200, 400, 800, 1,600, or 3,500 mg phenolphthalein/kg body weight to males and 200, 400, 800, 1,700, or 3,600 mg/kg to females) in feed for 13 weeks. Additional groups of 10 male and 10 female rats designated for clinical pathology evaluations were also given 0, 3,000, 6,000, 12,000, 25,000, or 50,000 ppm phenolphthalein in feed until day 21. All core study rats survived to the end of the study. The final mean body weight of the 50,000 ppm females and the body weight gains of the 25,000 and 50,000 ppm females were significantly lower than those of the controls. The final mean body weights and mean body weight gains of all other exposed groups were similar to those of the controls. There was no cathartic action or any other clinical finding attributed to exposure to phenolphthalein. The few differences in the hematology and clinical chemistry parameters were sporadic and were not considered to be chemical related. The percentage of motile sperm in the 12,000 ppm males was significantly greater than that in the controls, but no other significant differences in sperm morphology or vaginal cytology between exposed and control groups were observed. Absolute and relative liver weights of 25,000 and 50,000 ppm males were significantly greater than those of the controls. No chemical-related gross or microscopic lesions were observed. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were given 0, 3,000, 6,000, 12,000, 25,000, or 50,000 ppm phenolphthalein (equivalent to average daily doses of approximately 500, 1,000, 2,000, 4,100, or 9,000 mg phenolphthalein/kg body weight to males and 600, 1,200, 2,400, 5,000, or 10,500 mg/kg to females) in feed for 13 weeks. All mice survived until the end of the study. The final mean body weights and mean body weight gains of all exposed groups were similar to those of the controls. There was no cathartic action or any other clinical finding attributed to exposure to phenolphthalein. The absolute right cauda weight of the 12,000 ppm males and the absolute right epididymis weights of 12,000, 25,000, and 50,000 ppm males were significantly less than those of the controls. The percentages of abnormal sperm in 12,000, 25,000, and 50,000 ppm males were significantly greater than that in the control group, and the sperm concentrations in 12,000 and 50,000 ppm males were significantly less than that of the control group. The absolute and relative right testis weights of males exposed to 6,000 ppm or greater and the absolute right testis weight of 3,000 ppm mof 3,000 ppm males were significantly less than those of the controls. The incidences of hypoplasia of the bone marrow in males and females exposed to 12,000 ppm or greater were significantly greater than those in the controls. The incidences of hematopoiesis of the spleen in 25,000 and 50,000 ppm males were significantly greater than that in the controls. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female F344/N rats were given 0, 12,000, 25,000, or 50,000 ppm phenolphthalein (equivalent to average daily doses of approximately 500, 1,000, or 2,000 mg phenolphthalein/kg body weight to males and 500, 1,000, or 2,500 mg/kg to females) in feed for 2 years. Survival, Body Weights, and Clinical Findings: Survival of exposed males and females was similar to that of the controls. The mean body weights of exposed males were less than those of the controls through most of the second year of the study, and the mean body weights of exposed females were less than those of the controls from about week 16 until the end of the study. Clinical findings attributed to phenolphthalein exposure included thin appearance and ruffled fur in all exposed groups of males. Determinations of Total Phenolphthalein in Plasma: The mean plasma concentrations of total phenolphthalein (free and conjugated) after 2 years of exposure varied little with time of day. Plasma concentrations of total phenolphthalein were approximately the same between exposure groups and between males and females. Pathology Findings: The incidences of benign pheochromocytoma of the adrenal medulla in all exposed groups of males were significantly greater than those in the controls and occurred with a significant positive trend. The incidences of benign pheochromocytoma in 12,000 ppm females and of benign or malignant pheochromocytoma (combined) in 12,000 and 25,000 ppm females were significantly greater than those in the controls. The numbers of exposed males with bilateral benign pheochromocytomas exceeded the number of controls with these neoplasms. The incidences of malignant pheochromocytomas in exposed rats were similar to those in the controls. The incidences of focal hyperplasia of the adrenal medulla in the 12,000 and 50,000 ppm males were significantly greater than in the controls. The incidences of renal tubule adenoma in 50,000 ppm male rats and of renal tubule adenoma or carcinoma (combined) in 12,000 and 50,000 ppm male rats were significantly greater than those in the controls. Although the increased incidences were predominantly of renal tubule adenoma, four carcinomas were observed in exposed males (0 ppm, 0/50; 12,000 ppm, 1/50; 25,000 ppm, 1/50; 50,000 ppm, 2/50). The incidences of renal tubule neoplasms in exposed groups of females were similar to those in the controls. The findings from an extended evaluation (step section) of the kidneys of female rats were similar to those from the standard evaluation. The incidences of nephropathy in all exposed groups of females were significantly greater than in the controls, and the severity of nephropathy in all exposed groups of males and in 25,000 and 50,000 ppm females was significantly greater than in the controls. The incidences of diffuse hyperplasia of the parathyroid gland (0/41, 16/48, 14/49, 14/46), fibrous osteodystrophy of the bone (0/50, 17/50, 14/50, 12/50), and mineralization (0/50, 11/50, 5/50, 5/49) and degeneration (0/50, 11/50, 5/50, 4/49) of the glandular stomach in exposed groups of males were generally significantly greater than those in the controls. The incidences of hyperplasia of the thyroid gland C-cells (13/50, 3/50, 9/49, 4/49) in 12,000 and 50,000 ppm males were significantly less than in the controls. These lesions are commonly observed in male rats with more advanced nephropathy and are considered to be associated with a calcium/phosphorus imbalance created by compromised functional capacity of the kidney. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female B6C3F1 mice were given 0, 3,000, 6,000, or 12,000 ppm phenolphthalein (equivalent to average daily doses of approximately 300, 600, or 1,200 mg phenolphthalein/kg body weight to males and 400, 800, or 1,500 mg/kg to females) in feed for 2 years. Survival, Body Weights, and Clinical Findings: Survival of the 12,000 ppm females was significantly lower than that of the controls; survival of all other exposed groups of mice was similar to that of the controls. The mean body weights of 12,000 ppm males were slightly less than those of the controls beginning at week 93 of the study, and the mean body weights of the 3,000, 6,000, and 12,000 ppm females were less than those of the controls during most of the second year of the study. In exposed mice, there were no clinical findings related to phenolphthalein exposure. Determinations of Total Phenolphthalein in Plasma: The mean plasma concentrations of total phenolphthalein (free and conjugated) after 2 years of exposure varied little with time of day. Plasma concentrations of total phenolphthalein were approximately the same between exposure groups and between males and females. Pathology Findings: The incidences of histiocytic sarcoma in 6,000 and 12,000 ppm males and females were significantly greater than those in the controls and occurred with a significant positive trend. In this study, histiocytic sarcoma was consistently observed in the liver with several other sites (e.g., spleen, lung, bone marrow, and various lymph nodes) involved less frequently. The incidences of all types of malignant lymphoma and of lymphoma of thymic origin in all exposed groups of females were significantly greater than those in the controls and occurred with significant positive trends, while the incidences of all types of malignant lymphoma in all exposed groups of males were similar to that in the controls. The incidences of lymphoma of thymic origin were increased in exposed groups of males, but were significantly increased only in the 6,000 ppm group. The incidences of atypical hyperplasia of the thymus in 6,000 and 12,000 ppm males and in all exposed groups of females were significantly greater than those in the controls. The incidences of benign sex-cord stromal tumors of the ovary in all exposed groups of females were significantly greater than in the controls. The incidences of hyperplasia of the ovary in 3,000 and 12,000 ppm females were significantly greater than in the controls. The incidences of germinal epithelial degeneration of the testis in all exposed groups of males were significantly greater than that in the controls. There were increased incidences of myelofibrosis of the bone marrow in 12,000 ppm males (0 ppm, 3/50; 3,000 ppm, 8/50; 6,000 ppm, 8/50; 12,000 ppm, 19/49) and an increased severity but not incidence of this lesion in exposed females. There were also increased incidences of pigmentation of minimal to mild severity in the bone marrow of 6,000 and 12,000 ppm males (0/50, 2/50, 5/50, 16/49) and females (2/50, 3/50, 11/50, 11/50). Also, the incidences of hematopoietic cell proliferation in the red pulp of the spleen (10/50, 22/50, 28/50, 21/49) in all exposed groups of males were significantly greater than that in the controls, and the severity of this lesion increased with increasing exposure concentration. The incidences of hepatocellular adenoma in all exposed groups of males and females and of hepatocellular adenoma or carcinoma (combined) in 6,000 and 12,000 ppm males and all exposed groups of females were significantly less than those in the controls, and these lesions occurred with significant negative trends. Multiple hepatocellular adenomas were observed more frequently in the control groups than in the exposed groups. The incidences of clear cell and eosinophilic foci in all exposed groups of males and of mixed cell foci in 12,000 ppm males were significantly less than those in the controls. The incidences of eosinophilic foci in exposed groups of females were significantly less than that in the controls. GENETIC TOXICOLOGY: Phenolphthalein, tested in two laboratories, was not mutagenic in any of four strains of Salmonella typhimurium with or without S9 metabolic activation enzymes, and no induction of sister chromatid exchanges was observed in cultured Chinese hamster ovary cells treated with phenolphthalein with or without S9. However, significant increases in chromosomal aberrations were observed after treatment of cultured Chinese hamster ovary cells with phenolphthalein in the presence of S9, and the frequencies of micronucleated erythrocytes were increased in peripheral blood samples from male and female mice administered phenolphthalein in feed for 13 weeks. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was clear evidence of carcinogenic activity of phenolphthalein in male F344/N rats based on markedly increased incidences of benign pheochromocytomas of the adrenal medulla and of renal tubule adenomas and adenomas or carcinomas (combined). There was some evidence of carcinogenic activity of phenolphthalein in female F344/N rats based on the increased incidences of benign pheochromocytomas of the adrenal medulla in the 12,000 ppm group and of benign or malignant pheochromocytomas (combined) in the 12,000 and 25,000 ppm groups. There was clear evidence of carcinogenic activity of phenolphthalein in male B6C3F1 mice based on increased incidences of histiocytic sarcomas and of malignant lymphomas of thymic origin. There was clear evidence of carcinogenic activity of phenolphthalein in female B6C3F1 mice based on increased incidences of histiocytic sarcomas, malignant lymphomas of all types, lymphomas of thymic origin, and benign sex-cord stromal tumors of the ovary. Exposure of rats to phenolphthalein in feed for 2 years resulted in increased incidences of focal hyperplasia of the adrenal medulla in males and in increased incidences and/or severity of nephropathy of the kidney in males and females. Exposure of mice to phenolphthalein in feed for 2 years resulted in increased incidences of atypical hyperplasia of the thymus in males and females, degeneration of the germinal epithelium of the testis in males, and ovarian hyperplasia in females. Exposure of mice to phenolphthalein in feed for 2 years resulted in decreased incidences of hepatocellular neoplasms and nonneoplastic lesions in males and females. Synonyms: 3,3-Bis(4-hydroxyphenyl)-1(3H)-isobenzofuranone; 3,3-bis( p-hydroxyphenyl)phthalide; a-p -hydroxyphenyl)-a- (4-oxo-2,5-cyclohexadien-1-ylidene)- o-toluic acid Trade names: Agoral&amp;reg;, Alophen&amp;reg;, Colax&amp;reg;, Correctol&amp;reg;, Dialose&amp;reg;, Doxidan&amp;reg;, Espotabs&amp;reg;, Evac-U-Gen&amp;reg;, Evac-U-Lax&amp;reg;, Ex-Lax&amp;reg;, Feen-A-Mint&amp;reg;, FemiLax&amp;reg;, Kondremul&amp;reg;, LaxCaps&amp;reg;, Lax-Pills&amp;reg;, Medilax&amp;reg;, Modane&amp;reg;, Phenolax&amp;reg;, Prulet&amp;reg;

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Dear Editor, The costs of antipsychotic drugs (APDs) used in the treatment of mental disorders with psychosis are mentioned in treatment guidelines (APA 2021, NICE 2014). While the American Psychiatric Association guideline states that every specialist should make decisions according to the rules and conditions of their country and their region, the National Institute of Health and Clinical Excellence guideline emphasizes that drug costs must be taken into consideration in the treatment process. Classical or first-generation antipsychotic drugs (FAPDs) are relatively cheaper in terms of sales prices compared to atypical or second-generation antipsychotic drugs (SAPDs) with a slightly different effect mechanism. The price difference between the two drug groups can be so large that sometimes it may be necessary to consider whether the cost of a second-generation drug is worth its benefit. While deciding on the use of first-generation or second-generation drugs, a multifaceted assessment should be made, such as the patient's level of compliance with the treatment, the possibility of occurrence of side effects, the possible effects of these side effects on body health and treatment compliance, and whether or not the costs are covered. The most important criterion that determines the choice of medication for psychiatrists is of course the multi-dimensional benefit/harm ratio that the drug used will reveal in the long term. We think that in our country, which, in terms of economic indicators is not in a strong position as an importer of pharmaceutical raw materials from abroad, APDs' cost calculation should be considered because drug costs constitute an important part of the direct treatment costs of psychotic disorders in developing countries such as Turkey (Yıldız and Cerit 2006). We calculated the unit (mg) price based on the box prices of the APDs in use in 2020, thinking that it might work when calculating the cost of the illness using APDs as the main component of the treatment and calculated the annual average drug costs with the daily average dosage. Although the daily treatment dose varies with the stage of the illness and the individual characteristics of the patient, the average doses recommended for maintenance treatment were used here (Öztürk and Ulusahin 2018). The daily and annual cost calculations based on the assumption that the average maintenance treatment dose was used with the unit price obtained from (Drug Prices 2020) the drugs in the Turkish pharmaceutical market in September 2020 are shown in Table 1. A similar study was done in 2005 (Yıldız 2005). The purpose of this article is to redetermine the average costs of APDs in the Turkish pharmaceutical market every 15 years and to bring them to the attention of experts in terms of cost-effectiveness studies. When the costs in 2005 are examined, it is seen that the annual costs of the FAPDs were around 450 TRY, and the annual cost of oral preparations of SAPDs was 2,500 TRY (5 times the first generation). In 2005, there was only one depot of SAPD (risperidon consta) that allowed intramuscular (IM) administration, and its average annual cost was 5,400 TRY, 3 times more than the tablet form (1,700 TRY). In 2005, when the price of risperidone consta, which was the first second-generation depot APD, were compared with the prices of the first-generation depot drugs (fluphenazine = 380 TRY, flupentixol = 876 TRY, zuclopentixol = 730 TRY), the cost difference was 6-14 times. This almost-10-fold difference between the cost of the first and second generation APDs was remarkable. It is seen that this difference (risperidone consta = 10,807 TRY, fluphenazine = 916 TRY, flupentixol = 1,007 TRY, zuclopenthixol = 2,372 TRY, and haloperidol deconate 237 TRY) did not change in 2020. In 2020, the average RETHINKING THE COST OF ANTIPSYCHOTIC TREATMENT: THE AVERAGE COST OF THE DRUGS USED IN TURKEY IN 2020 2 Türk Psikiyatri Dergisi 2 Turkish Journal of Psychiatry Letter to the Editor 146 147 annual cost of oral use preparations of FAPDs is 925 TRY, while the average annual cost of oral forms of SAPDs is 2,580 TRY. The 5-fold difference observed in 2005 between the first and second-generation ones of the oral APDs decreased to 2.5 times in 2020. It is clear that while the difference between the cost of oral use of first- and second-generation drugs was halved in 2020, the difference between the costs of depot preparations applied with IM did not change. In 2005, the average dollar rate was 1.34 TRY, and in 2020 it was 7.02 TRY (Republic of Turkey Central Bank Exchange Rates, 2021). It is understood that the 5-fold increase in dollar exchange rate is not reflected in all drug prices in the same way. For example, there was a 3 to 4-fold increase in the prices of haloperidol, chlorpromazine, fluphenazine, trifluperazine and zuclopenthixol, while a less than two-fold increase in pimozide, flupenthixol, sulpiride, amisulpride and quetiapine and a decrease in the prices of clozapine, olanzapine, ziprasidone and risperidone in the tablet form. There is also a two-fold increase in the price of risperidone consta. The fluctuations in drug prices in 2005 and 2020 are shown in Table 2 in 500, 1,000, 2,000, 3,000 and 5,000 TRY brackets. It is noteworthy that while some drugs have moved into an upper price bracket in terms of annual costs, some have fallen into a lower price bracket. The prices of the second generation long-acting (depot) antipsycotic drugs (LA-APDs), which were not available in the Turkish pharmaceutical market in 2005, are quite high compared to others. In 2020, the annual cost of all of them, including risperidone consta, is over 10 thousand TRY. It is understood that the underlying reason for such price increase is the fact that the drug is wanted/sought after/new/marketed rather than the dollar exchange rate. For example, while there was a certain increase in the price of FAPDs, the increase in the price of some of the SAPDs (sulpiride, amisulpride, quetiapine tablet) was low, while the price of some others (clozapine, olanzapine, ziprasidone, risperidone tablet) decreased. It should also be taken into account that the effect of generic drugs entering the market during this period may have had an impact on price changes. It is noteworthy that while the annual cost of risperidone consta was approximately 3 times higher than the tablet form (5,400 TRY versus 1,700 TRY) in 2005, this difference reached 14 folds (10,807 TRY versus 742 TRY) in 2020. In 2005, the difference between the lowest daily cost (0.07 TRY) and the highest daily cost (14.80 TRY) was 211 times (Yıldız 2005), this difference had receded to 111 times (0.35 TRY versus 38.72 TRY) in 2020. Still a huge difference, isn't it? Table 1. Current Forms, Box Prices, Daily and Annual Costs in For Maintenance Treatment of Antipsychotic Drugs Available in the Pharmaceutical Market in September 2020 in Turkey No Generic name Trade name Dosage forms (mg) BV Price# TRY/Mg ADD Cost/d Cost/y 2005** 1 Haloperidol Norodol 5, 10, 20 tb 5/50 17.57 0.070 5 0.35 127 26 5, 10 amp 5/5 5.35 0.214 5 1.07 390 - 50, 150 LAI 50/1 9.80 0.196 1/15* 0.65 237 - 2 Chlorpromazine Largactil 25,100 tb 100/30 17.92 0.006 300 1.79 653 197 3 Fluphenazine Prolixin 25 LAI 25/1 17.57 0.703 1/7* 2.51 916 380 4 Trifluoperazine Stilizan 1, 2, 5 drj; 1 amp 5/30 14.52 0.096 10 0.97 354 91 5 Pimozide Nörofren 2 tb 2/30 19.33 0.322 4 1.29 470 365 6 Flupenthixol Fluanxol 3 drj 3/50 65.75 0.438 6 2.63 960 526 20 LAI 20/1 19.33 0.966 1/7* 2.76 1,007 876 7 Zuklopenthixol Clopixol 2, 10, 25 tb 2/50 38.65 0.386 20 7.72 2,817 701 200 LAI, 50 acu 200/1 45.55 0.227 1/7* 6.50 2,372 730 8 Sulpirid Dogmatil 200 tb 200/24 23.15 0.005 600 3.00 1,095 876 9 Amisulpirid Solian 200 tb 200/60 146.92 0.012 600 7.20 2,628 2,387 10 Quetiapine Seroquel 25, 50, 100, 200, 300, 400 tb 300/30 137.17 0.015 600 9.00 3,285 2,628 11 Clozapine Leponex 25, 100 tb 100/50 32.56 0.006 400 2.40 876 1,898 12 Olanzapine Zyprexa 5, 10, 20 tb 10/28 152.96 0.546 10 5.46 1,992 2,606 13 Ziprasidone Zeldox 20, 40, 60, 80 tb 60/56 189.89 0.056 120 6.72 2,452 3,541 14 Sertindole Serdolect 4, 12, 16, 20 tb 16/28 453.53 1.012 16 16.19 5,909 - 15 Risperidone Risperdal 1, 2, 3, 4 tb; 1 sol 2/20 20.34 0.508 4 2.03 741 1,719 Ris. Consta 25, 37.5, 50 LAI 37.5/1 444.17 11.840 1/15* 29.61 10,807 5,402 16 Paliperidone Invega 3, 6, 9 tb 6/28 213.15 1.268 6 7.61 2,777 - Xeplion 50, 75, 100, 150 LAI 100/1 1161.56 11.615 1/30* 38.72 14,132 - Trevicta 175, 263, 350, 525 LAI 350/1 3426.95 9.788 1/90* 38.08 13,899 - 17 Aripiprazole Abilify 5, 10, 15, 20 tb; 1 sol 20/28 113.25 0.404 20 8.08 2,949 - Abilify Main. 400 LAI 400/1 971.17 2.420 1/30* 32.37 11,815 - BV: Baseline value (in mg of the form and the number in the box), Price#: Box price of the base value in TRY, TRY/mg: Value per milligram in Turkish Lira, ADD: Average daily dose, Cost/d: Daily cost in TRY, Cost/y: Annual cost in TRY, mg: Milligram, tb: Tablet, drj: Dragee, amp: Ampoule, LAI: Long-acting injectable, acu: Acuphase, d: Day, TRY: Turkish Lira, *LAI per 7,15,30 or 90 days, **Annual cost in TRY in 2005. 148 Received: 14.01.2021, Accepted: 31.03.2021, Available Online Date: 07.01.2022 1Prof., 2Res. Assis., Kocaeli University School of Medicine, Department of Psychiatry, Kocaeli, Turkey. e-mail: [email protected] https://doi.org/10.5080/u26315 The difference in 2005 between oral FAPDs prices and SAPDs prices seems to have halved in 2020. In 2020, the average daily treatment cost of oral drugs, whether for the first generation or the second generation, is 3 TRY (approximately the same for FAPDs applied with IM), while the daily cost of LA-SAPDs is around 33 TRY. It is seen that the difference between costs is approximately 11 times. This difference increases to 50 times for haloperidol deconate. From here, the following judgment can be made: in order for LA-SAPDs to be preferred, they must be at a value that will constitute at least 11 times higher cost. This cost can and should be taken, especially for patients who are non-adherend with treatment and who do not adapt to LA-FAPDs. Because for clinicians, preventing the multi-dimensional destructiveness of psychosis in the individual, families and the society should be the priority. In this case, calculating the cost should not be a primary consideration. However, it is also known that patients who are non-adherend with treatment gain the ability to understand their illness and make consistent evaluations with its' results. If a psychosocial therapy has been carried out for a patient using IM medication for six months or a year, it is likely that this period provides insight and increases the level of treatment compliance. After one year of IM application, whether or not the patient will comply with oral treatment should be re-evaluated and the transition to oral treatment should be considered. If there is no problem in the patient's oral treatment compliance, it should be taken into account that the benefit of this transition will be at least 11-folds a year with this transition. Naturally, it will be necessary to apply IM for some patients for years. Moreover, there will be patients who need to switch from monthly administration of LA-SAPDs to quarterly usage patterns. However, we can say that most patients using LA-APDs will not need such use after a while, based on our clinical practice, although there is no study done in this field. With this study, we wanted to emphasize that while prescribing drugs used in the treatment of illnesses with psychotic symptoms, they should take into account the side effects of the drugs, as well as the daily, monthly, annual, and lifetime costs of the drugs. The principle of 'using an effective drug recommended for a specific disorder at the required dose, in sufficient time, at the lowest cost' adopted in the rational drug use guidelines should not be forgotten. It is expected that the modification of drug treatments, considering their costs as well as their efficiency, will contribute significantly to the country's economy in the long run. Mustafa Yıldız1, Emre Osman2 REFERENCES American Psychiatric Association (2021) The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Third edition. Washington, DC: American Psychiatric Association. Drug Prices. https://www.ilacrehberi.com/ilac-fihrist/ Accession date: 25th September 2020. National Institute for Health and Clinical Excellence (NICE) (2014) Psychosis and schizophrenia in adults: prevention and management. NICE Guideline CG178; https://www.nice.org.uk/guidance/cg178. Accession date: 4th April 2018. Öztürk MO, Uluşahin NA (2018) Mental Health and Disorders. 18th Edit. Ankara: Nobel Tıp Kitapevleri. (In Turkish) Republic of Turkey Central Bank Exchange Rates. https://www.tcmb.gov.tr/kurlar/kurlar_tr.html Accession date: 10th January 2021. Yıldız M (2005) The cost of treatment of psychotic disorders. Turk Psikiyatri Derg 16:146-7. (In Turkish) Yıldız M, Cerit C (2006) Annual cost of treatment for schizophrenia: Estimation from a university hospital data in Turkey. Bulletin of Clinical Psychopharmacology 16:239-44. Table 2. Comparison of the Annual Costs of Antipsychotic Drugs Calculated By The Daily Standard Average Dose Use, at Certain Price Ranges, for the Years 2005 and 2020 Price bracket (TRY) 2005 2020 500 ↓ Haloperidol tb, amp, Trifluoperazine drj, Chlorpromazine tb, Pimozid tb, Fluphenazine LAI Haloperidol tb, amp, depo, Trifluoperazine drj, Pimozid tb 500-1,000 Flupenthixol drj, LAI, Zuklopenthixol tb, acu, LAI, Sulpirid tb Chlorpromazine tb, Fluphenazine LAI, Flupenthixol drj, LAI, Clozapine tb, Risperidone tb 1,000-2,000 Clozapine tb, Risperidone tb Olanzapine tb, Sulpirid tb 2,000-3,000 Amisulpirid tb, Olanzapine tb, Quetiapine tb Zuklopenthixol tb, acu, LAI, Amisulpirid tb, Ziprasidone tb, Paliperidone tb, Aripiprazole tb 3,000-5,000 Ziprasidone tb Quetiapine tb 5,000-10,000 Risperidone consta Sertindole tb 10,000 ↑ Risperidone consta, Paliperidone monthly, Paliperidone 3 monthly, Aripiprazole maintana tb: Tablet, drj: Dragee, amp: Ampoule, LAI: Long-acting injectable, acu: Acuphase.

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Nickel oxide (NiO) "sinters" are used in stainless steel and alloy steel production. Nickel oxide was nominated by the National Cancer Institute to the NTP for testing because exposure to this form of nickel is prevalent in the nickel industry. Increased incidences of lung and nasal sinus cancers have occurred among workers in certain nickel refining facilities, and nickel oxide was studied as part of a class study of nickel compounds. Male and female F344/N rats and B6C3F1 mice were exposed to nickel oxide (high temperature, green nickel oxide; mass median diameter 2.2 +/- 2.6 &amp;mgr;m; at least 99% pure) by inhalation for 16 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in peripheral blood of B6C3F1 mice exposed to nickel oxide for 13 weeks. 16-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were exposed to 0, 1.2, 2.5, 5, 10, or 30 mg nickel oxide/m(3)(equivalent to 0, 0.9, 2.0, 3.9, 7.9, or 23.6 mg nickel/m(3)) by inhalation for 6 hours per day, 5 days per week for a total of 12 exposure days during a 16-day period. Additional groups of five male and five female rats were exposed to 0, 1.2, 5, or 10 mg/m(3) for tissue burden studies. All core study rats survived until the end of the study, final mean body weights of exposed male and female rats were similar to those of the controls, and there were no clinical findings related to nickel oxide exposure. Absolute and relative lung weights of male and female rats exposed to 10 or 30 mg/m(3) were significantly greater than those of the controls. Pigment particles in alveolar macrophages or within the alveolar spaces were observed in the lungs of exposed groups of males and females. Chronic-active inflammation and accumulation of macrophages in alveolar spaces of the lungs and hyperplasia in the respiratory tract lymph nodes were most severe in 10 and 30 mg/m(3) males and females. Hyperplasia of bronchial lymph nodes occurred in 30 mg/m(3) rats. Atrophy of the olfactory epithelium was observed in one male and one female exposed to 30 mg/m(3). The concentrations of nickel oxide in the lungs of exposed groups of rats were greater than those in the lungs of control groups (males, 42 to 267 mg nickel/g lung; females, 54 to 340 mg/g lung). 16-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were exposed to 0, 1.2, 2.5, 5, 10, or 30 mg nickel oxide/m(3) by inhalation for 6 hours per day, 5 days per week for a total of 12 exposure days during a 16-day period. Additional groups of five male and five female mice were exposed to 0, 1.2, 2.5, or 5 mg/m(3) for tissue burden studies. No exposure-related deaths occurred among core study mice, and final mean body weights of exposed male and female mice were similar to those of the controls. There were no chemical-related clinical findings. Pigment particles were present in the lungs of mice exposed to 2.5 mg/m(3) or greater. Accumulation of macrophages in alveolar spaces was observed in the lungs of 10 and 30 mg/m(3)males and females. The concentrations of nickel oxide in the lungs of exposed groups of mice were significantly greater than those in the lungs of control animals (males, 32 to 84 mg nickel/g lung; females, 31 to 71 mg/g lung). 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were exposed to 0, 0.6, 1.2, 2.5, 5, or 10 mg nickel oxide/m(3) (equivalent to 0, 0.4, 0.9, 2.0, 3.9, or 7.9 mg nickel/m(3)) by inhalation for 6 hours per day, 5 days per week for 13 weeks. Additional groups of 18 male and 18 female rats were exposed to 0, 0.6, 2.5, or 10 mg/m(3) for tissue burden studies. No exposure-related deaths occurred among core study rats, final mean body weights of exposed male and female rats were similar to those of the controls, and no clinical findings in any group were related to nickel oxide exposure. Lymphocyte, neutrophil, monocyte, and erythrocyte counts; hematocrit values; and hemoglobin and mean cell hemoglobin concentrations in exposed rats were minimally to mildly greater than those of the controls; these differences were most pronounced ironounced in females. Mean cell volumes in exposed rats were generally less than those in the controls. Absolute and relative lung weights of exposed groups of males and females were generally significantly greater than those of controls. Chemical-related nonneoplastic lesions were observed in the lungs of male and female rats exposed to concentrations of 2.5 mg/m(3) or higher, and the severity of these lesions generally increased with exposure concentration. Accumulation of alveolar macrophages, many of which contained black, granular pigment, was generally observed in all exposed groups of males and females, and increased incidences of inflammation occurred in males and females exposed to 2.5 mg/m(3) or higher. In addition, lymphoid hyperplasia and pigment occurred in the bronchial and mediastinal lymph nodes of 2.5, 5, and 10 mg/m(3) males and females. The concentration of nickel oxide in the lungs of 0.6, 2.5, and 10 mg/m(3)males was greater than in the lungs of controls at 4, 9, and 13 weeks, and nickel continued to accumulate in the lung at the end of the 13-week exposures (4 weeks, 33 to 263 mg nickel/g lung; 9 weeks, 53 to 400 mg/g lung; 13 weeks, 80 to 524 mg/g lung). 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were exposed to 0, 0.6, 1.2, 2.5, 5, or 10 mg nickel oxide/m(3) by inhalation for 6 hours per day, 5 days per week for 13 weeks. Additional groups of six male and six female mice were exposed to 0, 0.6, 2.5, or 10 mg/m(3) for tissue burden studies. No exposure-related deaths occurred among core study animals, final mean body weights of exposed male and female mice were similar to those of the controls, and no clinical findings in any group were related to nickel oxide exposure. Hematocrit values and erythrocyte counts in 5 and 10 mg/m(3) females were minimally greater than those of the controls, as was the hemoglobin concentration in 5 mg/m(3) females. Absolute and relative lung weights of 10 mg/m(3) males and females were significantly greater than those of controls, and absolute and relative liver weights of 10 mg/m(3) males were significantly less than those of controls. Accumulation of alveolar macrophages, many of which contained pigment particles, occurred in all groups of mice exposed to nickel oxide. Inflammation (chronic active perivascular infiltrates or granulomatous) occurred in 2.5, 5, and 10 mg/m(3) males and females. In addition, lymphoid hyperplasia and pigment occurred in the bronchial lymph nodes of males and females exposed to 2.5 mg/m(3) or higher. The concentration of nickel in the lung was greater than that of controls in 0.6, 2.5, and 10 mg/m(3) males at 13 weeks (42 to 736 mg nickel/g lung). 2-YEAR STUDY IN RATS: Survival, Body Weights, Clinical Findings, and Hematology Groups of 65 male and 65 female F344/N rats were exposed to 0, 0.62, 1.25, or 2.5 mg nickel oxide/m(3) (equivalent to 0, 0.5, 1.0, or 2.0 mg nickel/m(3)) by inhalation for 6 hours per day, 5 days per week for 104 weeks. Survival of exposed male and female rats was similar to that of the controls. Mean body weights of 1.25 mg/m(3) females and 2.5 mg/m(3) males and females were slightly lower than those of the controls during the second year of the study. No chemical-related clinical findings were observed in male or female rats during the 2-year study. No chemical-related differences in hematology parameters were observed in male or female rats at the 15-month interim evaluation. Pathology Findings: Absolute and relative lung weights of 1.25 and 2.5 mg/m(3) males and females were significantly greater than those of the controls at 7 and 15 months. At 2 years, there were exposure-related increased incidences of alveolar/bronchiolar adenomas alveolar/bronchiolar adenoma or carcinoma (combined) in males and females. Incidences of atypical alveolar epithelial hyperplasia in the lungs generally increased with increasing exposure concentration in male and female rats. Chronic inflammation of the lung was observed in most exposed rats at 7 and 15 months and at 2 years; the incidences in exposed males and females at 2 years were significantly greater than those in the controls, and the severity of the inflammation increased in exposed groups. The incidences of pigmentation in the alveolus of exposed groups of males and females were significantly greater than those of the controls at 7 and 15 months and at 2 years. Pigmentation in the bronchial lymph nodes similar to that in the lungs was observed in all exposure groups with the exception of 0.62 mg/m(3)males and females at 7 months. Lymphoid hyperplasia was observed in the bronchial lymph nodes of 1.25 and 2.5 mg/m(3) males and females at 7 and 15 months, and the incidence at 2 years generally increased with exposure concentration. At 2 years, there was an exposure-related increase in the incidence of benign pheochromocytoma in males and females. The incidences of benign pheochromocytoma and adrenal medulla hyperplasia in 2.5 mg/m(3) females and the incidence of benign or malignant pheochromocytoma (combined) in 2.5 mg/m(3) males were significantly greater than those in the controls. Tissue Burden Analyses: Nickel concentrations in the lungs of exposed rats were greater than those in the controls at 7 and 15 months (7 months, 173 to 713 mg nickel/g lung; 15 months, 262 to 1,116 mg/g lung), and nickel concentrations increased with increasing exposure concentration and with time. 2-YEAR STUDY IN MICE: Survival, Body Weights, Clinical Findings, and Hematology Groups of 74 to 79 B6C3F1 mice were exposed to 0, 1.25, 2.5, or 5 mg nickel oxide/m(3) by inhalation for 6 hours per day, 5 days per week for 104 weeks. Survival of exposed male and female mice was similar to that of the controls. Mean body weights of 5 mg/m(3) females were slightly lower than those of the controls during the second year of the study. No chemical-related clinical findings were observed in male or female mice during the 2-year study. No chemical-related differences in hematology parameters were observed in male or female mice at the 15-month interim evaluation. Pathology Findings: At 2 years, the incidence of alveolar/bronchiolar adenoma in 2.5 mg/m(3) females was significantly greater than that of the controls, as was the incidence of alveolar/bronchiolar adenoma or carcinoma (combined) in 1.25 mg/m(3) females. Generally, incidences of chronic inflammation increased with exposure concentration in males and females at 7 and 15 months. Bronchialization of minimal severity in exposed animals and proteinosis were first observed at 15 months. At 2 years, the incidences of chronic inflammation, alveolar epithelial hyperplasia, and proteinosis in exposed groups of males and females were significantly greater than those of the controls. The severity of chronic inflammation increased with exposure concentration in females, and proteinosis was most severe in 5 mg/m(3) males and females. Pigment occurred in the lungs of nearly all exposed mice at 7 and 15 months and at 2 years, and the severity increased with exposure concentration. Lymphoid hyperplasia occurred in two animals after 7 months; at 15 months, lymphoid hyperplasia occurred in males exposed to 2.5 and 5 mg/m(3) and in all exposed groups of females. At 2 years, lymphoid hyperplasia occurred in some control animals, but this lesion was still observed more often in exposed males and females and the incidence increased with exposure concentration. Pigmentation was observed in the bronchial lymph nodes of exposed males and females at 7 and 15 months and in nearly all exposed animals at 2 years. Tissue Burden Analyses: Nickel concentrations in the lungs of exposed mice were significantly greater than those in the controls at 7 and 15 months (7 months, 162 to 1,034 mg nickel/g lung; 15 months, 331 to 2,258 mg/g lung), and nickel concentrations increased with increasing exposure concentration and with time. GENETIC TOXICOLOGY: No increase in the frequency of micronucleated normochromatic erythrocytes was observed in peripheral blood samples from male or female mice exposed to nickel oxide. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was some evidence of carcinogenic activity of nickel oxide in male F344/N rats based on increased incidences of alveolar/bronchiolar adenoma or carcinoma (combined) and increased incidences of benign or malignant pheochromocytoma (combined) of the adrenal medulla. There was some evidence of carcinogenic activity of nickel oxide in female F344/N rats based on increased incidences of alveolar/bronchiolar adenoma or carcinoma (combined) and increased incidences of benign pheochromocytoma of the adrenal medulla. There was no evidence of carcinogenic activity of nickel oxide in male B6C3F1 mice exposed to 1.25, 2.5, or 5 mg/m(3). There was equivocal evidence of carcinogenic activity of nickel oxide in female B6C3F1 mice based on marginally increased incidences of alveolar/bronchiolar adenoma in 2.5 mg/m(3) females and of alveolar/bronchiolar adenoma or carcinoma (combined) in 1.25 mg/m(3) females. Exposure of rats to nickel oxide by inhalation for 2 years resulted in inflammation and pigmentation in the lung, lymphoid hyperplasia and pigmentation in the bronchial lymph nodes, and hyperplasia of the adrenal medulla (females). Exposure of mice to nickel oxide by inhalation for 2 years resulted in bronchialization, proteinosis, inflammation, and pigmentation in the lung and lymphoid hyperplasia and pigmentation in the bronchial lymph nodes. Synonyms: Bunsenite; C.I. 77777; green nickel oxide; mononickel oxide; nickel monoxide; nickel oxide sinter 75; nickel protoxide; nickel (II) oxide; nickel (T+) oxide; nickelous oxide

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If instead of the title "Prophylactic Oophorectomy: Reducing the U.S. Death Rate from Epithelial Ovarian Cancer," the title were "Drug X Reducing the U.S. Death Rate from Epithelial Ovarian Cancer," there would be great media and medical attention worldwide to such a report. Correctly so. Regrettably, there probably is no new Drug X in the foreseeable future that will significantly reduce the death rate from ovarian cancer, be it Taxol&amp;reg;, taxotere, topotecan, gemcitabine, or liposomal doxorubicin-although each may result in significant responses and some prolongation of median survival. Epithelial ovarian cancer is a much more complex disease than anyone envisioned, when it was believed that extensive debulking surgery and the newest cytotoxic chemotherapy would radically reduce the death rate from ovarian cancer in the United States. Over 20 years after the first patient was treated with cisplatin for epithelial ovarian cancer, the annual death rate from ovarian cancer continued to increase. Just in the past decade, the number of women in the United States dying from ovarian cancer has increased 18% (Fig. 1) [1]. Although ovarian cancer is estimated to account for 26,700 cases and 14,800 deaths in 1996, it is a low-prevalence disease in comparison with breast cancer, which in 1996 is estimated to account for 185,700 cases and 44,560 deaths. Inexplicably, similar to breast cancer, the lifetime risk for ovarian cancer in the United States continues to increase. The most recent Surveillance, Epidemiology and End Results (SEER) calculations of lifetime risk for ovarian cancer are that 1 in 55 women will develop ovarian cancer over their lifetime, or 1.8%, up from the 1970 figures of 1 in 70, or 1.4% [2]. The 1.8% baseline lifetime risk for the general population is used to estimate the lifetime risk of known ovarian cancer risk factors (Table 1). Even utilizing what are now believed to be two of the most effective cytotoxic drugs against stage III and IV epithelial ovarian cancer, Taxol&amp;reg; and cisplatin, researchers reported that this resulted in an increase in the median disease-free survival of only five months, as compared with those women allocated to receive cisplatin and cyclophosphamide (median disease-free survival of 18 and 12.9 months, respectively), felt then to be the standard therapy [3]. Patients treated with Taxol&amp;reg; and cisplatin survived a median of 14 months longer than those treated with cisplatin and cyclophosphamide. These results may improve in women whose cancers were optimally debulked to &lt;/=1 cm residual disease, since the current study included only women with residual cancer greater than 1 cm. Given these sobering statistics, the public health issue is whether prophylactic oophorectomy for two select groups of women may be one measure in reducing the mortality from ovarian cancer in the United States. The two groups of women are: A) women age 40 or older who undergo hysterectomy for non-cancerous uterine conditions and B) those with a family history of ovarian cancer. PROPHYLACTIC OOPHORECTOMY AT THE TIME OF HYSTERECTOMY IN WOMEN AGE 40 OR OLDER: Concerning the first group of women, researchers from the University of Miami reported that 4.5%-14.1% of women develop ovarian cancer after prior hysterectomy for non-ovarian conditions (Table 2) [4-9]. Utilizing their University of Miami experience and the three other similar series in the literature, they were able to determine the number of ovarian cancer patients who had previously undergone hysterectomy at age 40 or older for non-cancerous uterine conditions. Of the 2,632 ovarian cancer cases, they predicted that 5.2% (138) of the ovarian cancers could have been prevented if prophylactic oophorectomy were performed in women 40 years or older at the time of hysterectomy for benign disease. Confirming these results is a recent survey of the American College of Surgeons which reported that of 12,316 cases of ovarian cancer studied, 18.2% of these women had had a previous hysterectomy for benign disease with ovarian preservation, 57.4% of which were performed in women over the age of 40 [10]. Prophylactic oophorectomy in such cases has not been a uniformly accepted practice because it has been assumed that preserved ovaries continue to function normally and thus delay both the onset of osteoporosis and menopause with its effect on the cardiovascular system. However, as many as 30% of women have postmenopausal symptoms within 24 months of hysterectomy with preservation of the ovaries [11]. In addition, in an important cross-sectional study of bone density of premenopausal women who had undergone hysterectomy with ovarian conservation compared with a matched group which had not had hysterectomy, investigators reported that bone density in the hysterectomy group was significantly reduced [12]. They concluded that premenopausal women who had undergone hysterectomy with ovarian preservation will have a significantly low bone density, somewhat negating the value of ovarian preservation. Women age 40 or over who undergo prophylactic oophorectomy at the time of hysterectomy for benign uterine conditions can be started immediately on hormone replacement therapy, thus helping to prevent loss of bone density and the onset of osteoporosis. PROPHYLACTIC OOPHORECTOMY IN WOMEN WITH A FAMILY HISTORY OF OVARIAN CANCER: Since familial (also known as site-specific or hereditary) ovarian cancer is considered to be an autosomal dominant inheritance with variable penetrance, sisters and daughters of families with a history of familial ovarian cancer (two or more first-degree relatives [mother, sister, daughter-who share one-half of one's genes]) may have as high as a 50% chance of inheriting the deleterious gene. Easton has estimated that for women with a BRCA1 mutation, the lifetime risk for developing ovarian cancer by age 70 is 63% [13]. The lifetime risk for BRCA2 mutations has not yet been calculated [14]. We have included women with two or more first-degree or a first- and second-degree relative with epithelial ovarian cancer as having a history of familial ovarian cancer. However, the Breast Cancer Linkage Consortium stated that "families with three or more cases of ovarian cancer are generally considered to be examples of hereditary ovarian cancer" [15]. In 1982, we first recommended prophylactic oophorectomy in women with a history of familial ovarian cancer. This definition included any woman with two or more first-degree or first- and second-degree relatives with epithelial ovarian cancer [16]. Because of what appeared to be an apparent increase in frequency of familial ovarian cancer in the 1970s, the Familial Ovarian Cancer Registry was formed in 1981 to further evaluate familial ovarian cancer syndrome. The Registry, renamed the Gilda Radner Familial Ovarian Cancer Registry in 1989 in memory of the late comedienne after her death from ovarian cancer, has registered as of June 1996, 1,376 families with ovarian cancer. A report on the first 1,000 families was recently published [17]. Previously, it was estimated that 5%-10% of all ovarian cancers are hereditary. However, scientists from the University of Pennsylvania believed the estimate of ovarian cancer cases that are hereditary may be as high as 20%, based on their recent report of germline BRCA2 mutations in women with ovarian cancer but without a family history of ovarian cancer [18]. In the CASH study, researchers compared 493 women with ovarian cancer to 2,465 matched controls [19]. The relative risk for ovarian cancer for any first-degree relative was 3.6, resulting in a lifetime risk of 6.5% (Table 1). However, if the mother was the first-degree relative with ovarian cancer, the relative risk was 4.3 and the lifetime risk was 7.5%. Although the latter risk is almost four times that of the general population, it is currently not recommended that women with only one first-degree relative with ovarian cancer undergo prophylactic oophorectomy. This recommendation would also be applicable to women with a strong family history of breast cancer but only one case of ovarian cancer in their family and to hereditary non-polyposis colorectal cancer (Lynch Syndrome II) if there were only one case of ovarian cancer. However, if a first-degree relative in a family with only one case of ovarian cancer carries the same BRCA1 or BRCA2 mutation as the germline mutation in the patient with ovarian cancer, prophylactic oophorectomy would be indicated. Using complex segregation analysis in evaluating the observed number of cases of ovarian cancer as compared with the expected number of cases during the same time period in England and Wales, researchers from the Ovarian Cancer Screening Clinic at Kings College Hospital in the United Kingdom studied 391 ovarian cancer family pedigrees [20]. The overall risk for any first-degree relative (8.1%) was almost exactly the same as that of the CASH study (Table 1). However, if the mother developed ovarian cancer before the age of 45, the relative risk was 14.2 with a calculated lifetime risk of 25%. This young age is consistent with an inherited cancer even with only one first-degree relative. If this study can be confirmed by other researchers, then prophylactic oophorectomy in women who have one first-degree relative who developed ovarian cancer before the age of 45 would indeed be indicated. As previously stated, we have used the definition of familial ovarian cancer as any family with two or more first-degree (mother, sister, daughter) or first- and second-degree relatives (grandmother, aunt) with epithelial ovarian cancer, and, further, that these women are candidates for prophylactic oophorectomy after age 35 if they have completed their family and desire the surgery. In contrast, the Breast Cancer Linkage Consortium studying inherited ovarian and breast cancer stated that "families with three or more cases of ovarian cancer are generally considered to be examples of hereditary ovarian cancer, and families with a total of five or more breast or ovarian cancers in first- or second-degree relatives qualify" [15]. In a study by one member of the Breast Cancer Consortium of hereditary or familial ovarian cancer in southern Ontario, Canada, the author stated that "our distinction between hereditary and familial ovarian cancer is arbitrary. We have included families with three ovarian cancers or five or more cases of ovarian cancer or breast cancer in the hereditary group" [21]. The U.S. NIH Consensus Conference on Ovarian Cancer in its 1990 report did not define site-specific ovarian cancer in its statement that "less than 0.5% of women are at a significant risk (for the development of ovarian cancer) because of three hereditary ovarian cancer syndromes: (1) breast/ovarian cancer syndrome; (2) site-specific ovarian cancer; and (3) hereditary non-polyposis colorectal cancer (Lynch Syndrome II), colorectal, endometrial, GI, kidney, and ovarian cancer" [22]. With the "arbitrary" definition of site-specific ovarian cancer by the Breast Cancer Consortium and the absence of a definition by the NIH Consensus Conference on Ovarian Cancer, we continue to define familial or site-specific ovarian cancer as two or more first-degree or first- and second-degree relatives with ovarian cancer. As seen in Table 3, it can be very difficult to assess the risk of familial ovarian cancer. PRIMARY PERITONEAL CARCINOMA AFTER PROPHYLACTIC OOPHORECTOMY FOR A FAMILY HISTORY OF OVARIAN CANCER: In 1982, scientists from the National Cancer Institute reported that three women with a familial history of ovarian cancer developed widespread adenocarcinoma "indistinguishable histopathologically from ovarian cancer" 1, 5, and 11 years after undergoing prophylactic oophorectomy [23]. These three cases were from 16 families in which 28 women had undergone prophylactic oophorectomy. This important report brought into question the value of prophylactic oophorectomy for women in such families. To study this problem utilizing members of the Gilda Radner Familial Ovarian Cancer Registry, we evaluated the women in the Registry from its initiation in 1981 through July 1992 [24]. At that time, the Registry had registered 931 families totaling 2,221 cases of familial ovarian cancer. Of the 324 women who had undergone prophylactic oophorectomy, 103 had two or more first-degree relatives, 166 had a first- and a second-degree or more relative, 41 had two or more second-degree relatives, and 14 had other relatives with ovarian cancer. Six, or 1.8%, of these 324 women developed primary peritoneal carcinoma indistinguishable from ovarian cancer 1, 2, 5, 13, 15, and 27 years after prophylactic oophorectomy. Of these six women, whose ages ranged from 43 to 75, five had two or more first-degree relatives with ovarian cancer and the sixth had three second-degree relatives with ovarian cancer (Figure 2). The Registry was able to confirm primary peritoneal carcinoma similar to ovarian adenocarcinoma and previously normal ovaries in all six cases. To date, there have been 12 cases of primary peritoneal carcinoma after prophylactic oophorectomy for a family history of ovarian cancer (Table 4). However, there have also been five cases of stage IA ovarian cancer diagnosed in women undergoing prophylactic oophorectomy for a family history of ovarian cancer. Although prophylactic oophorectomy will provide 100% protection against the development of ovarian cancer, it is clear that a very small fraction of such women will subsequently develop primary peritoneal carcinoma. Whether the inherited BRCA1 and BRCA2 mutations that result in familial ovarian cancer also cause primary peritoneal carcinoma is as yet unknown. All such women are followed closely post prophylactic oophorectomy by physical examination and CA125 blood testing. In conclusion, it is posited that prophylactic oophorectomy in women with a history of familial ovarian cancer who have completed their family by age 35 and desire prophylactic oophorectomy and in women age 40 or older who undergo hysterectomy for benign uterine conditions may result in a significant decrease in the death rate from ovarian cancer - a disease in search of a highly sensitive screening test(s) and improved therapy.

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Dear Editor, The chapter on mental, behavioural and neurodevelopmental disorders of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11) has been now finalized. Reporting of health statistics by Member States to the World Health Organization (WHO) using the new diagnostic system will begin in 2022. The section on mood disorders of the ICD-11 is overall consistent with the corresponding section of the ICD-10. However, the definitions of a depressive and a manic episode have been slightly changed, making them consistent with the DSM-5 (see below), and an independent category of bipolar II disorder has been introduced. A significant effort has been made by the WHO and the American Psychiatric Association to harmonize the diagnostic systems they produce (the ICD-11 and the DSM-5). Indeed, the organizational framework ("metastructure") is now the same in the two systems. Nonetheless, several intentional differences between the two classifications remain, or have emerged as a consequence of changes made in the DSM- 5. Here we briefly summarize the convergences and the divergences between the ICD-11 and the DSM-5 regarding the section on mood disorders (see Table 1). A major convergence between the two diagnostic systems regards the minimum number of symptoms required for the diagnosis of major depression ("depressive episode" in the ICD-11). In the ICD-11, contrary to the ICD-10, the threshold for the diagnosis of depression is the same as in the DSM: at least five depressive symptoms. However, the ICD-11 requires at least five symptoms out of a list of ten (instead of nine as in the DSM-5). The additional symptom is "hopelessness", which has been found to outperform more than half of DSM symptoms in differentiating depressed from non-depressed people (McGlinchey et al. 2006). Table 1. Some Main Differences Between ICD-10, ICD-11 and DSM-5 Concerning the Diagnosis Of Mood Disorders ICD-10 ICD-11 DSM-5 Threshold for diagnosis of depressive episode At least four out of ten symptoms, two of which must be depressed mood, loss of interest and enjoyment, or increased fatigability At least five out of ten symptoms, one of which must be depressed mood or diminished interest or pleasure At least five out of nine symptoms, one of which must be depressed mood or diminished interest or pleasure The threshold for the diagnosis of depression is higher if the person is bereaved Not made explicit Yes No Antidepressant-related mania qualifies as a manic episode No Yes Yes Mixed episode is a separate diagnostic entity Yes Yes No Dysthymia is a separate diagnostic entity Yes Yes No Bipolar II disorder is a separate diagnostic entity No Yes Yes "Qualifiers" ("specifiers") for the diagnoses of mood disorders are provided No Yes Yes CONVERGENCES AND DIVERGENCES IN THE ICD-11 VS. DSM-5 CLASSIFICATION OF MOOD DISORDERS 294 The ICD-11 is also following the DSM-5 in requiring the presence of increased activity or a subjective experience of increased energy, in addition to euphoria (or irritability or expansiveness), for the diagnosis of a manic episode, in order to reduce the chance of false positive cases. The two diagnostic systems also converge in considering that a manic or hypomanic syndrome arising during antidepressant treatment, and enduring beyond the known physiological effects of that treatment, qualifies as a manic or hypomanic episode. Bipolar II disorder has become an independent category in the ICD-11 (it was just mentioned as an example of "other bipolar affective disorders" in the ICD-10). Furthermore, for the first time, the ICD follows the DSM in introducing "qualifiers" (corresponding to DSM-5 "specifiers") to the diagnoses of mood disorders, based on specific aspects of symptomatology or course. There are, however, three important aspects in which the two diagnostic systems diverge. All of them are a consequence of changes made in the DSM-5 that the relevant ICD-11 Committee has regarded as not sufficiently supported by the available research evidence. The first of these divergences concerns the issue of bereavement. In the ICD-11, in line with the DSM-IV and ICD-10 approach, it is stated that "a depressive episode should not be considered if the depressive symptoms are consistent with the normative response for grieving within the individual's religious and cultural context". However, the diagnosis of depression is not excluded if the person is bereaved; the diagnostic threshold is just raised, exactly as it happens in ordinary clinical practice. A depressive episode during bereavement is suggested by the persistence of symptoms for at least one month, and the presence of at least one symptom which is unlikely to occur in normal grief (such as extreme beliefs of low self-worth or guilt not related to the lost loved one, presence of psychotic symptoms, suicidal ideation, or psychomotor retardation). In contrast, the special status conferred by the DSM-IV to bereavement among life stressors has been eliminated in the DSM-5. However, two independent follow-up studies (Mojtabai 2011, Wakefield and Schmitz 2012) have reported that, in people with baseline bereavement-related depression, the risk for the occurrence of a further depressive episode during follow-up is significantly lower than in individuals with baseline non-bereavement-related depression, and not significantly different from the risk of people without a baseline history of depression to develop a first depressive episode during follow-up. This research evidence strongly supports the ICD-11 (and DSM-IV) approach. Furthermore, an intensive public debate has highlighted the consequences that the DSM-5 approach to the bereavement issue could have in several cultures, including a high rate of false positives and a trivialization of the concept of depression and consequently of mental disorder (Kleinman 2012). A second divergence between the ICD-11 and DSM-5 sections on mood disorders concerns mixed states. The category of mixed episode is kept in the ICD-11, defined by several prominent manic and depressive symptoms which either occur simultaneously or alternate very rapidly (from day to day or within the same day) during a period of at least two weeks. The mood state is altered throughout the episode (i.e., the mood should be depressed, dysphoric, euphoric or expansive for at least two weeks). When depressive symptoms predominate, common contrapolar symptoms are irritability, racing or crowded thoughts, increased talkativeness, and increased activity. When manic symptoms predominate, common contrapolar symptoms are dysphoric mood, expressed beliefs of worthlessness, hopelessness, and suicidal ideation. This definition is in line with the ICD-10 and completely consistent with both classic and recent research evidence, as well as with clinical experience. In contrast, the DSM-5 solution to eliminate the category of mixed episode and to introduce a specifier "with mixed features", applicable to manic, hypomanic and depressive episodes, has had the consequence to reduce the visibility of "mixity" in ordinary clinical practice (especially since the specifier is not codable, and is therefore at risk of not being recorded in clinical settings). Moreover, the DSM-5 definition of major depression with mixed features, requiring the presence of at least three "classic" manic symptoms (such as elevated mood, grandiosity, and increased involvement in risky activities) has been criticized for being inconsistent with the concept of mixed depression as delineated in both the classic and recent literature (e.g., Koukopoulos and Sani 2014). A third divergence between the two diagnostic systems consists in the fact that the ICD-11 has not followed the DSM-5 in combining dysthymic disorder and chronic major depressive disorder into a single category ("persistent depressive disorder"). In fact, the relevant ICD-11 Committee expert considered that the evidence that the two disorders represent the same condition, to be addressed therapeutically in the same way, is insufficient. The category of dysthymic disorder is kept in the ICD-11, while a qualifier "current episode persistent" is to be used when the diagnostic requirements for depressive episode have been met continuously for at least the past two years. For a discussion of other aspects of the classification of mood disorders, with the relevant therapeutic implications, as well as for information about the differences between the ICD-11 and the DSM-5 concerning other sections of the classification of mental disorders, we refer the reader to previous contributions (Demyttenaere et al. 2015, Fried et al. 2016, Haroz et al. 2017, Boschloo et al. 2019, Bryant 2019, Forbes et al. 2019, Fusar-Poli et al. 2019, Gureje et al. 2019, 295 Received: 13.09.2021, Accepted: 19.09.2021, Available Online Date: 30.11.2021 MD., University of Campania L. Vanvitelli, WHO Collaborating Centre for Research and Training in Mental Health, Naples, Italy. Dr. Arcangelo Di Cerbo, e-mail: [email protected] https://doi.org/10.5080/u26899 Reed et al. 2019, Kendall 2019, van Os et al. 2019, Cuijpers et al. 2020, Fava and Guidi 2020, Gaebel et al. 2019, 2020, Hasler 2020, Jarrett 2020, Kato et al. 2020, Maj et al. 2020, Reynolds 2020, Sanislow 2020, Stein et al. 2020). An International Advisory Group has been established to supervise the activities of translation, training of professionals and implementation of the ICD-11 chapter on mental disorders (see Giallonardo 2019, Pocai 2019, Perris 2020). The experience in the field will tell whether the above divergences from the DSM-5 in the ICD-11 classification of mood disorders are justified. Indeed, divergences in the description of the same mental health condition may sometimes be useful in order to allow the empirical comparison of different approaches to issues that are controversial. Arcangelo DI CERBO REFERENCES Boschloo L, Bekhuis E, Weitz ES et al (2019) The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis. World Psychiatry 18:183-91. Bryant RA (2019) Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry 18:259-69. Cuijpers P, Noma H, Karyotaki E et al (2020) A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry 19:92-107. Demyttenaere K, Donneau AF, Albert A et al (2015) What is important in being cured from depression? Discordance between physicians and patients (1). J Affect Disord 174:390-6. Fava GA, Guidi J (2020) The pursuit of euthymia. World Psychiatry 19:40-50. Fried EI, Epskamp S, Nesse RM et al (2016) What are "good" depression symptoms? 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Maj M, Stein DJ, Parker G et al (2020) The clinical characterization of the adult patient with depression aimed at personalization of management. World Psychiatry 19:269-93. McGlinchey JB, Zimmerman M, Young D et al (2006) Diagnosing major depressive disorder VIII. Are some symptoms better than others? J Nerv Ment Dis 194:785-90. Mojtabai R (2011) Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch Gen Psychiatry 68:920-8. Perris F (2020) ICD-11 sessions at the 19th World Congress of Psychiatry. World Psychiatry 19:263-4. Pocai B (2019) The ICD-11 has been adopted by the World Health Assembly. World Psychiatry 18:371-2. Reed GM, First MB, Kogan CS et al (2019) Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry 18:3-19. Reynolds CF 3rd (2020) Optimizing personalized management of depression: the importance of real-world contexts and the need for a new convergence paradigm in mental health. World Psychiatry 19:266-8. Sanislow CA (2020) RDoC at 10: changing the discourse for psychopathology. World Psychiatry 19:311-2. Stein DJ, Szatmari P, Gaebel W et al (2020) Mental, behavioural and neurodevelopmental disorders in the OCD-11: an international perspective on key changes and controversies. BMC Med 18:21. van Os J, Guloksuz S, Vijn TW et al (2019) The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? World Psychiatry 18:88-96. Wakefield JC, Schmitz MF (2012) Recurrence of bereavement-related depression: evidence for the validity of the DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study. J Ment Dis 200:480-5.

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Cervical kyphosis is rare in the pediatric population. It may be syndromic or acquired secondary to laminectomy, neoplasia, or trauma. Regardless, this should be avoided to prevent progressive spinal deformity and neurological deficit. Long-term follow-up is needed to evaluate fusion status, spine growth, potential instability, and neurological function. A retrospective review of 27 children (6 months to 16 years) with cervical kyphotic deformity was performed and limited to the MRI era until 2008, to provide a long-term follow-up after which complex instrumentation was available. There were 27 patients, 19 syndromic (average age 5.36 years), and 8 non-syndromic (average age 14 years). Syndromes encountered were spondyloepiphyseal dysplasia (SED) 4, spondylometaphyseal dysplasia 1, unnamed collagen abnormality syndrome 1, osteogenesis imperfecta (OI) 2, Aarskog syndrome 1, Weaver syndrome 1, Larsen syndrome 1, multiple cervical level disconnection syndrome 1, Klippel-Feil 3, congenital absence of C2 pars 4. Non-syndromic cases; 2 with neurofibromatosis (NF1) and prevertebral tumors, fibromatosis 1, spontaneous kyphosis 1, and postlaminectomy 4. Factors considered were age, pathology, flexibility on cervical spine dynamic films, reduction with traction and spinal cord compression. Patients with flexible kyphosis underwent dorsal fixation. Children with non-flexible ventral compression/kyphosis had crown halo traction. Irreducible kyphosis had ventral decompression and fusion as well as dorsal fusion. Eleven of 19 syndromic children with flexible and reducible kyphosis underwent dorsal fixation alone. Four of 8 non-syndromic (2 NF1) needed ventral and dorsal approaches. The preoperative deformity (global and local Cobb angles) as well as neurological status improved. Growth during follow-up was not impaired, and we did not encounter instability or junctional kyphosis. The only complications were seen in syndromic patients. One patient with SED showed delayed cantilever bending of the ventral fusion mass requiring reoperation, and 1 other OI child had left C5 and C6 nerve root weakness after anterior C4 and C5 decompression which resolved over 1 year. One child with SED developed cervicothoracic junction scoliosis 18 years later after thoracic scoliosis surgery. Syndromic pathology presented early with neurological dysfunction and 24% had rigid kyphosis. An attempt at traction/reduction was successful as in Tables 1 and 2. The majority exhibited long-term improvement in kyphosis and function. A treatment algorithm and literature review is presented. Table 1 Motor function of the modified Japanese Orthopedic Association (JOA) score in children [24, 37] Score Upper extremity •Unable to move hands or feed oneself 0 •Can move hands; unable to eat with spoon 1 •Able to eat with spoon with difficulty 2 •Able to use spoon; clumsy with buttoning 3 •Healthy; no dysfunction 4 Lower extremity •Unable to sit or stand 0 •Unable to walk without cane or walker 1 •Walks independently on level floor but needs support on stairs 2 •Capable to walking, clumsy 3 •No dysfunction 4 Table 2 Pediatric cervical kyphosis-preoperative evaluations Case ID, year presented Age Sex Diagnosis Presentation Imaging Apex Cobb angle degree Reducibility Preop traction Syndromic #1 2003 4 years M SED Progressive quadriparesis Bladder incontinence Severe C2-4 kyphosis with cord compression C3-4 85° No No #2 2001 3 years M SED Progressive quadriparesis C2-3 kyphosis. No dorsal C2. Buckled cord C2-3 25° No No Recurrent weakness after recovery 2 years later Kyphosis at fusion site C2-3 33° No No #3 1997 13 years M SED Neck pain. Hand weakness. Thoracic scoliosis C1-3 kyphosis Os odontoideum C2-3 30° Yes No #4 2006 6 years F SED Tingling in hands Bladder incontinence Deformed C2 body and odontoid C1-2 instability C2-3 27° Yes No #5 1997 4 years M SMD Quadriparesis. Previous C2-3 kyphosis with O-C3 dorsal fusion elsewhere Fixed C1-2 dislocation. C2-3 kyphosis. O-C4 fusion C2 35° Partial Yes 4 days #6 2007 13 years F Syndromic collagen abnormality Neck pain. Leg length discrepancies. T-L scoliosis. Quadriparesis Bilateral C2 and partial C3 spondylolysis C-T levoscoliosis C2-3 35° Partial Yes 4 days #7 2003 14 years F Osteogenesis imperfecta (OI) Only able to use right upper extremity C3-5 kyphosis. Canal diameter 4 mm at C4 C4 25° No No #8 1989 3 years F OI - Bruck's syndrome Quadriparesis age 9 months. Had C1-C3 posterior decompression and fusion elsewhere Progressive kyphosis Worse weakness Bend in fusion C1-2 40° No No #9 1996 11 years M Aarskog syndrome Neck pain with limited neck motion Cervical myelopathy Psychomotor delay C4-5 spondylolysis C5-6 kyphosis C5 30° No Yes 3 days #10 1989 3½ years F Weaver syndrome Quadriparesis age 2 years. Elsewhere C1-C3 dorsal rib fusion and wires Fusion failure C2-3 subluxation Cord compression C2-3 3° Yes Yes 1 day #11 1986 11 years F Larsen syndrome Neck pain in extension Quadriparesis C2-3 kyphosis. Deformed bodies C2-5 Os odontoideum C1-2 instability C2-3 28° Yes Yes 1 day #12 1996 5 years M Multilevel cervical disconnect syndrome Horner pupil on right Small right arm Quadriparesis C4, C5 vertebral bodies behind C5 C5 body in canal Left vertebral artery in C5 body C4-5 35° No No #13 1985 3 years F Klippel-Feil Neck pain. Weak hands Atlas assimilation C3-4 kyphosis No posterior bony arches C3, C4 C3-4 40° Yes No #14 1994 3 years F Klippel-Feil Unable to sit. Floppy. Quadriparesis C2-3 kyphosis No posterior arches C2-3 and L4 C2-3 45° Yes No #15 1993 11 months F Tuberous sclerosis Spondylolysis C2 Salam seizures Quadriparesis No pars C2 C2-3 kyphosis C2-3 30° Yes No #16 1998 2 years M C2 spondylolysis Quadriparesis, arms worse than legs C2 spondylolysis C2-3 kyphosis C2-3 35° Yes No #17 1998 6 months M C2 spondylolysis Failure to thrive Apneic spells Weak in arms after endoscopy C2-3 kyphosis No C2 lamina Cord compression C3-4 on MRI C2-3 45° Yes No #18 1990 4 years F C2 spondylolysis Developmental delay Quadriparesis C2 spondylolysis C2-3 kyphosis C3 45° Yes No #19 1994 4 years F Klippel-Feil No posterior C2 Torticollis age 6 mo Quadriparesis C2-3 kyphosis No posterior arch C2 Fused C3-4 bodies C2-3 45° Yes No Non-syndromic #20 1996 15 years M NF1. Ventral prevertebral plexiform neurofibroma Neck pain Weak arms Cervical myelopathy C4-5 kyphosis Cord draped over C4-5 Enhanced prevertebral tumor C4-5 60° Partial Yes 4 days #21 1996 6 years M NF1 Age 6 mo had C1-3 laminectomies elsewhere Progressive kyphosis Quadriparesis C3-5 plexiform neurofibromas C2-4 kyphosis C3-4 45° No No #22 1993 11 years M "Fibromatosis" Neck pain Gag ↓ Right hemiparesis C2 body and odontoid curved dorsally C2-3 kyphosis C2 40° No Yes 3 days #23 2007 13 F Mid-cervical kyphosis Neck pain Unable to move neck C3-4 kyphosis C3-4 45° Yes Halo vest elsewhere 6 weeks Repeat traction on referral #24 1998 12 years M Chiari I Syringohydromyelia Difficulty swallowing Quadriparesis Previous posterior fossa and C1-3 decompression Basilar invagination C3-4 kyphosis C3-4 50° Yes Halo traction 3 days #25 1994 16 years M Chiari I. SHM Difficult speech Quadriparesis Previous posterior fossa and C1-4 laminectomies C3-4 kyphosis Basilar invagination C3-4 55° Yes Halo traction 3 days #26 2002 11 years M Chordoma C3-5 Initial quadriparesis improved after posterior decompression then worse Dorsal and lateral tumor C3-4 C3-4 20° Yes Traction 3 days #27 2006 13 years M C4 lamina Aneurysmal bone cyst Neck and shoulder pain C4 laminectomy for tumor resection Worse 4 months later C4-5 kyphosis C3-4 40° Yes No Table 3 Pediatric cervical kyphosis-postoperative evaluations Case ID Diagnosis Treatment-operation Complication PO orthosis F/U time Fusion status Preop Cobb Postop Cobb Preop JOA Postop JOA Comments Syndromic #1 SED Crown halo traction 1. Median mandibular glossotomy. Resection C2-3 bodies with rib graft fusion 2. Dorsal O-C3 rib graft fusion None Halo vest 3 months Soft collar 3 months 8 years Complete anterior and posterior fusion 85° 10° 2 8 Complete neurological recovery #2 SED Crown halo traction 1. Median mandibular glossotomy. C2-4 corpectomies. C2-5 anterior rib graft fusion Recurrent weakness 2 years s later Halo vest 3 months 2 years Fused 25° 20° 4 5 T. scoliosis. Cardiac abnormalities. Walking then quadriparesis Redo ventral resection and C1-4 iliac bone graft Worsening quadriparesis Minerva brace 1 year 18 years Fused 33° 15° 3 5 Much improved in 6 months #3 SED Crown halo traction Dorsal O-C4 fusion with loop and rib graft None Miami J collar 3 months 10 years Fused 30° 13° 4 7 Works in bookstore #4 SED Crown halo traction Dorsal O-C3 fusion with loop and rib graft 4 years later developed C-T scoliosis after T. scoliosis surgery Miami J collar 3 months 14 years Fused 27° 5° 5 7 C-T scoliosis developed after thoracic scoliosis correction #5 SMD Crown halo traction Transoral C2 odontoid resection None Minerva brace 6 months 20 years No from preop status 35° 10° 1 4 In wheelchair. Works as programmer #6 Collagen abnormality Crown halo traction C2-5 ACDF C2-5 plate with C3-4 lag screws Junctional kyphosis 7 years later after scoliosis correction Miami J collar 6 weeks 12 years Fused 36° 5° 4 7 Abnormal vertebral arteries. Thoracic outlet syndrome May-Thurner syndrome #7 OI Crown halo traction C3-5 corpectomies C2-6 Orion plate with iliac crest graft None Soft collar 4 years Fused 25° 30° 1 5 Restrictive lung disease. Multiple fractures Expired #8 OI - Bruck syndrome 1. Redo C1-2 dorsal rib graft fusion No change Molded Minerva brace 4 years Fused 40° 35° 3 4 Increased weakness age 7 2. 11 years age anterior C3-7 decompression and plate C3-7 Worsening left deltoid and biceps function Molded Minerva brace 30 years Fused 52° 34° 3 5 Lives alone. Wheelchair. Computer technologist Uses hands well #9 Aarskog syndrome Crown halo traction C2-6 anterior cervical fusion with iliac crest graft None Molded Minerva brace 20 years Fused 30° 14° 4 7 Works on a farm. No myelopathy. Syndrome in family #10 Weaver syndrome Crown halo traction Redo C1-4 dorsal rib graft fusion None Miami J collar 2 years Fused 3° 10° 2 5 Neuroblastoma age 3 months. Chemotherapy Stable #11 Larsen syndrome Crown halo traction O-C5 dorsal fusion None Halo vest 6 weeks Miami J 3 months 6 years Fused 28° 10° 3 7 Doing well #12 Multilevel cervical disconnect syndrome Crown halo traction C5 corpectomy C4-6 iliac bone fusion anteriorly Dorsal C4-6 fusion None Halo vest 3 months 5 years Fused 35° 5° 3 7 Persistent Horner pupil #13 Klippel-Feil Crown halo traction C2-6 posterior rib graft fusion None Halo vest 3 months 19 years Fused 40° 12° 3 7 Hearing loss Genitourinary abnormalities Sprengel's deformity #14 Klippel-Feil Crown halo C2-5 dorsal rib graft fusion None Halo vest 3 months 35 years Fused 45° 10° 1 6 Hearing loss Genitourinary abnormalities #15 Tuberous sclerosis Spondylolysis C2 C1-4 dorsal interlaminar rib fusion None Halo vest 3 months 6 years Fused 30° 5° 1 6 Psychomotor delay #16 C2 spondylolysis C1-4 dorsal interlaminar fusion None Halo vest 3 months 4 years Fused 35° 10° 2 6 Recovered full function in one year #17 C2 spondylolysis Tracheostomy Molded cervicothoracic brace None Mold brace 4 years 6 years Formed C2 posterior arches 45° 20° 1 3 Reformed C2 at 4 years on CT Parents did not wish surgery #18 C2 spondylolysis Intraoperative traction C1-3 dorsal rib graft fusion None Neck brace 4 months 8 years Fused 45° 12° 2 5 Developed C2 posterior elements #19 Klippel-Feil Intraoperative traction O-C4 fusion with rib graft None Molded brace 6 months 1 years Fused O-C2 dorsally 45° 16° 1 4 Able to sit and use hands Non-syndromic #20 NF1 Resection of ventral tumor C3-6 C4-5 corpectomies; C4-5 iliac graft; C3-7 Orion plate None Halo vest 6 weeks 14 years Fused 60° 15° 3 7 Recovered in 6 weeks. Works on a farm #21 NF1 Intraoperative traction Resect prevertebral tumor C2-5 kyphectomies; C2-6 anterior fusion iliac crest None Halo vest 3 months 2 years Fused 45° 20° 3 5 Initial C1-3 decompression done elsewhere #22 Fibromatosis 1. Transoral C2 decompression 2. Dorsal O-C3 fusion with loop None Brace 3 months 12 years Fused 40° 12° 4 6 Age 2 years had neck mass resected. Diagnosis "fibromatosis" #23 Mid-cervical kyphosis Traction C2-5 lateral mass fusion with screws, rods and rib grafts Worse after removal of initial traction Brace 3 months 8 years Fused 45° 15° 7 8 Doing well #24 Chiari I SHM Intraoperative traction O-C5 rib graft fusion None Halo vest 3 months 21 years Fused 50° 7° 2 6 Facets atrophied C2, C3 at surgery #25 Chiari I SHM Intraoperative traction O-C5 dorsal fusion with loop and rib None Miami J brace 4 months 22 years Fused 55° 10° 3 6 Facets atrophied C2-4 at surgery #26 Chordoma C3-4 1. Dorsal lateral C3-6 fusion 2. C2-5 anterior fusion with iliac bone None Miami J brace 6 months 18 years Fused 20° 12° 5 8 Weak in hands after initial surgery elsewhere #27 ABC tumor C4 Anterior C3-5 fusion with plate and bone None Miami J brace 4 weeks 12 years Fused 40° 15° 5 8 No recurrence SED spondyloepiphyseal dysplasia, SMD spondylometaphyseal dysplasia, JOA Japanese Orthopedic Association, MRI magnetic resonance imaging, SHM syringohydromyelia, NF1 neurofibromatosis type 1, f/u follow up, OI osteogenesis imperfecta, CT computed tomography, JK junctional kyphosis.

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Epidemiological cohort studies have consistently found associations between long-term exposure to outdoor air pollution and a range of morbidity and mortality endpoints. Recent evaluations by the World Health Organization and the Global Burden of Disease study have suggested that these associations may be nonlinear and may persist at very low concentrations. Studies conducted in North America in particular have suggested that associations with mortality persisted at concentrations of particulate matter with an aerodynamic diameter of less than 2.5 μm (PM<sub2.5</sub) well below current air quality standards and guidelines. The uncertainty about the shape of the concentration-response function at the low end of the concentration distribution, related to the scarcity of observations in the lowest range, was the basis of the current project. Previous studies have focused on PM<sub2.5</sub, but increasingly associations with nitrogen dioxide (NO<sub2</sub) are being reported, particularly in studies that accounted for the fine spatial scale variation of NO<sub2</sub. Very few studies have evaluated the effects of long-term exposure to low concentrations of ozone (O<sub3</sub). Health effects of black carbon (BC), representing primary combustion particles, have not been studied in most large cohort studies of PM<sub2.5</sub. Cohort studies assessing health effects of particle composition, including elements from nontailpipe traffic emissions (iron, copper, and zinc) and secondary aerosol (sulfur) have been few in number and reported inconsistent results. The overall objective of our study was to investigate the shape of the relationship between long-term exposure to four pollutants (PM<sub2.5</sub, NO<sub2</sub, BC, and O<sub3</sub) and four broad health effect categories using a number of different methods to characterize the concentration-response function (i.e., linear, nonlinear, or threshold). The four health effect categories were (1) natural- and cause-specific mortality including cardiovascular and nonmalignant as well as malignant respiratory and diabetes mortality; and morbidity measured as (2) coronary and cerebrovascular events; (3) lung cancer incidence; and (4) asthma and chronic obstructive pulmonary disease (COPD) incidence. We additionally assessed health effects of PM<sub2.5</sub composition, specifically the copper, iron, zinc, and sulfur content of PM<sub2,5</sub. We focused on analyses of health effects of air pollutants at low concentrations, defined as less than current European Union (EU) Limit Values, U.S. Environmental Protection Agency (U.S. EPA), National Ambient Air Quality Standards (NAAQS), and/or World Health Organization (WHO) Air Quality Guideline values for PM<sub2.5</sub, NO<sub2</sub, and O<sub3</sub. We address the health effects at low air pollution levels by performing new analyses within selected cohorts of the ESCAPE study (European Study of Cohorts for Air Pollution Effects; Beelen et al. 2014a) and within seven very large European administrative cohorts. By combining well-characterized ESCAPE cohorts and large administrative cohorts in one study the strengths and weaknesses of each approach can be addressed. The large administrative cohorts are more representative of national or citywide populations, have higher statistical power, and can efficiently control for area-level confounders, but have fewer possibilities to control for individual-level confounders. The ESCAPE cohorts have detailed information on individual confounders, as well as country-specific information on area-level confounding. The data from the seven included ESCAPE cohorts and one additional non-ESCAPE cohort have been pooled and analyzed centrally. More than 300,000 adults were included in the pooled cohort from existing cohorts in Sweden, Denmark, Germany, the Netherlands, Austria, France, and Italy. Data from the administrative cohorts have been analyzed locally, without transfer to a central database. Privacy regulations prevented transfer of data from administrative cohorts to a central database. More than 28 million adults were included from national administrative cohorts in Belgium, Denmark, England, the Netherlands, Norway, and Switzerland as well as an administrative cohort in Rome, Italy. We developed central exposure assessment using Europewide hybrid land use regression (LUR) models, which incorporated European routine monitoring data for PM<sub2.5</sub, NO<sub2</sub, and O<sub3</sub, and ESCAPE monitoring data for BC and PM<sub2.5</sub composition, land use, and traffic data supplemented with satellite observations and chemical transport model estimates. For all pollutants, we assessed exposure at a fine spatial scale, 100 × 100 m grids. These models have been applied to individual addresses of all cohorts including the administrative cohorts. In sensitivity analyses, we applied the PM<sub2.5</sub models developed within the companion HEI-funded Canadian MAPLE study (Brauer et al. 2019) and O<sub3</sub exposures on a larger spatial scale for comparison with previous studies. Identification of outcomes included linkage with mortality, cancer incidence, hospital discharge registries, and physician-based adjudication of cases. We analyzed natural-cause, cardiovascular, ischemic heart disease, stroke, diabetes, cardiometabolic, respiratory, and COPD mortality. We also analyzed lung cancer incidence, incidence of coronary and cerebrovascular events, and incidence of asthma and COPD (pooled cohort only). We applied the Cox proportional hazard model with increasing control for individual- and area-level covariates to analyze the associations between air pollution and mortality and/or morbidity for both the pooled cohort and the individual administrative cohorts. Age was used as the timescale because of evidence that this results in better adjustment for potential confounding by age. Censoring occurred at the time of the event of interest, death from other causes, emigration, loss to follow-up for other reasons, or at the end of follow-up, whichever came first. A priori we specified three confounder models, following the modeling methods of the ESCAPE study. Model 1 included only age (time axis), sex (as strata), and calendar year of enrollment. Model 2 added individual-level variables that were consistently available in the cohorts contributing to the pooled cohort or all variables available in the administrative cohorts, respectively. Model 3 further added area-level socioeconomic status (SES) variables. A priori model 3 was selected as the main model. All analyses in the pooled cohort were stratified by subcohort. All analyses in the administrative cohorts accounted for clustering of the data in neighborhoods by adjusting the variance of the effect estimates. The main exposure variable we analyzed was derived from the Europewide hybrid models based on 2010 monitoring data. Sensitivity analyses were conducted using earlier time periods, time-varying exposure analyses, local exposure models, and the PM<sub2.5</sub models from the Canadian MAPLE project. We first specified linear single-pollutant models. Two-pollutant models were specified for all combinations of the four main pollutants. Two-pollutant models for particle composition were analyzed with PM<sub2.5</sub and NO<sub2</sub as the second pollutant. We then investigated the shape of the concentration-response function using natural splines with two, three, and four degrees of freedom; penalized splines with the degrees of freedom determined by the algorithm and shape-constrained health impact functions (SCHIF) using confounder model 3. Additionally, we specified linear models in subsets of the concentration range, defined by removing concentrations above a certain value from the analysis, such as for PM<sub2.5</sub 25 μg/m<sup3</sup (EU limit value), 20, 15, 12 μg/m<sup3</sup (U.S. EPA National Ambient Air Quality Standard), and 10 μg/m<sup3</sup (WHO Air Quality Guideline value). Finally, threshold models were evaluated to investigate whether the associations persisted below specific concentration values. For PM<sub2.5</sub, we evaluated 10, 7.5, and 5 μg/m<sup3</sup as potential thresholds. Performance of threshold models versus the corresponding no-threshold linear model were evaluated using the Akaike information criterion (AIC). In the pooled cohort, virtually all subjects in 2010 had PM<sub2.5</sub and NO<sub2</sub annual average exposures below the EU limit values (25 μg/m<sup3</sup and 40 μg/m<sup3</sup, respectively). More than 50,000 had a residential PM<sub2.5</sub exposure below the U.S. EPA NAAQS (12 μg/m<sup3</sup). More than 25,000 subjects had a residential PM<sub2.5</sub exposure below the WHO guideline (10 μg/m<sup3</sup). We found significant positive associations between PM<sub2.5</sub, NO<sub2</sub, and BC and natural-cause, respiratory, cardiovascular, and diabetes mortality. In our main model, the hazard ratios (HRs) (95% [confidence interval] CI) were 1.13 (CI = 1.11, 1.16) for an increase of 5 μg/m<sup3</sup PM<sub2.5</sub, 1.09 (CI = 1.07, 1.10) for an increase of 10 μg/m<sup3</sup NO<sub2</sub, and 1.08 (CI = 1.06, 1.10) for an increase of 0.5 × 10<sup-5</sup/m BC for natural-cause mortality. The highest HRs were found for diabetes mortality. Associations with O<sub3</sub were negative, both in the fine spatial scale of the main ELAPSE model and in large spatial scale exposure models. For PM<sub2.5</sub, NO<sub2</sub, and BC, we generally observed a supralinear association with steeper slopes at low exposures and no evidence of a concentration below which no association was found. Subset analyses further confirmed that these associations remained at low levels: below 10 μg/m<sup3</sup for PM<sub2.5</sub and 20 μg/m<sup3</sup for NO<sub2</sub. HRs were similar to the full cohort HRs for subjects with exposures below the EU limit values for PM<sub2.5</sub and NO<sub2</sub, the U.S. NAAQS values for PM<sub2.5</sub, and the WHO guidelines for PM<sub2.5</sub and NO<sub2</sub. The mortality associations were robust to alternative specifications of exposure, including different time periods, PM<sub2.5</sub from the MAPLE project, and estimates from the local ESCAPE model. Time-varying exposure natural spline analyses confirmed associations at low pollution levels. HRs in two-pollutant models were attenuated but remained elevated and statistically significant for PM<sub2.5</sub and NO<sub2</sub. In two-pollutant models of PM<sub2.5</sub and NO<sub2</sub HRs for natural-cause mortality were 1.08 (CI = 1.05, 1.11) for PM<sub2.5</sub and 1.05 (CI = 1.03, 1.07) for NO<sub2</sub. Associations with O<sub3</sub were attenuated but remained negative in two-pollutant models with NO<sub2</sub, BC, and PM<sub2.5</sub. We found significant positive associations between PM<sub2.5</sub, NO<sub2</sub, and BC and incidence of stroke and asthma and COPD hospital admissions. Furthermore, NO<sub2</sub was significantly related to acute coronary heart disease and PM<sub2.5</sub was significantly related to lung cancer incidence. We generally observed linear to supralinear associations with no evidence of a threshold, with the exception of the association between NO<sub2</sub and acute coronary heart disease, which was sublinear. Subset analyses documented that associations remained even with PM<sub2.5</sub below 20 μg/m<sup3</sup and possibly 12 μg/m<sup3</sup. Associations remained even when NO<sub2</sub was below 30 μg/m<sup3</sup and in some cases 20 μg/m<sup3</sup. In two-pollutant models, NO<sub2</sub was most consistently associated with acute coronary heart disease, stroke, asthma, and COPD hospital admissions. PM<sub2.5</sub was not associated with these outcomes in two-pollutant models with NO<sub2</sub. PM<sub2.5</sub was the only pollutant that was associated with lung cancer incidence in two-pollutant models. Associations with O<sub3</sub were negative though generally not statistically significant. In the administrative cohorts, virtually all subjects in 2010 had PM<sub2.5</sub and NO<sub2</sub annual average exposures below the EU limit values. More than 3.9 million subjects had a residential PM<sub2.5</sub exposure below the U.S. EPA NAAQS (12 μg/m<sup3</sup) and more than 1.9 million had residential PM<sub2.5</sub exposures below the WHO guideline (10 μg/m<sup3</sup). We found significant positive associations between PM<sub2.5</sub, NO<sub2</sub, and BC and natural-cause, respiratory, cardiovascular, and lung cancer mortality, with moderate to high heterogeneity between cohorts. We found positive but statistically nonsignificant associations with diabetes mortality. In our main model meta-analysis, the HRs (95% CI) for natural-cause mortality were 1.05 (CI = 1.02, 1.09) for an increase of 5 μg/m<sup3</sup PM<sub2.5</sub, 1.04 (CI = 1.02, 1.07) for an increase of 10 μg/m<sup3</sup NO<sub2</sub, and 1.04 (CI = 1.02, 1.06) for an increase of 0.5 × 10<sup-5</sup/m BC, and 0.95 (CI = 0.93, 0.98) for an increase of 10 μg/m<sup3</sup O<sub3</sub. The shape of the concentration-response functions differed between cohorts, though the associations were generally linear to supralinear, with no indication of a level below which no associations were found. Subset analyses documented that these associations remained at low levels: below 10 μg/m<sup3</sup for PM<sub2.5</sub and 20 μg/m<sup3</sup for NO<sub2</sub. BC and NO<sub2</sub remained significantly associated with mortality in two-pollutant models with PM<sub2.5</sub and O<sub3</sub. The PM<sub2.5</sub HR attenuated to unity in a two-pollutant model with NO<sub2</sub. The negative O<sub3</sub association was attenuated to unity and became nonsignificant. The mortality associations were robust to alternative specifications of exposure, including time-varying exposure analyses. Time-varying exposure natural spline analyses confirmed associations at low pollution levels. Effect estimates in the youngest participants (&lt;65 years at baseline) were much larger than in the elderly (&gt;65 years at baseline). Effect estimates obtained with the ELAPSE PM<sub2.5</sub model did not differ from the MAPLE PM<sub2.5</sub model on average, but in individual cohorts, substantial differences were found. Long-term exposure to PM<sub2.5</sub, NO<sub2</sub, and BC was positively associated with natural-cause and cause-specific mortality in the pooled cohort and the administrative cohorts. Associations were found well below current limit values and guidelines for PM<sub2.5</sub and NO<sub2</sub. Associations tended to be supralinear, with steeper slopes at low exposures with no indication of a threshold. Two-pollutant models documented the importance of characterizing the ambient mixture with both NO<sub2</sub and PM<sub2.5</sub. We mostly found negative associations with O<sub3</sub. In two-pollutant models with NO<sub2</sub, the negative associations with O<sub3</sub were attenuated to essentially unity in the mortality analysis of the administrative cohorts and the incidence analyses in the pooled cohort. In the mortality analysis of the pooled cohort, significant negative associations with O<sub3</sub remained in two-pollutant models. Long-term exposure to PM<sub2.5</sub, NO<sub2</sub, and BC was also positively associated with morbidity outcomes in the pooled cohort. For stroke, asthma, and COPD, positive associations were found for PM<sub2.5</sub, NO<sub2</sub, and BC. For acute coronary heart disease, an increased HR was observed for NO<sub2</sub. For lung cancer, an increased HR was found only for PM<sub2.5</sub. Associations mostly showed steeper slopes at low exposures with no indication of a threshold.

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Nickel sulfate hexahydrate is used in nickel plating, as a mordant in dyeing and printing textiles, as a blackening agent for zinc and brass, and in the manufacture of organic nickel salts. Nickel sulfate hexahydrate was nominated by the National Cancer Institute to the NTP as part of a class study of nickel compounds for which there was little information on the toxic and carcinogenic effects of inhalation exposure. Male and female F344/N rats and B6C3F1 mice were exposed to nickel sulfate hexahydrate (greater than 98% pure) by inhalation for 16 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in L5178Y mouse lymphoma cells. 16-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were exposed to 0, 3.5, 7, 15, 30, or 60 mg nickel sulfate hexahydrate/m(3) (equivalent to 0, 0.7, 1.4, 3.1, 6.1, or 12.2 mg nickel/m(3)). Rats were exposed on weekdays only, for a total of 12 exposure days during a 16-day period. Additional groups of four or five male and female F344/N rats were exposed to 0, 3.5, 15, or 30 mg nickel sulfate hexahydrate/m(3)for tissue burden studies. In the core study, two 60 mg/m(3) males, one 30 mg/m(3) female, and all 60 mg/m(3)females died before the end of the study. Final mean body weights of all exposed groups of males and females were significantly lower than those of the controls, as were mean body weight gains of male rats. Clinical findings included increased rates of respiration and reduced activity levels in rats in all exposure groups, except those exposed to 3.5 mg/m(3). Absolute lung weights of 60 mg/m(3) males and of all exposed groups of females were significantly greater than those of the controls, as were the relative lung weights of all exposed groups of males and females. Inflammation (including degeneration and necrosis of the bronchiolar epithelium) occurred in the lungs of all exposed groups of males and females. Atrophy of the olfactory epithelium occurred in the nasal passages of all exposed groups of males (except 60 mg/m(3)) and in 15, 30, and 60 mg/m(3) females. Lymphoid hyperplasia in the bronchial or mediastinal lymph nodes was observed in 30 mg/m(3) males and in 60 mg/m(3) males and females. The concentration of nickel in the lungs of all exposed groups of males and females was greater than in control animals. 16-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were exposed to 0, 3.5, 7, 15, 30, or 60 mg nickel sulfate hexahydrate/m(3). Mice were exposed on weekdays only, for a total of 12 exposure days during a 16-day period. Additional groups of five male and five female B6C3F1 mice were exposed to 0 or 3.5 mg nickel sulfate hexahydrate/m(3)for tissue burden studies. All core study mice exposed to 7 mg/m(3) or greater died before the end of the study; all control and 3.5 mg/m(3)mice survived to the end of the study. Final mean body weights and weight gains of 7, 15, 30, and 60 mg/m(3)males and females were significantly less than those of the controls, and clinical findings in these groups included emaciation, lethargy, and rapid respiration rates. Absolute and relative lung weights of male and female mice exposed to 7 mg/m(3) or greater were significantly greater than those of the controls. Only tissues from mice exposed to 0, 3.5, or 7 mg/m(3) were examined histopathologically. Inflammation occurred in the lungs of 3.5 and 7 mg/m(3) males and females; necrosis of the alveolar and bronchiolar epithelium was a component of the inflammation in 7 mg/m(3)males and females. In addition, atrophy of the olfactory epithelium of the nasal passages was observed in 3.5 mg/m(3) males and females. Nickel concentrations in the lungs of mice exposed to 3.5 mg/m(3) were greater than those in the controls. 13-WEEK STUDY IN RATS: Groups of ten male and ten female F344/N rats were exposed to 0, 0.12, 0.25, 0.5, 1, or 2 mg nickel sulfate hexahydrate (equivalent to 0, 0.03, 0.06, 0.11, 0.22, or 0.44 mg nickel/m(3)), 5 days per week for 13 weeks. Additional groups of six male and six female F344/N rats were exposed to 0, 0.12, 0.5, or 2 mg nic mg nickel sulfate hexahydrate/m(3)for tissue burden studies. In the core study, one 2 mg/m(3)male rat died before the end of the study; all other males and all females survived until the end of the study. Final mean body weights and body weight gains of all exposed groups were similar to those of the controls. There were no significant clinical findings noted during the study. Exposure-related increases in neutrophil and lymphocyte numbers occurred and were most pronounced in female rats. With the exception of 0.12 mg/m(3)rats, absolute and relative lung weights of all exposed groups were generally significantly greater than those of the controls. Exposure-related increases in the incidence and severity of inflammatory lesions (alveolar macrophages, chronic inflammation, and interstitial infiltration) occurred in the lungs of all exposed groups of males and females. Lymphoid hyperplasia of the bronchial and/or mediastinal lymph nodes occurred in males exposed to 0.5 mg/m(3)or greater. Atrophy of the olfactory epithelium occurred in males and females exposed to 0.5, 1, and 2 mg/m(3)and in 0.25 mg/m(3)females. The concentration of nickel in the lungs of 0.5 and 2 mg/m(3) rats was greater than that in the lungs of control animals at 4, 9, and 13 weeks for males and at 13 weeks for females. 13-WEEK STUDY IN MICE: Groups of ten male and ten female B6C3F1 mice were exposed to 0, 0.12, 0.25, 0.5, 1, or 2 mg nickel sulfate hexahydrate, 5 days per week for 13 weeks. Additional groups of up to five or six male and female B6C3F1 mice were exposed to 0, 0.12, 0.5, or 2 mg nickel sulfate hexahydrate/m(3)for tissue burden studies. In the core study, four control males, three control females, and one 0.12 mg/m(3)male died before the end of the study; the deaths were not considered to be chemical related, and all other mice survived to the end of the study. The final mean body weights and body weight gains of all exposed groups were similar to those of the controls. There were no chemical-related clinical findings. Hematology changes similar to those reported in female rats occurred in female mice, but the mice were minimally affected. The absolute and relative lung weights of 1 mg/m(3)males and 2 mg/m(3)males and females were significantly greater than those of the controls. Increased numbers of alveolar macrophages occurred in all males and females exposed to 0.5 mg/m(3)or greater. Chronic active inflammation and fibrosis occurred in 1 and 2 mg/m(3)males and females. Lymphoid hyperplasia of the bronchial lymph node and atrophy of the olfactory epithelium in the nasal passages were observed in 2 mg/m(3)males and females. Nickel concentration in the lung of 2 mg/m(3)females was significantly greater than in control animals. 2-YEAR STUDY IN RATS: Groups of 63 to 65 male and 63 to 64 female rats were exposed to nickel sulfate hexahydrate by inhalation at concentrations of 0, 0.12, 0.25, or 0.5 mg/m(3) (equivalent to 0, 0.03, 0.06, or 0.11 mg nickel/m(3)). Animals were exposed for 6 hours plus T90 (8 minutes) 5 days per week for 104 weeks. Five male and five female rats from each group were evaluated at 7 months for histopathology; an additional seven males and seven females from each group were evaluated at 7 months for nickel tissue burden in the lung and kidney; and five males and five females from each group were evaluated at 15 months for alterations in hematology, nickel tissue burden in the lung and kidney, and histopathology. Survival, Body Weights, Clinical Findings, and Hematology The survival rates of all exposed groups of males and females were similar to those of the controls. Mean body weights of 0.5 mg/m(3)female rats were slightly lower (6&amp;percnt; to 9&amp;percnt;) than those of the controls throughout the second year of the study; final mean body weights of all exposed groups of males and 0.12 and 0.25 mg/m(3)females were similar to those of the controls. There were no clinical findings or hematology differences that were considered to be related to nickel sulfate hexahydrate administration. Pathology Findings No exposure-related neoplasms occurred in male or female rats exposed by inhalation to nickel sulfate hexahydrate for 2 years. Increased incidences of inflammatory lung lesions were generally observed in all exposed groups of male and female rats at the end of the study. The incidences of chronic active inflammation, macrophage hyperplasia, alveolar proteinosis, and fibrosis were markedly increased in male and female rats exposed to 0.25 or 0.5 mg/m(3). Increased incidences of lymphoid hyperplasia in the bronchial lymph nodes occurred in 0.5 mg/m(3)male and female rats at the end of the 2-year study. The incidences of atrophy of the olfactory epithelium in 0.5 mg/m(3)males and females were significantly greater than those in controls at the end of the study. Tissue Burden Analyses Lung nickel burdens in exposed male and female rats were greater than those in the controls at the 7- and 15-month interim evaluations, and lung nickel burdens values increased with increasing exposure concentration. 2-YEAR STUDY IN MICE: Groups of 80 male and 80 female mice were exposed to nickel sulfate hexahydrate by inhalation at concentrations of 0, 0.25, 0.5, or 1 mg/m(3) (equivalent to 0, 0.06, 0.11, or 0.22 mg nickel/m(3)). Animals were exposed for 6 hours plus T90 (8 minutes) 5 days per week for 104 weeks. Five male and five female mice from each group were evaluated at 7 months for histopathology; five males and five females from each group were evaluated at 7 months for nickel tissue burden in the lung and kidney; five males and five females from each group were evaluated at 15 months for alterations in hematology and histopathology; and five males and five females from each group were evaluated at 15 months for nickel tissue burden in the lung and kidney. Survival, Body Weights, Clinical Findings, and Hematology The survival rates of all exposed groups of males and females were similar to those of the controls. The mean body weights of 1 mg/m(3)males and of all exposed groups of females were lower than those of the controls during the second year of the study. There were no clinical findings or hematology differences considered to be related to chemical exposure. Pathology Findings Inflammatory lesions of the lung generally occurred in all exposed groups of male and female mice at the end of the 2-year study. These lesions included macrophage hyperplasia, chronic active inflammation, bronchialization (alveolar epithelial hyperplasia), alveolar proteinosis, and infiltrating cells in the interstitium. Incidences of macrophage hyperplasia and/or lymphoid hyperplasia occurred in the bronchial lymph nodes of most of the 1 mg/m(3)males and females and in some 0.5 mg/m(3)females at the end of the 2-year study. Atrophy of the olfactory epithelium was observed in 0.5 and 1 mg/m(3)males and in all exposed groups of females at the end of the 2-year study. Tissue Burden Analyses At the 7- and 15-month interim evaluations, lung nickel burden parameters measured in control and exposed groups were below the limit of detection. Absolute lung weights of 0.5 and 1 mg/m(3)lung burden study females were significantly greater than those of the controls at 15 months. GENETIC TOXICOLOGY: Nickel sulfate hexahydrate (500 to 800 g/mL) was tested for induction of trifluorothymidine resistance in L5178Y mouse lymphoma cells. A positive response was observed in the absence of S9. The test was not performed with S9. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was no evidence of carcinogenic activity of nickel sulfate hexahydrate in male or female F344/N rats exposed to 0.12, 0.25, or 0.5 mg/m(3) (0.03, 0.06, or 0.11 mg nickel/m(3)). There was no evidence of carcinogenic activity of nickel sulfate hexahydrate in male or female B6C3F1 mice exposed to 0.25, 0.5, or 1 mg/ m3 (0.06, 0.11, or 0.22 mg nickel/m(3)). Exposure of rats to nickel sulfate hexahydrate by inhalation for 2 years resulted in increased incidences of chronic active inflammation, macrophage hyperplasia, alveolar proteinosis, and fibrosis of the lung; lymphoid hyperplasia of the bronchial lymph node; and atrophy of the olfactory epithelium. Exposure of mice to nickel sulfate hexahydrate by inhalation for 2 years resulted in increased incidences of chronic active inflammation, bronchialization (alveolar epithelial hyperplasia), macrophage hyperplasia, interstitial infiltration, and alveolar proteinosis of the lung; lymphoid and macrophage hyperplasia of the bronchial lymph node; and atrophy of the olfactory epithelium. Synonyms: Blue salt; hexahydrate, nickel (2+) salt; nickel monosulfate hexahydrate; nickel (2+) sulfate hexahydrate; nickel (II) sulfate hexahydrate; nickel sulphate hexahydrate; nickelous sulfate hexahydrate; nickelous sulphate hexahydrate; single nickel salt, sulfuric acid

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Salicylazosulfapyridine is widely used for the treatment of ulcerative colitis and Crohn's disease. It has been beneficial in the treatment of psoriasis and rheumatoid arthritis, and it has been used in veterinary medicine for the treatment of granulomatous colitis. Salicylazosulfapyridine was nominated for toxicity and carcinogenicity testing by the National Cancer Institute on the basis of its widespread use in humans and because it is a representative chemical from a class of aryl sulfonamides. Salicylazosulfapyridine is a suspect carcinogen because reductive cleavage of the azo linkage yields a p-amino aryl sulfonamide (sulfapyridine), and a related p-amino aryl sulfonamide (sulfamethoxazole) has been shown to produce thyroid neoplasms in rats. Toxicology and carcinogenicity studies were conducted in F344/N rats and B6C3F1 mice. Rats and mice were administered salicylazosulfapyridine (96% to 98% pure) in corn oil by gavage for 16 days, 13 weeks, or 2 years. The gavage route of administration was selected for these studies because it approximates the typical route of human exposure to the chemical. Genetic toxicology studies were conducted in vitro in Salmonella typhimurium and cultured Chinese hamster ovary cells and in vivo in rat and mouse bone marrow and mouse peripheral blood cells. 16-DAY STUDY IN RATS: Groups of five male and five female rats were administered 0, 675, 1,350, or 2,700 mg salicylazosulfapyridine/kg body weight in corn oil by gavage for 16 days excluding weekends. All rats survived to the end of the study. With the exception of the 675 mg/kg male group, the final mean body weights of all dosed groups of males and females were significantly lower than those of controls. Mean body weight gains of all dosed groups were less than those of controls. Clinical findings included ruffled fur and distended abdomens in male and female rats receiving 2,700 mg/kg. Hypothyroidism, evidenced by decreased serum triiodothyronine and thyroxine concentrations and increased thyroid-stimulating hormone concentrations, occurred in 2,700 mg/kg male and female rats. The absolute and relative thymus weights of male rats receiving,350 or 2,700 mg/kg and female rats receiving 2,700 mg/kg were significantly lower than those of controls. At necropsy, all dosed rats had enlarged cecae/large intestines. Male rats receiving 1,350 mg/kg and male and female rats receiving 2,700 mg/kg had red, enlarged thyroid glands. Chemical-related microscopic lesions were present in the forestomach, thymus, thyroid gland, and pituitary gland. Minimal to mild hyperplasia of the forestomach mucosa was present in the 1,350 and 2,700 mg/kg male and female groups. Lymphoid depletion was observed in the thymus of three male and three female rats in the 2,700 mg/kg groups. Male and female rats receiving 1,350 and 2,700 mg/kg had thyroid gland follicular cell hyperplasia and an increase in thyroid-stimulating hormone producing cells in the pars distalis of the pituitary gland. 16-DAY STUDY IN MICE: Groups of five male and five female mice were administered 0, 675, 1,350, or 2,700 mg salicylazosulfapyridine/kg body weight in corn oil by gavage for 16 days excluding weekends. There were no chemical-related deaths, and final mean body weights of dosed mice were similar to those of controls. No chemical-related clinical findings were noted for male or female mice. There were no differences in triiodothyronine, thyroxine, or thyroid-stimulating hormone concentrations between dosed and control mice. There were no biologically significant differences in absolute or relative organ weights between dosed and control male and female mice. At necropsy, male mice receiving 2,700 mg/kg had enlarged cecae/large intestines. There were no biologically significant histopathologic lesions attributed to salicylazosulfapyridine administration. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were administered 0, 84, 168.8, or 337.5 mg salicylazosulfapyridine/kg body weight in corn oil by gavage for 13 weeks. All rats survived to the end of the study. The finaludy. The final mean body weights of dosed male rats were similar to those of controls; the final mean body weights and body weight gains of dosed females were significantly lower than those of controls. No chemical-related clinical findings were noted in dosed male or female rats during the 13-week study. No significant differences in hematology or urinalysis parameters between control and dosed rats were observed. The absolute and relative right kidney weights of 337.5 mg/kg females were significantly greater than those of controls. At necropsy, some 337.5 mg/kg male rats had red, enlarged thyroid glands. Histopathologic changes were noted primarily in the thyroid gland and pituitary gland of males and females in the 337.5 mg/kg groups. The thyroid gland lesions observed were similar to those present in the 16-day study. Nine male rats receiving 168.8 mg/kg and ten male and seven female rats receiving.5 mg/kg had minimal but consistent changes in thyroid gland follicular cells. In the pituitary gland of 337.5 mg/kg males and females, the thyroid-stimulating hormone producing cells were enlarged and contained pale-staining cytoplasm and prominent Golgi complexes. Decreased serum triiodothyronine and thyroxine concentrations and increased thyroid-stimulating hormone concentration, similar to differences observed in the 16-day study, occurred in 337.5 mg/kg male rats; thyroid hormone concentrations were not affected in female rats. Sperm motility of all dosed groups of males was significantly lower than that of controls. Vaginal cytology parameters of dosed groups of females were similar to those of controls. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were administered 0, 675, 1,350, or 2,700 mg salicylazosulfapyridine/kg body weight in corn oil by gavage for 13 weeks. All mice survived to the end of the study. The final mean body weights of dosed male and female mice were similar to those of controls. The mean body weight gains of 1,350 and 2,700 mg/kg male mice were less than that of controls. No chemical-related clinical findings were noted in dosed male or female mice during the 13-week study. There was minimal evidence of a responsive anemia in mice in the 13-week study. The anemia was probably related to a methemoglobinemia. There were minimal decreases in thyroxine concentration in all dosed groups of male and female mice in the -week study. There were, however, no differences in triiodothyronine and thyroid-stimulating hormone concentrations between dosed and control animals. Absolute and relative liver weights of all groups of dosed male and female mice were significantly greater than those of controls. There were no chemical-related gross lesions. Microscopic evaluation of the liver revealed centrilobular hypertrophy in five 1,350 mg/kg and all 2,700 mg/kg male mice. The right cauda weight of the 1,350 mg/kg group and the right epididymis weights of all dose groups were significantly lower than those of controls. There was no evidence of chemical-related alteration in the vaginal cytology parameters of female mice. 2-YEAR STUDY IN RATS: Groups of 60 male and 60 female rats were administered 84, 168, or 337.5 mg salicylazosulfapyridine/kg body weight in corn oil by gavage for up to 105 weeks. Groups of 70 male and 60 female rats were administered the corn oil vehicle by gavage for up to 105 weeks. A stop-exposure group of 70 male rats was administered 337.5 mg/kg salicylazosulfapyridine in corn oil by gavage for 6 months, after which animals received the corn oil vehicle by gavage for the remainder of the 2-year study. Ten animals from the vehicle control male group and 10 animals from the 337.5 mg/kg stop-exposure group were evaluated at 6 months; animals from each core-study group were evaluated at 15 months. Survival, Body Weights, and Clinical Chemistry: Survival of 337.5 mg/kg male core-study rats was significantly lower than that of controls; survival of 84 and 168 mg/kg core-study males, all groups of dosed females, and the stop-exposure male group was similar to controls. Mean body weights of core-study males and stop-exposure males were similar to controls throughout the study. From week 45 to the end of the study, females in the 337.5 mg/kg group had mean body weights that were lower than those of controls. The serum thyroxine concentration in 337.5 mg/kg core-study males at study termination was minimally lower than that of controls; the serum thyroid-stimulating hormone, triiodothyronine, and reverse triiodothyronine concentrations of dosed males and females were similar to those of controls. Pathology Findings: Administration of salicylazosulfapyridine for 2 years was associated with transitional epithelial papilloma in the urinary bladder of male rats and may have been associated with transitional epithelial papilloma of the kidney and of the urinary bladder of female rats. Nonneoplastic effects in the urinary bladder and kidney of male and female rats and in the spleen of male rats were also observed. Dosed male and female rats had increased incidences of grossly and microscopically observed urinary bladder concretions (diagnosed grossly as calculi at necropsy); male and female rats that developed transitional epithelial papillomas of the urinary bladder had grossly observed concretions (calculi) in the urinary bladder at necropsy. The microscopic neoplastic and nonneoplastic urinary bladder and kidney effects observed in dosed male rats during the 2-year continuous study did not occur in dosed rats during the 2-year stop-exposure study, nor were there gross observations of concretions (calculi) at necropsy. The incidences of mononuclear cell leukemia in male and female rats were decreased. The thyroid gland hyperplasia seen in the -week study was not observed in the 2-year study, and there was no evidence of chemical-related thyroid gland follicular cell adenomas or carcinomas. 2-YEAR STUDY IN MICE: Groups of 60 male and 60 female mice were administered 0, 675, 1,350, or 2,700 mg salicylazosulfapyridine/kg body weight in corn oil by gavage for up to 104 weeks. Ten animals from each group were evaluated at 15 months. Survival, Body Weights,and Clinical Chemistry: Survival of all the dosed groups of male and female mice was similar to that of controls. Mean body weights of 675 and 1,350 mg/kg male and female mice were similar to controls throughout the study. From week 12 to the end of the study, 2,700 mg/kg male mice had mean body weights that were lower than those of controls. From week 14 to the end of the study, the 2,700 mg/kg female mice had mean body weights that were lower than those of controls. There were no chemical-related differences in triiodothyronine, reverse triiodothyronine, thyroxine, or thyroid-stimulating hormone concentrations between dosed and control mice at the 15-month evaluation. Pathology Findings: Exposure of mice to salicylazosulfapyridine in corn oil by gavage for 2 years was associated with increased incidences of hepatocellular neoplasms in males and females. Nonneoplastic effects in the liver and spleen were also observed in male and female mice. The incidences of forestomach squamous cell papilloma in females and forestomach hyperplasia in males and females were decreased. GENETIC TOXICOLOGY: Salicylazosulfapyridine was not mutagenic in Salmonella typhimurium strains TA97, TA98, TA100, or TA1535, and it did not induce sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells. These in vitro assays were performed with and without S9 metabolic activation enzymes. Results from in vivo mouse bone marrow chromo somal aberration tests were uniformly negative, while results of micronucleus assays performed on male or female mice exposed to salicylazosulfapyridine for periods ranging from 3 days to weeks were positive. Micronucleus tests in male mice for shorter exposure times (1 to 2 days) yielded negative or very weakly positive results. A three-treatment (72-hour exposure time) micronucleus test performed in male rats yielded equivocal results. Overall, results of these in vivo assays indicate that salicylazosulfa pyridine is capable of inducing chromosomal damage, possibly in the form of aneuploidy, in mouse bone marrow cells after multiple administrations. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was some evidence of carcinogenic activity of salicylazosulfapyridine in male and female F344/N rats based on increased incidences of neoplasms in the urinary tract. There was an increased incidence of transitional epithelial papilloma of the urinary bladder in males and a low incidence of rare transitional epithelial papillomas of the kidney and of the urinary bladder in females. There was clear evidence of carcinogenic activity of salicylazosulfapyridine in male and female B6C3F1 mice based on increased incidences of hepatocellular neoplasms. Increased incidences of nonneoplastic lesions of the urinary bladder and kidney in male and female rats and of the spleen in male rats were observed. Increased incidences of nonneoplastic lesions of the liver and spleen in male and female mice were observed. Decreased incidences of mononuclear cell leukemia in male and female rats were related to salicylazosulfapyridine administration. Decreased incidences of forestomach squamous cell papilloma in female mice and forestomach hyperplasia in male and female mice were related to salicylazosulfapyridine administration. Synonyms: 2-Hydroxy-5-[[4-[2-(pyridinylamino)sulfonyl]phenyl]azo]benzoic acid; 5-[p- (2-pyridylsulfamoyl)phenylazo]salicylic acid; sulfasalazine; salazosulfapyridine; 5-[4-(2-pyridylsulfamoyl)phenylazo]-2-hydroxybenzoic acid; 4-(pyridyl-2-amidosulfonyl)-3'-carboxy-4'-hydroxyazobenzene; sulphasalazine Trade names: Azopyrin, Azulfidine, Benzosulfa, Colo-Pleon, Reupirin, Salazopyrin

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Theophylline is an alkaloid found in tea (Thea sinensis) and chocolate and is structurally related to caffeine and theobromine. Theophylline is used as a pharmaceutical agent. It stimulates the heart and central nervous system, relaxes the smooth muscles of the bronchi and blood vessels, and causes diuresis. The drug is used mainly as a bronchodilator in obstructive airway diseases, such as bronchial asthma, and for myocardial stimulation. Theophylline was nominated for toxicologic and carcinogenicity testing as a representative of the purine structural subclass, particularly because of its relationship to purines such as caffeine, 1-methyl-3-hydroxyguanine, and 3-hydroxy-1-methylxanthine, the latter two compounds having been shown to induce sarcomas in rats. Additional reasons for testing theophylline included its widespread use in humans as a pharmaceutical agent, its possible genotoxicity in vitro, and the lack of information on its potential toxicity and/or carcinogenicity under conditions of chronic oral usage. Based on reported teratogenicity and testicular toxicity, it was also recommended that reproductive studies be included in the evaluation of theophylline. The oral route of administration was selected because it is the primary route of human exposure, and the gavage route was selected because it mimics the pharmaceutical use of theophylline in humans. Male and female F344/N rats and B6C3F1 mice were given theophylline (greater than 99% pure) in feed or in corn oil by gavage for 16 days or 14 weeks or in corn oil by gavage for 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, mouse bone marrow, and mouse peripheral blood. 16-DAY FEED STUDY IN RATS: Groups of five male and five female F344/N rats were given 0, 500, 1,000, 2,000, 4,000, or 8,000 ppm theophylline in feed for 16 days, which resulted in approximate daily doses of 50, 100, 250, 450, or 1,000 mg theophylline/kg body weight to males and 75, 150, 250, 450, or 1,100 mg/kg to females. All rats survived until the end of the study. The final mean body weights and body weight gains of 8,000 ppm males and females were significantly less than those of the controls. The absolute and relative testis weights of 4,000 ppm males were significantly greater than those of the controls. Increased incidences of uterine hypoplasia were observed microscopically in exposed groups of females. 16-DAY GAVAGE STUDY IN RATS: Groups of five male and five female F344/N rats were given 0, 12.5 (twice daily), 25 (once daily), 50 (once daily), 50 (twice daily), 100 (once daily), 200 (once daily), 200 (twice daily), or 400 (once daily) mg theophylline/kg body weight in corn oil by gavage. All rats receiving 400 mg/kg once daily and all but one female receiving 200 mg/kg twice daily died during the study. In groups dosed once daily, final mean body weights and body weight gains of males receiving 100 or 200 mg/kg and mean body weight gains of females receiving 50, 100, or 200 mg/kg were less than those of controls. The final mean body weights and body weight gains of groups receiving theophylline twice daily were generally similar to those of groups receiving the same daily dosages once daily. Clinical findings included rapid or labored respiration, hunched posture, and squinting. In groups dosed once daily, absolute and relative uterus weights of females receiving 100 or 200 mg/kg once daily were significantly less than those of the controls, and the absolute and relative uterus weights of females receiving 100 mg/kg once daily were significantly less than those of females receiving 50 mg/kg twice daily. Uterine atrophy was observed in three females receiving 200 mg/kg twice daily. Periarteritis of the mesenteric arteries was observed in two males and two females receiving 400 mg/kg once daily. 16-DAY FEED STUDY IN MICE: Groups of five male and five female B6C3F1 mice were given 0, 500, 1,000, 2,000, 4,000, or 8,000 ppm theophylline in feed for 16 days, resulting in approximate daily doses of 250, 475, 950, 1,800, or800, or 2,000 mg theophylline/kg body weight to males and 300, 450, 1,225, 2,000, or 4,375 mg/kg to females. All mice survived until the end of the study. Final mean body weights of 4,000 and 8,000 ppm females and mean body weight gains of 2,000, 4,000, and 8,000 ppm females were significantly greater than those of the controls. Feed consumption by exposed groups was similar to that by the controls, except that by the 8,000 ppm males, which was approximately 40&amp;percnt; the amount of feed consumed by the control group. Histopathologic examinations were not performed due to the absence of mortality and significant exposure-related lesions. 16-DAY GAVAGE STUDY IN MICE: Groups of five male and five female B6C3F1 mice were given 0, 12.5 (twice daily), 25 (once daily), 50 (once daily), 50 (twice daily), 100 (once daily), 200 (once daily), 200 (twice daily), or 400 (once daily) mg theophylline/kg body weight in corn oil by gavage. Three males and all females receiving 400 mg/kg once daily died on day 1. There were no significant differences in final mean body weights or body weight gains. There were no histopathologic findings attributed directly to theophylline. 14-WEEK FEED STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were given 0, 1,000, 2,000, or 4,000 ppm theophylline in feed for 14 weeks, which resulted in approximate daily doses of 75, 125, or 250 mg theophylline/kg body weight to males and 75, 125, or 275 mg/kg to females. The final mean body weight of 1,000 ppm females was significantly greater than that of the control group. Feed consumption by exposed groups was similar to that by the controls. Mean cell volume and mean cell hemoglobin were significantly greater in males exposed to 2,000 or 4,000 ppm than those in the control group. Segmented neutrophil counts of all groups of exposed females were significantly greater than that of the control group. The absolute and relative kidney weights of 4,000 ppm males were significantly greater than those of the controls, and there was an exposure-related increase in the severity of nephropathy in males. Exposure-related increases in the incidences of mesenteric and/or pancreatic periarteritis were observed in males and females. 14-WEEK GAVAGE STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were given 0, 37.5, 75, or 150 mg theophylline/kg body weight in corn oil by gavage for 14 weeks. One male and one female receiving 150 mg/kg died before the end of the study. The mean body weight gain of 150 mg/kg females was significantly greater than that of the controls. Mean cell volume of 150 mg/kg males and mean cell hemoglobin of all groups of dosed males were significantly greater than those of the control group. There were slight dose-dependent increases in the incidences of mesenteric periarteritis in dosed males and females. 14-WEEK FEED STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were given 0, 1,000, 2,000, or 4,000 ppm theophylline in feed for 14 weeks, resulting in approximate daily doses of 175, 400, or 800 mg theophylline/kg body weight to males and 225, 425, or 850 mg/kg to females. All mice survived until the end of the study. The final mean body weights and body weight gains of all exposed groups of males and females were significantly less than those of the controls. Feed consumption by exposed groups was similar to that by the controls. Leukocyte, segmented neutrophil, and lymphocyte counts of 4,000 ppm males were significantly greater than those of the controls. Leukocyte and segmented neutrophil counts of 2,000 or 4,000 ppm females were significantly greater than those of the controls. There were no histopathologic findings attributed directly to theophylline exposure. 14-WEEK GAVAGE STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were given 0, 75, 150, or 300 mg theophylline/kg body weight in corn oil by gavage for 14 weeks. Three males and all females receiving 300 mg/kg, one 75 mg/kg male, and one control female died before the end of the study. Final mean body weights and body weight gains of 150 and 300 mg/kg males were significantly less than those of the controls. Mean cell volume and mean cell hemoglobin of 300 mg/kg males were significantly greater than those of the controls. There were no histopathologic findings attributed directly to theophylline treatment. 2-YEAR GAVAGE STUDY IN RATS: Groups of 50 male and 50 female rats were given 7.5, 25, or 75 mg theophylline/kg body weight in corn oil by gavage for 2 years. Survival and Body Weights: There were no significant differences in survival between dosed and control groups. Final mean body weights of all groups of dosed males and females were significantly less than those of the controls. Pathology Findings: There were no significantly increased incidences of neoplasms in dosed rats. The incidence of chronic inflammation of the mesenteric arteries was significantly increased in males receiving 75 mg/kg compared to the controls. There were doserelated negative trends in the incidences of mammary gland fibroadenoma and fibroadenoma or carcinoma (combined) in females; these differences correlated with decreased body weights. 2-YEAR GAVAGE STUDY IN MICE: Groups of 50 male B6C3F1 mice were given 0, 15, 50, or 150 mg theophylline/kg body weight and groups of 50 female B6C3F1 mice were given 0, 7.5, 25, or 75 mg/kg in corn oil by gavage for 2 years. Survival and Body Weights: Survival of 150 mg/kg males was significantly less than that of the controls. The final mean body weights of 150 mg/kg males, 25 mg/kg females, and 75 mg/kg females were significantly less than those of the control groups. Pathology Findings: There were no treatment-related increases in incidences of nonneoplastic lesions or neoplasms. In males and females, there were decreased incidences of hepatocellular adenoma and of the combined incidences of hepatocellular adenoma or carcinoma compared to the controls. Male mice had a pattern of nonneoplastic liver lesions along with silver-staining helical organisms in the liver consistent with Helicobacter hepaticus infection. The incidences of these liver lesions in 150 mg/kg males were significantly lower than those in control males. Increases in the incidences of hepatocellular neoplasms in male mice have been shown to be associated with H. hepaticus infection when hepatitis is also present. Because of this association, interpretation of the decreased incidence of liver neoplasms in male mice was more difficult. Incidences of lesions at other sites in this study were not considered to have been significantly impacted by H. hepaticus infection or its associated hepatitis. GENETIC TOXICOLOGY: Theophylline was not mutagenic in Salmonella typhimurium, with or without metabolic activation (S9). It induced sister chromatid exchanges but not chromosomal aberrations in cultured Chinese hamster ovary cells. The positive sister chromatid exchange response was noted only in the absence of S9. In vivo, a mouse bone marrow sister chromatid exchange test showed positive results at a standard 23-hour harvest time; however, this test was not repeated and the response is unconfirmed. An in vivo mouse bone marrow chromosomal aberrations test, that employed both standard and extended exposure protocols, gave negative results. The frequency of micronucleated erythrocytes was determined in peripheral blood of male and female mice exposed to theophylline in dosed feed or in corn oil by gavage for 14 weeks. No significant increases in the frequencies of micronucleated cells were seen in male or female mice in either of the studies. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was no evidence of carcinogenic activity of theophylline in male or female F344/N rats administered 7.5, 25, or 75 mg/kg. There was no evidence of carcinogenic activity of theophylline in male B6C3F1 mice administered 15, 50, or 150 mg/kg or female B6C3F1 mice administered 7.5, 25, or 75 mg/kg. Gavage administration of theophylline caused chronic inflammation of the mesenteric arteries in dosed male rats. Decreased incidences of mammary neoplasms in female rats were likely associated with lower body weights. There were dose-related decreases in the incidences of hepatocellular adenoma and hepatocellular carcinoma in male and female mice. Synonyms: 3,7-dihydro-1,3-dimethyl-1H-purine-2,6-dione; 1,3-dimethylxanthine; 1H-purine-2,6-dione; NSC 2066; pseusdotheophylline; theocin; theophyllin; theophylline, anhydrous Trade names: Accurbron; Aerobin; Aerolate III; Afonilum; Aminophylline; Aquaphyllin; Armophylline; Asmalix; Bilordyl; Bronchoretard; Bronkodyl; Cetraphylline; Constant-T; Diffumal; Duraphyl; Duraphyllin; Elixicon; Elixophyllin; Euphylline L.A.; Euphylong; LaBID; Labophylline; Lanophyllin; Lasma; Liquophylline; Optiphyllin; Parkophyllin; Phylocontin; Physpan; Pro-Vent; PulmiDur; Pulmo-Timelets; Quibron; Respbid; Rona-Phyllin; Sabidal; Slo-bid; Slo-Phyllin; Solosin; Sustaire; Tefamin; Teobid; Teofyllamin; Tesona; Theal tablets; Theo-24; Theobid; Theocap; Theochron; Theoclear; Theocontin; Theo-Dur; Theofol; Theograd; Theolair; Theolan; Theolix; Theophyl; Theoplus; Theo-Sav; Theosol; Theospan; Theostat; Theovent; TheoX; T-Phyl; Truphylline; Uni-Dur; Unifyl; Uniphyl; Uniphyllin; Xanthium

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Prostate cancer (PCa) is the most common solid cancer affecting men worldwide. Serum prostate-specific antigen (PSA) is at present the most commonly used biomarker for PCa screening, as well as a reliable marker of disease recurrence after initial treatment. Bone metastases (BM) are present in advanced stages of the disease. Imaging of BM is important not only for localization and characterization, but also to evaluate their size and number, as well as to follow-up the disease during and after therapy. Bone metastases formation is triggered by cancer initiating cells in the bone marrow and is facilitated by the release of several growth factors. Although BM from PCa are very heterogenic, the majority of them are described as "osteoblastic", while pure "osteolytic" metastases are very rare. The PSA levels, along with other parameters, may determine the risk of having BM. A classification report, which is currently in use, divides patients into three categories according to the risk of having BM: low risk (PSA&lt;10ng/mL, clinical stage T1-T2a, Gleason Score ≤6), intermediate risk (PSA 10.1-20ng/mL, clinical stage T2b-T2c, Gleason Score=7) and high risk (PSA&gt;20ng/mL, clinical stage T3a or higher, or Gleason Score ≥8). Even though PSA remains the only biomarker of this disease in clinical practice, it is not always analogue with the severity of the disease and should be evaluated along with the clinical and diagnostic imaging findings. Detection of BM is not always easy, as there may be unexpected sites and occult metastases. The clinical importance of revealing BM in patients with PCa is to determine the overall survival of the patients and their quality of life, as BM may lead to high morbidity and mortality. There are many options of treating BM, such as chemotherapy, immunotherapy, external beam radiotherapy, bone modifying agents and recently prostate-specific membrane antigen (PSMA) targeted therapies. Another potential therapy is radioguided surgery, in patients with occult and/or focally recurrent PCa. Such a single occult metastasis causing very high levels of PSA has been presented using technetium-99m (<sup99m</sup Tc) labeled PSMA imaging. Diagnosis and staging of PCa mostly relies on the morphology of imaging, using computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography/CT (PET/CT) using fluorine-18-fluorodeoxyglucose (<sup18</sup F-FDG). The radiopharmaceuticals used in Nuclear Medicine for BM in PCa are: a) those that target lesions, such as <sup99m</sup Tc-phosphonates, <sup18</sup F-sodium fluoride (<sup18</sup F-NaF) and b) those that target the cancer cells, such as <sup18</sup F or carbon-11 (<sup11</sup C)-choline, <sup18</sup F-FDG and <sup18</sup F or gallium-68 (<sup68</sup Ga)-PSMA. Bone scan with <sup99m</supTc-phosphonates is widely used for the evaluation of bone metabolism in patients with PCa. It is a low cost, widely available radiopharmaceutical having the advantage of a whole body evaluation. Planar and single photon emission tomography (SPET) may also be applied. The sensitivity of the whole body scan (WBS) ranges from 75%-95%, while the specificity is lower, ranging from 60%-75% due to false positive findings in benign conditions (arthritis, inflammation etc) who also have increased bone metabolism. Sensitivity and specificity however, perform better (96% and 94% respectively) when SPET and SPET/CT techniques are applied. Of course, bone marrow metastases cannot be detected in a WBS. The PSA marker is used to predict the pre-test probability of BM and in case of a bone scan several retrospective analyses showed that PSA levels &lt;20ng/mL can exclude with high probability a positive WBS, with a high negative predictive value (almost 99%). The European Association of Urology (EAU) guidelines state that a bone scan can be omitted in patients with PSA levels &lt;20ng/mL and with a Gleason Score ≤7. Imaging with <sup18</sup F-NaF PET/CT is characterized by high and rapid bone uptake, minimal serum protein binding and rapid blood clearance which lead to a fast and high target to background ratio with a short acquisition time (30 minutes). Sensitivity and specificity for the detection of BM in high risk PCa patients is almost 100%. The main advantages provided by <sup18</sup F-NaF PET/CT are the better imaging quality along with a whole body acquisition and the fusion technique. Fluorine-18-choline and <sup11</sup C-choline PET/CT came to practice lately, reflecting the cell membrane metabolism. Choline is an essential component of phospholipids and is trapped in the cells after a phosphorylation by a choline kinase. The sensitivity and specificity of <sup18</sup F-choline PET/CT for detecting BM in patients with PCa is reported to be 79% and 97% respectively. However, the performance of choline PET/CT seems to be dependent of the levels of the PSA, in cases of biochemical recurrence and reaches about 75%% in those PCa patients with PSA levels &gt;3ng/mL, with a poor performance when the PSA level is low. Fluorine-18-FDG is the most commonly used radiotracer in PET/CT, however has a little value in staging and restaging of PCa. Because of its low sensitivity <sup18</sup F-FDG is trapped in cancer cells through the activation of the glycolytic pathways and in case of BM is an index of increased glucose metabolism in PCa cells rather than in bone lesion per se. Osteolytic lesions show more increased metabolic activity than the osteoblastic lesions and are better revealed with 18F-FDG. Therefore, <sup18</sup F-FDG PET/CT is suggested to be performed only in selected patients with PCa, those with most aggressive tumors and high Gleason score. Fluorine-18-PSMA PET/CT The need of a more sensitive and specific agent has been evident. Prostate specific monoclonal antibody (PSMA) is a folate hydrolase cell surface glycoprotein. It is mainly expressed in four tissues of the body, including prostate epithelium, the proximal tubules of the kidney, the jejunal brush border of the small intestine and ganglia of the nervous system. So consequently may in some cases be expressed in cancers other than PCa and also in benign processes. It is localized in the cytoplasm and the apical side of the prostate epithelium that lines prostatic ducts. In case of malignant transformation, PSMA is transferred from the cytoplasm to the luminal surface of the prostatic ducts and thus becomes membrane bound. It has a unique three-parts structure, an external portion, a transmembrane portion and an internal-cytoplasmatic portion. Prostate specific monoclonal antibody is also upregulated and thus overexpressed in most PCa, but weakly expressed in normal prostatic tissue. Imaging by PSMA PET/CT has been shown to detect sites of disease recurrence at lower PSA levels than conventional imaging. The PSMA overexpression is even present when the cell becomes castrate-resistant and that is the reason why it is the most favorable target for PET imaging. Prostate cancer expresses 100 to 1000 times more PSMA than normal tissue and is increasing even more in higher grade tumors as well as in increased castrate resistance. Therefore, PSMA represents an excellent target for both diagnostic imaging and endoradiotherapy of PCa. For diagnostic purposes PSMA ligands, mainly small-molecule inhibitors, are most commonly labeled either with <sup68</sup Ga or <sup18</sup F. The <sup18</sup F-PSMA-1007 (((3S,10S,14S)-1-(4-(((S)-4-carboxy-2-((S)-4-carboxy-2-(6-<sup18</sup F-fluoronicotinamido) butanamido) methyl phenyl)-3- (naphthalen-2-ylmethyl)-1,4,12-trioxo-2,5,11,13-tetraazahexadecane- 10,14,16-tricarboxylic acid)) seems to be more favorable among other <sup18</sup F-PSMA ligands candidate compounds because it demonstrates high labeling yields, better tumor uptake and non-urinary background clearance. On the contrary, <sup68</sup Ga-PSMA is rapidly excreted via the urinary tract resulting in intense accumulation in the bladder, thus, obscuring the prostate. Compared to <sup68</sup Ga, <sup18</sup F has many advantages such as it is produced in larger amounts, it has a longer half life and a higher physical spatial resolution. The short half-life of <sup68</sup Ga relative to <sup18</sup F (68 vs. 110 min) makes <sup68</sup Ga-PSMA inconvenient for longer transport, so that it is almost mandatory to use local gallium generators, which have a higher cost and lower yields at the end of their first half-life. Each generator provides only one or two elutions per day and it requires separate syntheses at different times of the day in a local radiopharmacy. Furthermore, the resolution of <sup68</sup Ga-labeled tracers is physically limited because of positron range effects. In contrast, <sup18</sup F labels avoid these intrinsic difficulties and can be produced at high yields in central cyclotrons. Fluorine-18-PSMA-1007 has been recently used by us in the Nuclear Medicine Department of "Evangelismos" general hospital of Athens and our experience so far showed favorable results, with high image resolution acquisitions and lesions which showed PSMA avidity. Fluorine-18-PSMA-1007 PET/CT imaging was carried out with a dual phase protocol, consisting of two separate scans. One (early scan) at 60min post injection starting from the diaphragm to the middle of the thighs and the late scan at 180min from the dome of the skull to the knee joints. Patients were asked to urine before the examination. Images were acquired with a scan time of 3min per bed position on a General Electric PET/CT system and the image reconstruction was performed by the standard software method provided by the manufacturer. A low dose CT scan, without a contrast agent, was performed before the PET scan in order to be used for the attenuation correction. Administered activities were calculated based on the department's protocols with a suggested injected activity of 4MBq/kg. Any areas of focally increased radiotracer uptake, at both the early and late PET scans, were considered as abnormal, despite the presence or absence of morphological changes of the CT scan. The normal distribution of the radiotracer was taken under consideration, which includes mainly the liver and the gallbladder, as it has hepatobiliary clearance rather than renal, the spleen, the pancreas, the submandibular, sublingual, lacrimal and parotid glands, the kidneys, the urinary bladder and the small intestine. The maximum standardized uptake value (SUVmax) was calculated for each lesion. A typical case of a 78 years man with PCa having PSA 7,3ng/mL and also having Paget's disease was tested by the above procedure for initial staging. The <sup18</sup F-PSMA-1007 PET/CT imaging revealed diffusely increased radiotracer uptake in the bones of the pelvis with a SUVmax 9. The CT imaging of the pelvis was consistent with Paget's disease, with diffuse mixed osteosclerotic and osteolytic lesions, accompanied with bone expansion. The primary PCa was also revealed with focally increased radiotracer uptake in the left prostatic lobe with a SUVmax 19, as well as a second small focus of pathologically increased PSMA uptake in the right prostatic lobe with a SUVmax 23. Another patient 79 years old, with PCa was studied with <sup18</sup F-choline PET/CT which showed diffuse bone metastasis in the pelvis. He had PSA level, 412ng/mL. The <sup18</sup F-PSMA-1007 PET/CT imaging showed multiple foci of increased radiotracer uptake throughout the whole skeleton, including the skull, both humerus and femoral bones with indicative SUVmax 26. Computed tomography showed rather similar BM. There were also lymph nodes metastases at the left internal mammary chain as well as the left inguinal areas, with a SUVmax 25. The first case indicated that <sup18</sup F-PSMA PET/CT could easily differentiate PCa BM from Paget's disease, however benign conditions such as Paget's disease may also show PSMA uptake and the second case that <sup18</sup F-PSMA PET/CT scan was more sensitive than the <sup18</sup F-choline PET/CT scan, with high quality images. According to other authors the SUVmax value of BM in PCa was 16.57±23.59 using the <sup18</sup F-PSMA PET/CT scan. This imaging modality in accordance to other authors is better than <sup68</sup Ga-labelled PSMA-ligands and can better differentiate BM from healing fractures. Very recently a novel PET radiopharmaceutical has been approved both in USA and Europe: <sup18</sup F-fluciclovine (trans-1-amino-3-[<sup18</sup F] fluoro-cyclobutane carboxylic acid). Fluorine-18-fluciclovine is a synthetic amino acid that is transported by multiple sodium-dependent and sodium-independent channels found to be upregulated in PCa cells. The main indication of use includes the detection and localization of PCa recurrence in patients with a rising PSA following prior therapy. The main advantages of <sup18</sup F-fluciclovine are the low urinary excretion, which allows for better evaluation of prostate bed and the low uptake in inflammatory cells (e.g. macrophages). There are no studies in the literature comparing <sup18</sup F-PSMA to <sup18</sup F-fluciclovine, however two studies comparing <sup18</sup F-fluciclovine to <sup68</sup Ga-PSMA, showed better performance for <sup68</sup Ga-PSMA in PCa patients with biochemical recurrence. So, <sup18</sup F-PSMA-1007 PET/CT imaging seems to be very promising in staging and restaging patients with PCa, especially when biochemical relapse is under consideration. Although it seems to perform better than other imaging modalities like bone scan, <sup18</sup F-FDG PET/CT or <sup18</sup F-choline PET/CT, its high cost and low availability must be considered. Further large studies need to be conducted in order to evaluate the accuracy and the predictive values of this method, emphasizing on bone metastases.

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There is widespread concern over the health effects of oxidant air pollutants. The state of California and the Health Effects Institute (HEI) (a nonprofit research institute funded jointly by the U.S. Environmental Protection Agency [USEPA] and combustion engine manufacturers) nominated ozone for evaluation in long-term animal studies. The NTP study designs were a result of a series of meetings at the NIEHS with scientists from NIEHS, USEPA, and HEI, as well as experts from academic institutions working in the area of air pollutants. Male and female F344/N rats and B6C3F1 mice were exposed to ozone by inhalation for 4 weeks, 2 years, or for 124 weeks (rats) or 130 weeks (mice). The oxygen used to generate the ozone was greater than 99.9% pure. Additional groups of male F344/N rats were administered injections of 4-(N-methyl-Nnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) (~99% pure) 3 times per week for 20 weeks and exposed to ozone by inhalation for 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium. 4-WEEK OZONE STUDY IN RATS: Groups of five male and five female F344/N rats were exposed to 0, 0.5, or 1.0 ppm ozone by inhalation 6 hours per day, 5 days per week, for a total of 20 days. All rats survived to the end of the study. The final mean body weights and mean body weight gains of 0.5 ppm males and females and of 1.0 ppm females were similar to those of the controls. The final mean body weight of 1.0 ppm males was 7% lower than that of the controls. Clinical findings included hypoactivity in 1.0 ppm males and females and ruffled fur in exposed groups of males. Male and female rats exposed to 0.5 or 1.0 ppm developed multifocal lesions of the lung, which consisted of infiltration of granulocytes and macrophages with extension of the bronchial epithelium into the alveolar ducts. Female rats exposed to ozone developed minimal squamous metaplasia of the laryngeal epithelium at the base of the epiglottis. Absolute and relative lung weights of all exposed groups of males and females were greater than those of the controls, and absolute and relative thymus weights of all exposed groups were generally lower than those of the controls. 4-WEEK OZONE STUDY IN MICE: Groups of five male and five female B6C3F1 mice were exposed to 0, 0.5, or 1.0 ppm ozone by inhalation 6 hours per day, 5 days per week, for a total of 20 days. All mice survived to the end of the study. The final mean body weights and body weight gains of all exposed groups of mice were less than those of the controls. Hypoactivity was observed in 1.0 ppm mice. Male and female mice exposed to 0.5 or 1.0 ppm ozone developed patchy, multifocal lesions of the lung, which consisted of infiltration of granulocytes and macrophages with extension of the bronchial epithelium into the alveolar ducts. The relative lung weight of 1.0 ppm males was significantly greater than that of the controls. There were no other statistically significant differences in absolute or relative organ weights in males or females. 2-YEAR OZONE STUDY IN RATS: The 2-year study was designed to include the present USEPA standard (0.12 ppm), the maximum concentration believed compatible with long-term survival (1.0 ppm), and an intermediate concentration (0.5 ppm). Groups of 50 male and 50 female F344/N rats were exposed to 0, 0.12, 0.5, or 1.0 ppm ozone by inhalation for 6 hours per day, 5 days per week, for 105 weeks. Survival, Body Weights, and Clinical Findings: Survival of exposed groups of rats was similar to that of the controls at the end of the study. The mean body weights of 0.12 and 0.5 ppm males and females were similar to those of the controls throughout the study. The mean body weights of 1.0 ppm males and females were slightly lower than those of the controls throughout the study. Hypoactivity was observed in male and female rats exposed to ozone. Pathology Findings: Increased incidences of ozone-induced metaplasia occurred in the nose and lung of rats exposed to 0.5 or 1.0 ppm ozone. The lesions in the nose were characterized by an increase in the number of goblin the number of goblet cells in the respiratory epithelium with mild squamous metaplasia of the cuboidal epithelium on the lateral wall. The increase in the number of goblet cells was found primarily in level I and II epithelium occurring along the lateral wall and on the maxilloturbinates and nasoturbinates. The metaplasia in the lung was a patchy multifocal lesion consisting of extension of the bronchial epithelium into the alveoli of the centriacinar region. This may represent more an extension of the bronchial epithelium into the pulmonary parenchyma than an actual transition of one epithelial cell type into another. There were increased incidences of squamous metaplasia at the base of the epiglottis characterized by one or more layers of flattened epithelial cells where low cuboidal cells are normally found. There were no increases in the incidences of alveolar/bronchiolar adenoma or carcinoma in either males or females exposed to ozone. LIFETIME OZONE STUDY IN RATS: For this study, rats were exposed to 0.5 and 1.0 ppm ozone for an additional 6 months to determine the effect of extended exposure on neoplasm incidence. Groups of 50 male and 50 female F344/N rats were exposed to 0, 0.5, or 1.0 ppm ozone by inhalation for 6 hours per day, 5 days per week, for 125 weeks. Survival, Body Weights, and Clinical Findings: Survival rates of exposed rats were similar to those of the controls. The mean body weights of 0.5 ppm males and females were similar to those of the controls throughout the study. The mean body weights of 1.0 ppm males and females were slightly lower than those of the controls for the first two years of the study. Hypoactivity was observed in exposed groups of males and females. Pathology Findings: Increased incidences of metaplasia occurred in the nose, larynx, and lung of rats exposed to 0.5 or 1.0 ppm ozone. The lung lesions were multifocal, centriacinar and were characterized by the presence of cuboidal epithelium (ciliated and nonciliated) along the alveolar ducts where type I epithelium is normally present. Inflammation (histiocytic infiltration) and interstitial fibrosis were observed in the lung of exposed males and females, and hyperplasia was observed in the nose of exposed male and female groups. There were no ozone-related increased incidences of neoplasms. 2-YEAR OZONE/NNK STUDY IN MALE RATS: An intermediate concentration of 0.5 ppm ozone was combined with exposure to two levels of a known carcinogen (0.1 and 1.0 mg NNK/kg body weight) in order to determine if ozone promotes the carcinogenic process or acts as a cocarcinogen. Groups of 48 male F344/N rats were exposed to 0 or 0.5 ppm ozone by inhalation, 6 hours per day, 5 days per week for 105 weeks. During the first 20 weeks of the study, these rats were subcutaneously injected with 0, 0.1, or 1.0 mg NNK per kg body weight in trioctanoin three times weekly. Survival and Body Weights: Two-year survival rates of male rats were similar in all groups. Final mean body weights of all males exposed to NNK alone or NNK and ozone were similar to that of the controls, with the exception of rats exposed to 1.0 mg NNK/kg body weight and 0.5 ppm ozone. Hypoactivity was observed in males exposed to NNK and ozone, in those exposed to NNK without ozone, and in those exposed to ozone only. Pathology Findings: Alveolar epithelial metaplasia and interstitial fibrosis occurred in all groups of rats exposed to ozone or to NNK and ozone, but not in those exposed to NNK without ozone. Increased incidences of hyperplasia occurred in groups of rats exposed to NNK or to ozone and NNK. Incidences of hyperplasia were similar among groups of rats exposed to NNK only. An increased incidence of alveolar/bronchiolar adenoma or carcinoma (combined) occurred in rats administered 1.0 mg/kg NNK, with or without ozone. The administration of ozone did not affect the occurrence of pulmonary neoplasms or nonneoplastic lesions in rats administered NNK. 2-YEAR OZONE STUDY IN MICE: The 2-year study was designed to include the present USEPA standard (0.12 ppm), the maximum concentration believed compatible with long-term survival (1.0 ppm), and an intermediate concentration (0.5 ppm). Groups of 50 male and 50 female B6C3F1 mice were exposed to 0, 0.12, 0.5, or 1.0 ppm ozone by inhalation for 6 hours per day, 5 days per week, for 105 weeks. Survival, Body Weights, and Clinical Findings: Survival rates of exposed mice were generally similar to those of the controls; the 2-year survival rate of 1.0 ppm females was greater than that of the controls. The mean body weights of 0.12 and 0.5 ppm males were similar to that of the controls throughout the study; the mean body weights of 1.0 ppm males and of all exposed groups of females were generally lower than those of the controls throughout the study. Hypoactivity was observed in male and female mice exposed to ozone. Pathology Findings: Increased incidences of metaplasia occurred in the nose and lung of mice exposed to 0.5 or 1.0 ppm ozone. The metaplasia in the nose consisted of increased thickening and extension of the squamous epithelium in the anterior portion of the nasal passage. The metaplasia in the lung consisted of extension of the bronchial epithelium into the alveoli of the centriacinar region. There were increased incidences of hyperplasia in the nose characterized by thickening of the noncuboidal (transitional) epithelium. There were increased incidences of hyperplasia in the epiglottis of female mice, a change that was characterized by a minimal increase in the thickness of the epithelium. Incidences of alveolar/bronchiolar adenoma or carcinoma (combined) were marginally increased in 0.5 and 1.0 ppm males (0 ppm, 14/50; 0.12 ppm, 13/50; 0.5 ppm, 18/50; 1.0 ppm, 19/50) and were increased in 1.0 ppm females (6/50, 7/50, 9/49, 16/50). LIFETIME OZONE STUDY IN MICE: For this study, mice were exposed to 0.5 and 1.0 ppm ozone for 30 months to determine the effect of extended exposure on neoplasm incidence. Groups of 50 male and 50 female B6C3F1 mice were exposed to 0, 0.5, or 1.0 ppm ozone by inhalation for 6 hours per day, 5 days per week, for 130 weeks. Survival and Body Weights: Survival rates of exposed mice were similar to those of the controls. The mean body weights of 0.5 ppm males and females were similar to those of the controls throughout the study. The mean body weights of 1.0 ppm males and females were generally lower than those of the controls throughout the study. Hypoactivity was observed in male and female mice exposed to ozone. Pathology Findings: The incidences of alveolar/bronchiolar adenoma and carcinoma (combined) were marginally increased in exposed males (0 ppm, 16/49; 0.5 ppm, 22/49; 1.0 ppm, 21/50) and in exposed females (6/50, 8/49, 12/50). Increased incidences of metaplasia occurred in the nose, larynx, and lung of exposed groups of males and females, and the incidences of hyperplasia were increased in the larynx and nose of exposed mice. The morphology of the lesions was similar to that seen in the 2-year study. There were no ozone-related increases in alveolar epithelial hyperplasia. GENETIC TOXICOLOGY: Ozone was mutagenic in Salmonella typhimurium strain TA102, with and without S9 metabolic activation. CONCLUSIONS: Under the conditions of these 2-year and lifetime inhalation studies, there was no evidence of carcinogenic activity of ozone in male or female F344/N rats exposed to 0.12, 0.5, or 1.0 ppm. There was equivocal evidence of carcinogenic activity of ozone in male B6C3F1 mice based on increased incidences of alveolar/bronchiolar adenoma or carcinoma. There was some evidence of carcinogenic activity of ozone in female B6C3F1 mice based on increased incidences of alveolar/bronchiolar adenoma or carcinoma. There was no evidence that exposure to 0.5 ppm ozone enhanced the incidence of NNK-induced pulmonary neoplasms in male rats. Exposure of male and female rats to ozone for 2 years or 125 weeks was associated with goblet cell hyperplasia and squamous metaplasia in the nose, squamous metaplasia in the larynx, and metaplasia (extension of bronchial epithelium into the centriacinar alveolar ducts) and interstitial fibrosis in the lung. Exposure of male and female mice to ozone for 2 years or 130 weeks was associated with hyperplasia and squamous metaplasia in the nose and inflammation (histiocytic infiltration) and metaplasia (extension of bronchial epithelium into the centriacinar alveolar ducts) of the lung.

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Vaccine hesitancy is a major hurdle for stopping the COVID-19 pandemic. Recently, fear of vaccine side effects created widespread concern and paused global vaccination efforts. Many studies find that how medical risks are framed and communicated can influence individuals' perceptions and behavior, yet there is little evidence on how the communication of COVID-19 vaccine side-effect risks influences vaccine intentions. The primary objective of our study is to evaluate how the framing of vaccine-side effect risks impacts individuals' vaccine intentions and perceptions of vaccine safety. The study will assess the impact of 3 dimensions of side-effect framing: 1. Qualitative risk labels: Determine whether attaching a qualitative risk label (e.g. adding "very low risk" next to the actual numerical risk) impacts individuals' willingness to take a vaccine and their perceptions of its safety. 2. Comparison groups: Determine how framing side-effect risks in comparison to other causes of mortality (COVID-19 mortality and motor vehicle mortality) impacts individuals' willingness to take a vaccine and their perceptions of its safety. 3. How the comparison risks are presented: Determine whether comparisons to other causes of mortality are presented on an absolute or relative scale impacts individuals' willingness to take a vaccine and their perceptions of its safety. Secondarily, we will also randomize a subset of individuals to receive the "status-quo" framing, where the vaccine side-effect risks are presented like how they were presented in the media. We will then compare vaccine intentions and perceptions of vaccine safety between the status-quo and the pooled intervention group samples to provide some insight into how "harmful" the status-quo framing was. Ultimately, we believe that our results will provide the some of the first experimental evidence on how the communication of COVID-19 vaccine risks may impact the public's willingness to be vaccinated and can inform future efforts to increase vaccination rates. Our study is an online-based randomized controlled trial designed to evaluate the effect of different vaccine side-effect framings on COVID-19 vaccine intentions and perceived safety for a hypothetical COVID-19 vaccine. Using a factorial design, we will experimentally assess the impact of 3 risk framing strategies, varying whether the risk is presented: (1) with a qualitative label, (2) whether the risk is presented with a comparison risk, and (3) for comparison cases, whether the comparison is in absolute or relative terms. We will also randomize a portion of respondents to a status quo framing where the side effect risk mimics the media's communication in early April 2021. This will be an online study setting. We will use Prolific to recruit participants and host our study on the Gorilla platform. To be eligible, participants must be 18 years old or over (male, female, or other), have current residence in the US or UK, and be able to speak English. Participants will be excluded from the study if they do not meet our inclusion criteria. Our study content will consist of five pages presented to individuals online. Page 1 will explain the purpose of the study and contain the consent information. Page 2 will contain basic sociodemographic questions, including participants' age, sex, and schooling level. Page 3 will set up the experiment by telling individuals that we will describe a hypothetical new COVID-19 vaccine and that we would like to know how likely they would be to take the vaccine and how safe they think the vaccine is. On this page, we will also encourage individuals to respond truthfully and remind them that their answers are confidential and cannot be linked back to any personal identifying information. Page 4 will be the main experimental slide, where we will present individuals with information on the vaccine, varying how the vaccination risk is communicated based on which experimental framing arm they are randomized to. We will factorially randomize across the following factors in the following order (separately by country). First, we will determine whether individuals are randomized to the status quo framing, or the intervention framings (1500 respondents to the status quo, and 4500 to the intervention). Among those randomized to the intervention framing, we will randomize (equal allocation) whether the side effect is presented without a comparison, with a comparison to COVID-19 mortality, or with a comparison to motor vehicle mortality. We will then factorially randomize (equal allocation) whether the risk is presented with a qualitative risk label or not (e.g. "very low risk"). To ensure that the factors are independent of one another, we will do this by randomizing individuals to the risk labels within strata of the comparison group factor. Lastly, among those randomized to the comparison group, we will factorially randomize whether the risk is presented as an absolute or relative comparison. As previously, we will ensure independence by doing this randomization within strata of comparison group*risk labelling. This entire design is visualized in the full protocol. The experimental text for each arm is: Arm 1: With regards to side effects, so far 8 individuals have developed potentially life-threatening blood clots. This is among the approximately 7 million adults that have received the vaccine so far. Arm 2: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. Arm 3: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). Arm 4: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, 170 out of every 100,000 unvaccinated Americans died of COVID-19 based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, 108 out of every 100,000 unvaccinated individuals in the UK died of COVID-19 based on data from the past year. Arm 5: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, this is 1/170th of the risk of COVID-19 mortality among unvaccinated Americans based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, this is 1/108th of the risk of COVID-19 mortality among unvaccinated individuals in the UK based on data from the past year. Arm 6: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, 170 out of every 100,000 unvaccinated Americans died of COVID-19 based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, 108 out of every 100,000 unvaccinated individuals in the UK died of COVID-19 based on data from the past year. Arm 7: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, this is 1/170th of the risk of COVID-19 mortality among unvaccinated Americans based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, this is 1/108th of the risk of COVID-19 mortality among unvaccinated individuals in the UK based on data from the past year. Arm 8: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, 12 out of every 100,000 Americans died in a motor vehicle accident based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, 2.6 out of every 100,000 individuals in the UK died in a motor vehicle accident based on data from the past year. Arm 9: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, this is 1/12th of the risk of dying in a motor vehicle accident based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots. As a reference, this is almost 1/4th of the risk of dying in a motor vehicle accident based on data from the past year. Arm 10: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, 12 out of every 100,000 Americans died in a motor vehicle accident based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, 2.6 out of every 100,000 individuals in the UK died in a motor vehicle accident based on data from the past year. Arm 11: Text for USA participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, this is 1/12th of the risk of dying in a motor vehicle accident based on data from the past year. Text for UK participants: With regards to side effects, 1 out of 100,000 vaccinated individuals may develop serious blood clots (very low risk). As a reference, this is nearly 1/4th of the risk of dying in a motor vehicle accident based on data from the past year. The risk information will be presented on a single page along with the two main outcome questions. Lastly, for individuals that reported that they are unlikely or unsure about whether they would take the vaccine, the final page will ask them their reason (question based on a recently published study of COVID-19 vaccine hesitancy). Our primary outcome is individuals' willingness to take the hypothetical COVID-19 vaccine. We will measure this outcome by asking, "How likely would you be to take this vaccine?" allowing individuals to choose from a four-point Likert response of "Unlikely, Unsure leaning towards unlikely, Unsure leaning towards likely, Very likely." This outcome variable, including the categories and phrasing, is based on a recently published study on COVID-19 vaccine hesitancy conducted by researchers with the Vaccine Hesitance Project at the London School of Hygiene and Tropical Medicine. Our secondary outcome is individuals' perceived safety of the vaccine. We will assess this outcome by asking individuals, "How safe do you feel this vaccine is?" allowing them to choose answers ranging from 1-10 where 1 is extremely unsafe, and 10 is extremely safe. Both outcomes will be measured at the time of the questionnaire. Participants can take up to 45 min to complete the questions but will not be able to go back and change their responses after submitting their questionnaire. Using a web-based randomization algorithm, Gorilla will randomly allocate participants to each of the experimental arms. Gorilla allows for two randomization options - independent randomization of each individual based on a probability draw and balanced randomization, which randomizes without replacement such that among groups of respondents a fixed proportion will end up in each experimental arm. We will use the "balanced randomization" option to ensure that our experimental arms are balanced. Participants will be randomized based on the allocations described above. Because Prolific handles the interaction between the study investigators and participants, the participants will be completely anonymous to the study investigators. The outcome measures will be self-reported and submitted anonymously. All persons in the study team will be blinded to the group allocation. We will randomize 6000 participants per country for a total sample of 12000 individuals. The protocol version number is 1.0 and the date is July 14, 2021. Recruitment is expected to begin on 26 July 2021 and end by August 10, 2021. The study and its outcomes were registered at the German Clinical Trials Register ( www.drks.de ) on July 12th, 2021: # DRKS00025551 . The full protocol is attached as an additional file, accessible from the Trials website (Full_Protocol_20Jul2021) In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

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Triamterene is a potassium-sparing diuretic used in the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and other diseases in which edema may occur. Toxicity and carcinogenicity studies were conducted by administering triamterene (greater than 99% pure) in feed to groups of male and female F344/N rats and B6C3F1 mice for 15 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and Chinese hamster ovary cells. 15-day Studies: Groups of five male and five female rats were fed diets containing 0, 1,000, 3,000, 10,000, 30,000, or 60,000 ppm triamterene. The diets containing 10,000 ppm or more were unpalatable, and feed consumption by the 3,000 ppm groups was reduced. Rats exposed to 1,000 or 3,000 ppm triamterene received approximate doses of 80 or 60 mg/kg body weight per day (males) or 70 or 50 mg/kg per day (females). One male rat and two female rats receiving 3,000 ppm died during the second week of the study. The final mean body weights of 3,000 ppm male and female rats were significantly lower than those of controls. Rats in the 3,000 ppm groups had renal tubule regeneration and cytoplasmic vacuolization of the zona glomerulosa of the adrenal gland. Groups of five male and five female mice were fed diets containing 0, 300, 1,000, 3,000, 10,000, or 30,000 ppm triamterene, but the diets containing 10,000 or 30,000 ppm were unpalatable. All mice receiving 3,000 ppm died by day 6. Mice exposed to 300 or 1,000 ppm triamterene received approximate doses of 40 or 155 mg/kg body weight per day (males) or 45 or 170 mg/kg body weight per day (females). The final mean body weights of mice in the 300 and 1,000 ppm groups were similar to those of the controls. Renal tubule degeneration and necrosis were observed in the kidney of 3,000 ppm mice. 13-Week Studies: Groups of 10 male and 10 female rats were fed diets containing 0, 150, 300, 600, 1,200, or 2,400 ppm triamterene. All rats receiving 2,400 ppm died before the end of the study; all other rats survived to the end of the study. Rats exposed to 150, 300, 600, or 1,200 ppm triamterene received approximate doses of 10, 20, 40, or 70 mg/kg body weight per day (males) or 10, 20, 40, or 80 mg/kg per day (females). Body weight gains and final mean body weights of rats in the 1,200 ppm groups were significantly lower than those of controls. There were no biologically significant differences in hematologic, clinical chemistry, or urinalysis parameters among exposed and control rats. Calculi were observed in the renal pelvis of four male rats in the 1,200 ppm group. Chemical-related lesions were observed in the kidney and adrenal gland of rats in the 1,200 and 2,400 ppm groups. These consisted of degeneration and regeneration of the renal tubule epithelium and cytoplasmic vacuolization of cells of the zona glomerulosa of the adrenal cortex. Depletion of hematopoietic cells from the bone marrow and of lymphocytes from the spleen and thymus of rats in the 2,400 ppm groups may have been related to debilitation and reduced feed consumption rather than chemical exposure. Groups of 10 male and 10 female mice were fed diets containing 0, 100, 200, 400, 800, or 1,600 ppm triamterene. All mice receiving 1,600 ppm, one 800 ppm female, one 200 ppm male, and four 100 ppm males died before the end of the study. Mice exposed to 100, 200, 400, or 800 ppm triamterene received approximate doses of 15, 25, 50, or 90 mg/kg body weight per day (males) or 15, 25, 50, or 115 mg/kg per day (females). The body weight gain and final mean body weight of male mice receiving 800 ppm were significantly lower than those of the controls. The total leukocyte and lymphocyte counts of males receiving 800 ppm and of females receiving 100, 400, or 800 ppm were significantly lower than those of controls. No other differences in hematologic, clinical chemistry, or urinalysis parameters were considered to be biologically significant. Necrosis of Lymphocytes was observed in the lymph node, spleen, and thymus of mice in the 800 and 1,600 ppm groups groups. 2-Year Studies: The doses selected for the 2-year studies were based on lower body weights, mortality, and chemical-related lesions observed in exposed animals during the 13-week studies. Groups of 70 male and 70 female rats were fed diets containing 0, 150, 300, or 600 ppm triamterene and groups of 70 male and 70 female mice were fed diets containing 0, 100, 200, or 400 ppm. Ten animals from each group were included for interim evaluations at 3 and 15 months. Because of a dosing error involving the high-dose mice at week 40, a second study was conducted with groups of 60 male and 60 female mice fed diets containing 0 or 400 ppm triamterene. In the 2-year studies, rats exposed to 150, 300, or 600 ppm triamterene received approximately 5,10, or 25 mg/kg body weight per day (males) and 5, 15, or 30 mg/kg (females) and mice exposed to 100, 200, or 400 ppm received approximately 10, 25, or 45 mg/kg (males) and 15, 30, or 60 mg/kg (females) per day. 3-Month and 15-Month Interim Evaluations in the 2-Year Studies: There were no biologically significant differences in hematologic, clinical chemistry, or urinalysis parameters between exposed and control rats or mice at the 3- or 15-month interim evaluations. At necropsy, the mean body weights of exposed rats and mice were similar to those of the controls. There were no chemical-related lesions in exposed rats at 3 months or in exposed mice at 3 or 15 months. At the 15-month evaluation, basophilic, clear cell, and mixed cell foci of the liver occurred in exposed male rats. No chemical-related lesions were observed in female rats at 15 months. Survival, Body Weights, Clinical Findings, and Feed Consumption in the 2-Year Studies: Survival of exposed rats was similar to that of controls (males: 0 ppm, 25/47; 150 ppm, 25/50; 300 ppm, 19/50; 600 ppm, 27/50; females: 29/50, 34/50, 34/50, 29/50). The mean body weights of 600 ppm rats were consistently lower than, but within 5&amp;percnt; of, those of controls after week 49. Feed consumption by male and female rats was similar among exposed and control groups throughout the studies. There were no clinical findings of toxicity. Survival of 400 ppm male mice in the first study was lower than that of controls because of the dosing accident at week 40. Survival of 100 and 200 ppm male mice and of all exposed groups of female mice in the first study and of exposed males and females in the second study was similar to controls (males: first study, 0 ppm, 47/50; 100 ppm, 45/50; 200 ppm, 46/50; 400 ppm, 46/60; second study, 0 ppm, 43/50; 400 ppm, 39/50; females: first study, 38/50; 43/50; 43/50; 43/60; second study, 40/50; 38/51). Mean body weights of exposed mice were similar to those of controls throughout the first study with one exception; in the week following the dosing error, the mean body weight of 400 ppm males was 16&amp;percnt; lower than that of controls. In the second study, mean body weights of 400 ppm mice were slightly lower than those of controls during the final 8 weeks. Feed consumption by exposed mice was similar to that by controls throughout the studies. There were no clinical findings of toxicity in exposed mice. Neoplasms and Nonneoplastic Lesions in the 2-Year Studies: The incidences of mixed cell foci and focal hyperplasia of the liver were significantly increased in 300 and 600 ppm male rats, and the incidences of clear cell and mixed cell foci were significantly increased in 300 and 600 ppm female rats. Hepatocellular adenomas occurred in all groups of exposed male rats, but none occurred in controls; the incidence of hepatocellular adenoma in the 150 ppm males was significantly higher than that of controls (O ppm, 0/50; 150 ppm, 6/50; 300 ppm, 4/50; 600 ppm, 3/49). Hepatocellular adenomas were observed in two 600 ppm female rats, but not in the lower exposure groups or in controls. No hepatocellular carcinomas were seen in exposed or control rats. The incidences of nephropathy in exposed rats were similar to those of controls, but the average severity of the lesion was marginally increased in male rats receiving 300 ppm and in female rats receiving 600 ppm (males: 47/50, 2.4; 49/50, 2.7; 50/50, 3.0; 49/50, 2.8; females: 38/50, 1.1; 45/50, 1.2; 45/50, 1.3; 45/50, 1.4). Although in the first study the incidences of hepatocellular adenoma in exposed male mice were similar to that of controls, the incidences of multiple adenomas were greater in the exposed groups, and the incidence of hepatocellular carcinoma in the 400 ppm group was marginally greater (hepatocellular adenoma: 0 ppm, 17/50; 100 ppm, 22/50; 200 ppm, 19/50; 400 ppm, 20/60; hepatocellular carcinoma: 5/50; 7/50; 3/50; 13/60). In the second study, the incidence of hepatocellular adenoma in the 400 ppm males was significantly higher than that of controls (hepatocellular adenoma: 0 ppm, 21/50; 400 ppm, 36/50; hepatocellular carcinoma: 9/50; 11/50). The incidences of hepatocellular adenoma in exposed female mice in the first and second studies were significantly greater than those of controls (hepatocellular adenoma, first study: 10/50; 22/50; 23/50; 36/60; second study: 7/50; 28/51). The incidences of multiple adenoma were also increased in the exposed groups. Although the incidences of hepatocellular carcinoma were similar among exposed and control female mice in the first study, the incidence of hepatocellular carcinoma in the 400 ppm females in the second study was marginally greater than that of controls (hepatocellular carcinoma, first study: 4/50; 4/50; 3/50; 8/60; second study: 5/50; 11/50). In both studies, hepatocellular foci (basophilic, eosinophilic, clear cell, or mixed cell) also occurred more frequently in exposed female mice than in controls. The incidences of thyroid gland follicular cell hyperplasia in the 200 and 400 ppm males and in all exposed groups of females were significantly greater than those of controls in the first study. These findings were confirmed in the second study (follicular cell hyperplasia: males, first study, 3/50, 8/50, 16/50, 20/60; second study, 0/50,16/50; females, first study, 4/49,17/49,18/50, 28/60; second study, 9/50, 32/51). The incidences of follicular cell neoplasms were similar among exposed and control mice in both studies. The incidences (28/50, 36/50, 43/50, 49/60) and average severity (0.56, 0.80, 1.00, 1.07) of nephropathy were marginally higher in exposed female mice than in controls in the first study. In the second study, the differences in incidence (15/50, 21/50) and severity (0.38, 0.55) were not as great. It is uncertain if these increases were related to the ingestion of triamterene. The incidences and severity of nephropathy were similar among exposed and control male mice in both studies. Genetic Toxicology: Triamterene was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 with or without exogenous metabolic activation (S9). It did not induce chromosomal aberrations in Chinese hamster ovary cells, with or without S9. Positive results were obtained for induction of sister chromatid exchanges in Chinese hamster ovary cells with and without S9. Conclusions: Under the conditions of these 2-year feed studies, there was equivocal evidence of carcinogenic activity of triamterene in male F344/N rats based on a marginal increase in the incidence of hepatocellular adenoma. There was no evidence of carcinogenic activity of triamterene in female F344/N rats administered 150, 300, or 600 ppm. There was some evidence of carcinogenic activity of triamterene in male B6C3F1 mice based on a marginal increase in the incidence of hepatocellular carcinoma in the first study and a significantly increased incidence of hepatocellular adenoma in the second study. There was some evidence of carcinogenic activity of triamterene in female B6C3F1 mice based on significantly increased incidences of hepatocellular adenoma and of adenoma and carcinoma (combined). Exposure to triamterene was associated with an increased incidence of hepatocellular foci, primarily mixed cell type, and an increase in the severity of nephropathy in female rats. In mice, exposure to triamterene was associated with an increased incidence of hepatocellular foci in females and an increased incidence of thyroid gland follicular cell hyperplasia in males and females. Synonyms: 6-Phenyl-2,4,7-pteridinetnamine; 6-phenyl-2,4,7-triaminopteridine; 2,4,7-triamino-6-phenypteridine; ademin; pterofen; pterophane; NSC-77625; SKF 8542 Trade names: Dyrenium, Dyazide, Dyren, Dytac, Jatropur, Maxzide, Noridyl, Triteren, Teriam, Urocaudal

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o-Nitroanisole is used as an intermediate for the preparation of o-anisidine and in the manufacture of azo dyes. Toxicology and carcinogenesis studies were conducted by administering o-nitroanisole (&gt;99% pure) in the diet to groups of male and female F344 rats and B6C3F1 mice for 14 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, Chinese hamster ovary cells, and mouse lymphoma cells. 14-DAY STUDIES: Groups of five male and five female F344 rats received diets containing 0, 583, 1,166, 2,332, 4,665, or 9,330 ppm o-nitroanisole. Mean body weight gains and final mean body weights of males in the 4,665 and 9,330 ppm groups were lower than those of the controls. Absolute liver weights were significantly increased in males receiving 1,166 ppm or more and in females receiving 583 ppm or more. Groups of five male and five female B6C3F1 mice received diets containing 0, 250, 500, 1,000, 2,000, or 4,000 ppm o-nitroanisole. Mean body weight gains and final mean body weights of males that received 250 ppm and females that received 4,000 ppm were significantly lower than those of the controls. No other chemical-associated effects were observed. 13-WEEK STUDIES: Groups of 10 male and 10 female F344 rats received diets containing 0, 200, 600, 2,000, 6,000, or 18,000 ppm o-nitroanisole. Final mean body weights and feed consumption by male and female rats receiving 6,000 and 18,000 ppm were lower than those of the controls. Hemoglobin and hematocrit values were significantly lower and methemoglobin levels significantly higher in males in the 6,000 and 18,000 ppm groups than in controls. Absolute liver weights were significantly increased in females that received 200, 600, 2,000, and 6,000 ppm, absolute kidney weights were significantly increased in males that received 600, 2,000, and 6,000 ppm, and absolute spleen weights were significantly increased in males and females that received 6,000 and 18,000 ppm. Groups of 10 male and 10 female B6C3F1 mice received diets containing 0, 60, 200, 600, 2,000, or 6,000 ppm o-nitroanisole. Final mean body weight gains, final mean body weights, and feed consumption by male and female mice receiving 6,000 ppm were lower than those of the controls. Hemoglobin and hematocrit values in males and females that received 2,000 or 6,000 ppm were significantly lower than those in the controls. The absolute and relative liver weights of females in the 600 ppm group and relative liver weights of males and females in the 2,000 and 6,000 ppm groups were significantly greater than those of controls. Lesions associated with exposure to o-nitroanisole were present in the urinary bladder, spleen, kidney, liver, testis, and uterus of rats. Diffuse hyperplasia of the transitional epithelium of the urinary bladder occurred in all male and female rats that received 6,000 and 18,000 ppm. A transitional cell papilloma occurred in one male and transitional cell carcinomas occurred in two males and three females receiving 18,000 ppm. Congestion of the red pulp and capsular hyperplasia of the spleen and hepatocellular hypertrophy of the liver were present in males and females from the 18,000 ppm groups. Multifocal degeneration and necrosis of the renal tubule epithelium with infiltration of mononuclear inflammatory cells were present in male rats that received 600, 2,000, and 6,000 ppm. At the 18,000 ppm level, degeneration of the seminiferous epithelium accompanied by loss of spermatogenic cells and decreased numbers of spermatozoa were observed in the testes of male rats, while uterine atrophy was observed in female rats. Hepatocyte hypertrophy of the centrilobular and midzonal regions of liver lobules was present in mice that received 200 ppm and increased in severity at higher exposure levels. 2-YEAR STUDIES: The doses selected for the 2-year study of o-nitroanisole in rats were based on lower mean body weights, reduced feed consumption, and increased severity of regenerative anemia in male and female rats receiving 6,000 and 18,000 ppm during the 13-week study. Groups of 6roups of 60 male and 60 female F344 rats received diets containing 0, 222, 666, or 2,000 ppm o-nitroanisole. Groups of 60 male and 60 female B6C3F1 mice received diets containing 0, 666, 2,000, or 6,000 ppm o-nitroanisole. After 15 months, up to 10 animals from each group were evaluated for chemical-related lesions. Survival, Body Weights, Feed Consumption, and Clinical Findings: Survival of male rats receiving 2,000 ppm was significantly lower than that of the controls due to increased severity of nephropathy. Survival of 222 and 666 ppm male rats and all exposed female rats was similar to that of the controls. Survival of groups of exposed male and female mice was similar to that of the controls. The final mean body weight of male rats receiving 2,000 ppm was lower than that of the controls. Final mean body weights of male and female mice that received 2,000 and 6,000 ppm were lower than those of the controls. Feed consumption by male and female rats was similar to that by the controls. The only clinical finding in male or female mice attributable to chemical administration was discolored urine. Neoplasms and Nonneoplastic Lesions: The incidence of mononuclear cell leukemia was significantly increased in male rats that received 666 and 2,000 ppm and in female rats that received 2,000 ppm (males: 0 ppm, 26/50; 222 ppm, 25/50; 666 ppm, 42/50; 2,000 ppm, 34/50; females: 14/50, 11/50, 14/50, 26/50). Nephropathy occurred in all male rats; the severity increased with exposure level. Focal hyperplasia of the renal tubule epithelium was present in three males receiving 222 ppm and two males receiving 2,000 ppm. Renal tubule adenomas occurred in one male from each of the 222, 666, and 2,000 ppm groups, and renal tubule carcinomas occurred in two males from the 2,000 ppm group. Focal hyperplasia of the transitional epithelium of the urinary bladder was present in one female rat that received 222 ppm and two male rats and six female rats that received 2,000 ppm. A transitional cell papilloma occurred in the urinary bladder of one female rat from the 2,000 ppm group, and a transitional cell carcinoma occurred in another female from the 2,000 ppm group. The incidence of forestomach ulcers increased in male rats that received 2,000 ppm, and the incidence of focal hyperplasia of the forestomach increased with exposure level in male and female rats. In addition, squamous cell papillomas of the forestomach were present in one female receiving 222 ppm, one male receiving 666 ppm, and one male and one female receiving 2,000 ppm, while squamous cell carcinomas were present in one male receiving 666 ppm and one male and one female receiving 2,000 ppm. The incidences of pituitary gland adenomas in male rats and mammary gland fibroadenomas in female rats decreased with exposure level. The incidence of cellular alteration in the liver was significantly increased in exposed groups of male and female mice. The incidences of hepatocellular adenoma, hepatocellular adenoma or carcinoma (combined), and hepatocellular carcinoma or hepatoblastoma (combined) were significantly increased in male mice receiving 2,000 and 6,000 ppm. The incidences of hepatocellular adenoma or carcinoma were significantly increased in female mice that received 2,000 ppm. STOP-EXPOSURE STUDY: Groups of 60 male and 60 female F344 rats received diets containing 0, 6,000, or 18,000 ppm o-nitroanisole for 27 weeks and were then maintained on control feed without further chemical exposure for up to an additional 77 weeks. Up to 10 rats from each group were evaluated for the presence of chemical-related lesions at 3, 6, 9, and 15 months. Survival and Body Weights: Survival of exposed male and female rats was significantly lower than that of the controls as a result of moribund deaths associated with significantly increased incidences of urinary bladder neoplasms, primarily transitional cell carcinomas. All male rats that received 18,000 ppm were dead by week 48 and all females that received 18,000 ppm were dead by week 61. Mean body weights of exposed male and female rats were lower than those of the controls throughout the study. Neoplasms and Nonneoplastic Lesions: Hyperplasia of the transitional epithelium of the urinary bladder was present in nearly all exposed male and female rats examined at the interim evaluations. A transitional cell carcinoma was first observed at the 3-month interim evaluation in a male rat that received 18,000 ppm. At the 6- and 9-month interim evaluations, transitional cell papillomas or carcinomas were observed in both exposed groups of male rats. Transitional cell carcinomas were observed at the 6-month interim evaluation in females receiving 18,000 ppm and at the 9-month interim evaluation in females receiving 6,000 and 18,000 ppm. Adenomatous polyps of the large intestine were observed in a small number of exposed rats at the 6-, 9-, and 15-month interim evaluations. At the end of the study, the incidence of adenomatous polyps of the large intestine was significantly increased in all exposed groups and carcinomas of the large intestine were present in four males and two females from the 18,000 ppm groups. The incidence of hyperplasia of the transitional epithelium of the kidney pelvis was significantly increased in exposed male and female rats and transitional cell papillomas were present in three males and one female that received 18,000 ppm. Transitional cell carcinomas of the kidney were present in one male receiving 6,000 ppm and six males and one female receiving 18,000 ppm. Transitional cell carcinomas of the urinary bladder were seen in nearly all exposed male and female rats. Of the males and females receiving 6,000 ppm which were without carcinomas, three males and one female had transitional cell papillomas. Generalized centrilobular hypertrophy, focal hepatocellular necrosis, multifocal hepatocellular cytoplasmic vacuolation, and Kupffer cell pigmentation were observed in the livers of male and female rats at the 3- and 6-month interim evaluations; however, only Kupffer cell pigmentation was observed at the end of the study. Congestion of the red pulp of the spleen was observed in nearly all exposed male and female rats at the 3-, 6-, and 9-month interim evaluations but the incidence was only slightly increased in the 18,000 ppm groups at the end of the study. Degeneration and atrophy of the seminiferous tubule epithelium of the testes were observed at the 3- and 6-month interim evaluations in all male rats receiving 18,000 ppm. GENETIC TOXICOLOGY: o-Nitroanisole was tested in two laboratories for mutagenicity in Salmonella typhimurium strains TA97, TA98, TA100, TA1535, and TA1537 with and without exogenous metabolic activation (S9). Positive responses were observed at both laboratories in TA100 with and without S9 activation. One laboratory found no increase in mutations, while the second laboratory detected a weakly positive response in TA1535 without S9. No mutagenic activity was observed in the other tester strains. o-Nitroanisole was positive in the mouse lymphoma assay for induction of trifluorothymidine resistance in L5178Y cells without S9 activation. In cytogenetic tests with Chinese hamster ovary cells, o-nitroanisole induced a significant increase in chromosomal aberrations at the highest dose tested in the presence of S9 activation; sister chromatid exchanges were induced both with and without S9. CONCLUSIONS: Under the conditions of these feed studies there was clear evidence of carcinogenic activity of o-nitroanisole in male and female F344 rats that received diets containing 6,000 or 18,000 ppm for 6 months based on overall increased incidences of benign and malignant neoplasms of the urinary bladder, transitional cell neoplasms of the kidney, and benign and malignant neoplasms of the large intestine. There was a chemical-related increased incidence of mononuclear cell leukemia in male and female rats receiving diets containing 222, 666, or 2,000 ppm o-nitroanisole for 2 years. Marginally increased incidences of uncommon renal tubule neoplasms in male rats and forestomach neoplasms in male and female rats were considered uncertain findings. There was clear evidence of carcinogenic activity of o-nitroanisole in male B6C3F1 mice based on increased incidences of benign and malignant hepatocellular neoplasms. There was some evidence of carcinogenic activity of o-nitroanisole in female B6C3F1 mice based on increased incidences of hepatocellular adenomas. Increased severity of nephropathy in male rats, and increased incidences of focal hyperplasia of the renal tubule epithelium and forestomach ulcers in male rats, and of transitional cell hyperplasia of the urinary bladder, focal hyperplasia of the forestomach, and hyperplasia of transitional epithelium of the kidney pelvis in male and female rats were associated with exposure to o-nitroanisole. Synonyms: Methoxynitrobenzene, nitrophenyl methyl ether

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Oxazepam is one of a number of benzodiazepines used therapeutically as a sedative-hypnotic and antianxiety agent. Toxicology and carcinogenesis studies were performed by administering oxazepam (greater than 99% pure) in feed to male and female Swiss-Webster and B6C3F1 mice for 14 weeks, 57 weeks (Swiss-Webster), or 2 years (B6C3F1). Neurobehavioral assessments were performed during the studies. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells, and peripheral blood samples were analyzed for frequency of micronucleated normochromatic erythrocytes. Supplemental studies were performed to compare the metabolism and toxicokinetics of oxazepam in the two mouse strains, to evaluate the effect on liver cell replication rates, to perform clinical pathology assessments, and to examine the mutation spectrum and frequency of activated H-ras oncogenes in liver neoplasms from the 2-year study with B6C3F1 mice. 14-WEEK STUDY IN SWISS-WEBSTER MICE: Groups of 10 male and 10 female Swiss-Webster mice received oxazepam in feed at concentrations of 0, 625, 1,250, 5,000, 10,000 ppm for 14 weeks. One 625 ppm male and one 10,000 female were killed moribund before the end of the study, and the condition of the female mouse was attributed to oxazepam exposure. Mean body weight gains of exposed groups were similar to those of the controls. Exposed mice displayed chemical-related sedation and lethargy during the first study week, but appeared normal thereafter. In the neurobehavioral studies, reductions in grip strength were evident in both male and female mice at week 2 and persisted in males through week 11. An antianxiety effect was detected in exposed mice in measures of motor activity, startle response, and reactions to thermal stimulus. At necropsy, absolute and relative liver weights were increased in an exposure-related manner and were approximately two-fold greater in 10,000 ppm mice than in controls. Centrilobular hepatocellular hypertrophy was present only in exposed mice, and the severity increased with dose. 14-WEEK STUDY IN B6C3F1 MICE: Groups of 10 male and 10 female B6C3F1 mice received oxazepam in feed at concentrations of 0, Groups of 10 male and 10 female Swiss-Webster mice 625, 1,250, 2,500, 5,000, or 10,000 ppm for 14 weeks. received oxazepam in feed at concentrations of 0, There were no deaths that were clearly related to 625,1,250, 2,500, 5,000, or 10,000 ppm for 14 weeks. oxazepam exposure. Mean body weight gains of One 625 ppm male and one 10,000 ppm female were exposed groups were similar to those of the controls. Exposed mice displayed chemical-related sedation and lethargy during only the first study week. In neurobehavioral studies, reductions in grip strength were evident in males at week 2 but were no longer observed at week 12. An antianxiety effect was noted in exposed mice in measures of motor activity, startle response, and reactions to a thermal stimulus (females). At necropsy, absolute and relative liver weights were increased in an exposure-related manner and were approximately two-fold greater in 10,000 ppm mice than in controls. Centrilobular hepatocellular hypertrophy was present only in exposed mice, and the severity increased with dose. CHRONIC STUDIES: Groups of 60 male and 60 female Swiss-Webster and B6C3F1 mice received oxazepam in feed at concentrations of 0, 2,500, or 5,000 ppm. Additional groups of 60 male and 60 female B6C3F1 mice received 125 ppm in feed to allow for study of a group with projected serum concentrations of oxazepam similar to those achieved in humans taking a therapeutic dose. Ten male and 10 female B6C3F1 mice per group were evaluated at 15 months. Average daily oxazepam consumption varied throughout the studies, and the overall daily average ranged from 10 to 29 mg/kg body weight for the 125 ppm groups, 234 to 512 mg/kg for the 2,500 ppm groups, and 444 to 1,085 mg/kg for the 5,000 ppm groups. Serum oxazepam concentrations determined at 57 weeks in Swiss-Webster mice and at the 15-month interim evaluation of B6C3F1 mice 1 mice were approximately 1 ug/mL in the 125 ppm groups, 4 to 7 &amp;mu;g/mL in the 2,500 ppm groups, and 7 to 10 &amp;mu;g/mL in the 5,000 ppm groups. Neurobehavioral assessments during the chronic studies of each strain of mice were confounded by the poor survival and deteriorating condition of mice with hepatic neoplasia. However, within the limitations of the studies, there were no notable changes in the types of behaviors observed compared to those observed in the 14-week studies, nor was there an enhancement in the degree to which they were exhibited. 57-Week Study in Swiss-Webster Mice: Survival, Body Weights, Feed and Compound Consumption, and Clinical Findings: At 57 weeks, survival of exposed mice was significantly lower than that of controls (males: O ppm, 45/60; 2,500 ppm, 19/60; 5,000 ppm, 10/60; females: 47/60, 28/59, 17/59), causing the study to be terminated. Mean body weights of exposed males were similar to controls until week 17; afterwards, mean body weights of exposed male groups were lower than those of controls. Final mean body weights of exposed males were 9% lower than that of the controls. The mean body weight of 2,500 ppm females was greater than that of the controls throughout the study. Females receiving 5,000 ppm had a mean body weight greater than that of the controls early in the study; after week 29, the mean body weight of this group was similar to that of the controls. Feed consumption by exposed males and females was slightly lower than that by the controls, and females in all groups, including controls, consumed slightly more feed than males throughout the study. Dietary levels of 2,500 and 5,000 ppm oxazepam resulted in average daily compound consumption levels of 270 and 570 mg/kg for males and 320 and 670 mg/kg for females. Hypoactivity and sedation were observed in exposed mice during the first week of the study. There were no other clinical findings associated with oxazepam exposure. Pathology Findings: Systemic amyloidosis was the principal cause of death in mice dying before the study was terminated. The lower survival of mice receiving oxazepam was attributed to an increase in the extent and severity of amyloid deposits in many organs, including the heart and kidney. Atrial thrombosis and pulmonary lesions consistent with chronic heart failure occurred at higher incidences and with greater severity in exposed mice. The incidence of hepatocellular adenomas (males: 1/60, 35/60, 50/60; females: 0/60, 22/59, 47/59) and carcinomas (males: 0/60, 5/60,19/60; females: 1/60, 1/59, 11/59) were increased in exposed mice. The incidences of eosinophilic foci were also increased in exposed mice (males: 0/60, 22/60, 22/60; females: 0/60, 20/59, 14/59), and there was evidence of increased centrilobular hepatocyte hypertrophy (males: 12/60, 46/60, 47/60; females: 3/60, 51/59, 53/59). 2-Year Study in B6C3F1 Mice: Survival, Body Weights, Feed and Compound Consumption, and Clinical Findings: Survival of mice receiving 2,500 and 5,000 ppm was significantly lower than that of controls (males: O ppm, 45/50; 125 ppm, 44/50; 2,500 ppm, 15/50; 5,000 ppm, 0/50; females: 39/50, 41/50, 2/50, 0/50). Mean body weight gains of exposed male and female mice were similar to controls until about week 15 when weight gains for mice exposed to 2,500 or 5,000 ppm slowed in relation to controls, resulting in weight gains approximately 30&amp;percnt; to 40&amp;percnt; lower than those of the controls throughout the remainder of the study. Mean body weight gain of male mice exposed to 125 ppm was similar to that of the controls, while that of female mice receiving 125 ppm was 10&amp;percnt; to 15&amp;percnt; lower than that of the controls after about week 45. Feed consumption by exposed males and females was similar to that by controls. Dietary levels of 125, 2,500, and 5,000 ppm resulted in average daily oxazepam consumption levels of 12, 310, and 690 mg/kg body weight for males and 15, 350, and 780 mg/kg for females. In the 5,000 ppm groups, lethargy and sedation were observed in a few mice during the first week of study. Pathology Findings: The early deaths of many of the B6C3F1 mice exposed to oxazepam were attributed to a marked increase in the incidences of hepatoblastoma (males: 0/49, 2/50, 21/50, 13/50; females: 0/50, 1/50, 8/50, 8/50), hepatocellular adenoma (males: 17/49,18/50, 34/50, 32/50; females: 25/50, 35/50, 35/50, 36/50), and hepatocellular carcinoma (males: 9/49, 5/50, 45/50, 50/50; females: 9/50, 5/50, 49/50, 44/50). Moderate hypertrophy of centrilobular hepatocytes occurred in mice receiving 2,500 and 5,000 ppm (males: 0/49, 2/50, 26/50, 43/50; females: 0/50, 2/50,11/50, 29/50). An increase in the incidence of follicular cell hyperplasia of the thyroid gland occurred in all exposed groups of mice (males: 4/49, 22/50, 49/50, 47/50; females: 16/50, 34/50, 49/50, 44/50), and thyroid gland follicular cell adenoma was increased in exposed females (0/50, 4/50, 5/50, 6/50). Testicular atrophy occurred in the 2,500 and 5,000 ppm groups (1/50, 0/50, 25/50, 38/50), and the incidence of epididymal Iymphocyte infiltration was increased in all exposed groups (2/50,14/50, 33/50, 21/50). The frequency of hepatocellular neoplasms with an activated H-ras oncogene in the B6C3F1 mice and the mutation spectrum of the H-ras gene were determined. The mutation spectrum of the H-ras genes in the relatively few neoplasms from exposed mice that did have an activated H-ras did not differ from the spectrum of mutations observed in neoplasms from controls, but the proportion of neoplasms with an activated H-ras gene decreased with increasing oxazepam dose. While 11 of 19 (58&amp;percnt;) neoplasms from control mice had an activated H-ras gene, only 1 of 40 neoplasms from mice receiving 2,500 or 5,000 ppm oxazepam exhibited a similar molecular lesion. Thirteen of 37 (35&amp;percnt;) neoplasms from mice in the 125 ppm group had an activated H-ras oncogene, suggesting that, although the incidence of all liver neoplasms was not statistically increased compared to controls, there was an increase in a similar subset of neoplasms (lacking an activated H-ras) that occurred with increased incidence at higher doses. SUPPLEMENTAL STUDIES: Because exposure to oxazepam caused increased incidences of liver neoplasms, supplemental short-term studies were performed. Oxazepam given in feed to male B6C3F1 mice at 25, 125, 2,500, or 5,000 ppm for up to 13 weeks was found to cause a dose-related increase in nuclear labeling index in studies measuring the incorporation of bromodeoxyuridine into replicating liver cells. This increase was statistically significant at all but the 25 ppm exposure level and was limited to mice evaluated at 15 days. Cell replication rates in most groups evaluated at 30 days and after were similar to control rates. There was minimal evidence suggestive of hepatocyte necrosis either by light microscopy or in clinical chemistry measures. There was, however, evidence of cholestasis, likely due to physical obstruction of bile canaliculi by swollen hepatocytes. The metabolic fate and toxicokinetics of oxazepam were evaluated in each strain of mice and were compared to published data from human studies. Both mice and humans form glucuronides of oxazepam and form 3- and 4-hydroxy and methoxy derivatives of the phenyl group. Oxidative metabolism of the phenyl group appears to be more prevalent in mice than is reported for humans. Elimination half-lives of parent compound do not differ between Swiss-Webster and B6C3F1 mice and are similar to values reported for humans. GENETIC TOXICOLOGY: Oxazepam was not mutagenic in any of several strains of Salmonella typhimurium, nor did it induce sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells. These in vitro tests were performed with and without S9 metabolic activation. Results from an in vivo mouse peripheral blood micronucleus test performed on the B6C3F1 mice used in the 14-week study were also negative. CONCLUSIONS: Under the conditions of these feed studies, there was clear evidence of carcinogenic activity of oxazepam in male and female Swiss-Webster mice based on increased incidences of hepatocellular adenoma and carcinoma. There was clear evidence of carcinogenic activity of oxazepam in male and female B6C3F1 mice based on increased incidences of hepatoblastoma and hepatocellular adenoma and carcinoma. Increased incidences of hyperplasia of thyroid gland follicular cells in male and female B6C3F1 mice and of follicular cell adenomas in female B6C3F1 mice were also related to oxazepam exposure. Administration of oxazepam to Swiss-Webster mice resulted in centrilobular hepatocellular hypertrophy and increased incidences and severity of systemic amyloidosis. Administration of oxazepam to B6C3F1 mice also resulted in centrilobular hepatocellular hypertrophy. Synonyms: 7-Chloro-1,3-dihydro-3-hydroxy-5-phenyl-2 H - 1,4-benzodiazepin-2-one Trade Names: Tazepam, Wy-3498, Serax

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Oxymetholone is a synthetic anabolic steroid used to treat a variety of conditions, including hypogonadism and delayed puberty. It is also used to correct hereditary angioneurotic edema, manage carcinoma of the breast, promote a positive nitrogen balance following injury or surgery, and stimulate erythropoiesis. Considerable amounts of androgens are consumed by athletes in attempts to improve athletic performance. The National Institute of Environmental Health Sciences and the National Cancer Institute nominated oxymetholone for study based on its extensive illicit pharmaceutical use and the limited evidence that it is a potential human carcinogen. Male and female F344/N rats received oxymetholone (greater than 99% pure) in 0.5% methylcellulose by gavage for 16 days, 14 weeks, or 2 years, and male and female B6C3F1 mice received oxymetholone in 0.5% methylcellulose by gavage for 16 days or 14 weeks. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and mouse peripheral blood erythrocytes. 16-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were administered 0, 160, 315, 625, 1,250, or 2,500 mg oxymetholone/kg body weight in 0.5% methylcellulose by gavage for 16 days. All male rats survived to the end of the study; one 2,500 mg/kg female died on day 14. The mean body weights of all dosed groups of males were significantly less than those of the vehicle controls, while those of 160 and 315 mg/kg females were significantly greater. 16-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were administered 0, 320, 630, 1,250, 2,500, or 5,000 mg/kg in 0.5% methylcellulose by gavage for 16 days. All mice survived to the end of the study. The final mean body weights of all dosed groups of females were greater than those of the vehicle controls. 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were administered 0, 80, 160, 315, 625, or 1,250 mg/kg in 0.5% methylcellulose by gavage for 14 weeks. One male rat each in the 625 and 1,250 mg/kg groups died before the end of the study. The mean body weights of males administered 160 mg/kg or greater were significantly less than those of the vehicle controls; in contrast, the mean body weights of all dosed groups of females were significantly greater. A dose-related erythrocytosis, evidenced by increases in erythrocyte counts, total hemoglobin concentrations, and hematocrit values, occurred in dosed groups of rats at week 14. A dose-related hypocholesterolemia occurred at all time points in all dosed groups of rats. Dose- and time-related decreases in 5 -nucleotidase activity occurred in treated rats. There was a transient, treatment-related increase in the activity of alanine aminotransferase in males and females. For male rats administered oxymetholone, cauda epididymis, epididymis, and testis weights and spermatid counts and total spermatid heads per testis were significantly less than those of the vehicle controls, and total spermatid heads per gram testis were significantly greater. Female rats in the 80 mg/kg group spent more time in diestrus and less time in estrus than did the vehicle controls. Kidney weights of males and females and liver and uterus weights of females were increased compared to vehicle controls in rats that received 315 mg/kg or greater; thymus weights of males and females and sartorius muscle and testis weights of males were less. Compared to the vehicle controls, rats that received 160 mg/kg or greater had increased incidences of nonneoplastic lesions of the kidney and mammary gland, and the incidences of hydrometra of the uterus and dysgenesis of the ovary were increased in dosed groups of females. Female rats administered 315 mg/kg or greater had increased incidences of cytoplasmic vacuolization of the adrenal gland and myocardial degeneration of the heart. The severities of these lesions generally increased with increasing dose. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were administered 0, 160, 320, 630, 1,250, or 2,500 mg/kged 0, 160, 320, 630, 1,250, or 2,500 mg/kg in 0.5&amp;percnt; methylcellulose by gavage for 14 weeks. All mice administered oxymetholone survived until the end of the study. The mean body weights of all dosed groups were similar to those of the vehicle controls. The percentages of motile sperm in 1,250 and 2,500 mg/kg males were significantly less than those of the vehicle controls. The estrous cycle lengths of 630, 1,250, and 2,500 mg/kg females were significantly longer, and females in the 1,250 and 2,500 mg/kg groups spent more time in diestrus and less time in estrus. Kidney and liver weights of males and females were greater and thymus weights of females were less than those of the vehicle controls. All dosed females had hyperplasia of the clitoral gland, metaplasia of the parietal layer epithelium of the Bowman's capsule in the kidney, and cytoplasmic alteration of the submandibular gland; these lesions were not observed in the vehicle control group. The incidences of hypoplasia of the ovary in 320 mg/kg or greater females and of parotid gland atrophy in 1,250 and 2,500 mg/kg females were increased. The results of the 14-week oral gavage studies were generally similar in rats and mice, but rats were much more sensitive to oxymetholone. Because it was not likely that a long-term mouse study would provide significant additional toxicity information, the NTP decided to conduct a 2-year study in rats only. 2-YEAR STUDY IN RATS: Groups of 90 male F344/N rats were administered 0, 3, 30, or 150 mg/kg in 0.5&amp;percnt; methylcellulose by gavage, and 90 female F344/N rats were administered 0, 3, 30, or 100 mg/kg in 0.5&amp;percnt; methylcellulose by gavage for up to 104 weeks, with 9 or 10 rats per group evaluated at 3, 6, 12, or 18 months. Survival and Body Weights: Survival of all dosed groups was similar to that of the vehicle controls. The mean body weights of the 30 mg/kg male group were generally within 10&amp;percnt; of those of the vehicle controls, but those of the 150 mg/kg group were markedly decreased. Mean body weights of 3 and 30 mg/kg females were generally greater than those of the vehicle controls throughout the study. Determinations of Oxymetholone in Plasma: The concentrations of oxymetholone in plasma of male and female rats receiving 3 mg/kg for 6, 12, or 18 months were generally below the limits of quantification; therefore, all plasma concentrations in the 3 mg/kg group are considered to be estimates (Table 8). The plasma concentrations at 30 mg/kg were approximately one order of magnitude greater than those of the estimates for males and females receiving 3 mg/kg. There were no dose-related differences in plasma concentrations in female rats receiving 30 or 100 mg/kg, but plasma concentrations in males were significantly elevated in the 150 mg/kg group. It was concluded that oxymetholone kinetics was saturated at 30 mg/kg in female but not male rats. Pathology Findings: A wide spectrum of neoplasms and nonneoplastic lesions was seen in rats administered oxymetholone for 2 years. The incidences of hepatocellular adenoma and hepatocellular adenoma or carcinoma (combined) were significantly increased in 100 mg/kg females as were the incidences of basophilic and clear cell foci in 150 mg/kg males and 100 mg/kg females compared to vehicle controls. The incidences of alveolar/bronchiolar adenoma and adenoma or carcinoma (combined) were significantly increased in 30 mg/kg females. The incidences of mineralization in the lung of 150 mg/kg males and 30 and 100 mg/kg females were significantly increased. The incidence of keratoacanthoma was increased in 30 mg/kg females, and the combined incidence of squamous cell papilloma, keratoacanthoma, basal cell adenoma, squamous cell carcinoma, or carcinoma of the sweat gland was significantly increased in 100 mg/kg females. The incidences of subcutaneous tissue fibroma and fibroma or fibrosarcoma (combined) were significantly increased in 3 mg/kg males. At 2 years, the incidences of benign pheochromocytoma and benign or malignant pheochromocytoma (combined) of the adrenal gland in 150 mg/kg males and medullary hyperplasia in 100 mg/kg females were significantly increased. The incidences of cytoplasmic vacuolization of adrenal cortical cells were significantly increased in 30 and 150 mg/kg males at 18 months and 2 years and in 100 mg/kg females beginning at 12 months and in 30 mg/kg females at 2 years. The incidences of renal tubule adenoma in 3 and 150 mg/kg males were slightly increased. An extended evaluation of the kidney was conducted, and additional incidences of renal tubule adenoma were observed in step sections in vehicle control and dosed male rats. The combined single- and step-section incidence of renal tubule adenoma was significantly increased in 3 mg/kg males. The incidences of nephropathy were significantly increased in 30 and 150 mg/kg males at 2 years and in 100 mg/kg females beginning at 3 months. The severities of nephropathy were significantly increased in dosed groups of males at 2 years and in 100 mg/kg females at 18 months and 2 years. The incidences of mineralization of the kidney were significantly increased in 150 mg/kg males at all time points. The incidences of ovarian dysgenesis were significantly increased in 100 mg/kg females beginning at 3 months and in 30 mg/kg females beginning at 6 months, and severities increased with increasing dose. The incidences of chronic myocardial degeneration (cardiomyopathy) were significantly increased in 100 mg/kg females at 6 months and 2 years and the severity was increased at 2 years. The incidences of lobular hyperplasia were increased in 150 mg/kg males at 18 months and 2 years and in 30 and 100 mg/kg females at all time points. The incidences of seminiferous tubule degeneration were significantly increased in 30 and 150 mg/kg males at 2 years, and the incidences of mineralization of the testis were increased in 150 mg/kg males at 12 months and in 30 mg/kg males at 18 months and at 2 years. Decreased incidences of neoplasms occurred in male and female rats. The incidence of uterine stromal polyp or stromal sarcoma (combined) was significantly decreased in 100 mg/kg females at 2 years. The incidences of mammary gland fibroadenoma and fibroadenoma or carcinoma (combined) were significantly decreased in all dosed groups of females. The incidences of pituitary gland pars distalis adenoma were significantly decreased in 30 and 100 mg/kg females at 2 years. The incidences of testicular interstitial cell adenoma were significantly decreased in 30 and 150 mg/kg males at 18 months and in all dosed groups at 12 months and 2 years. The incidences of mononuclear cell leukemia were significantly decreased in 30 and 150 mg/kg males and 100 mg/kg females at 2 years. GENETIC TOXICOLOGY: Oxymetholone was not mutagenic in S. typhimurium strain TA97, TA98, TA100, or TA1535, with or without S9 metabolic activation. It did not induce chromosomal aberrations in cultured Chinese hamster ovary cells, with or without S9, and no increase in the frequency of micronucleated normochromatic erythrocytes was noted in peripheral blood samples from male or female mice treated for 14 weeks with oxymetholone. CONCLUSIONS: Under the conditions of this 2-year gavage study, there was equivocal evidence of carcinogenic activity of oxymetholone in male F344/N rats based on increased incidences of subcutaneous tissue fibromas and fibromas or fibrosarcomas (combined) of the skin, variably increased incidences of benign and benign or malignant pheochromocytomas (combined) of the adrenal gland, and increased incidences of renal tubule adenomas. There was clear evidence of carcinogenic activity of oxymetholone in female F344/N rats based on increased incidences of hepatocellular neoplasms. Increased incidences of alveolar/bronchiolar neoplasms and skin neoplasms in female rats were also related to oxymetholone administration. Decreased incidences of alveolar/bronchiolar neoplasms and testicular interstitial cell adenomas in males; uterine stromal polyps or stromal sarcomas (combined), mammary gland neoplasms, and pituitary gland pars distalis adenomas in females; and mononuclear cell leukemia in males and females were related to oxymetholone administration. In addition, gavage administration of oxymetholone to male and female F344/N rats resulted in a spectrum of nonneoplastic effects frequently reported with administration of synthetic anabolic androgens. Synonyms: Adroidin; anadroyd; anasteron; anasteronal; anasterone; androstan-3-one, androstano[2,3-c]1,2,5-oxadiazol-17-ol, 17-methyl-, (5-a,17-b)-; becorel; 4,5-dihydro-2-hydroxymethylene-17-a-methyltestosterone; dynasten; HMD; 17b-hydroxy-2- (hydroxymethyl)-17-methyl-5-a-androstan-3-one; 17-hydroxy-2-(hydroxymethylene)-17-methyl-(5-a,17-b)-; 17-hydroxy- 2-(hydroxymethylene)-17-methyl-5-a-17-b-androst-3-one; 17b-hydroxy-2-(hydroxymethylene)-17-a-methyl-5-a-androstan-3-one; 17b-hydroxy-2-(hydroxymethylene)-17-methyl-5a-androstan-3-one; 17-hydroxy-2-(hydroxymethylene)-17-methyl-5-a-17- b-androstan-3-one; 17b-hydroxy-2-hydroxymethylene-17a-methyl-3-androstanone; 2-hydroxymethylene-17-a-methyl-5- a-androstan-17-b-ol-3-one; 2-hydroxymethylene-17a-methyl dihydrotestosterone; 2-hydroxymethylene-17-a-methyl-17-b- hydroxy-3-androstanone; methabol; 17a-methyl-2-hydroxymethylene-17-hydroxy-5-a-androstan-3-one; oximetholonum; oximetolona; oxitosona-50; oxymethenolone; roboral; zenalosyn Trade names: Adroyd; Anadrol; Anapolon; Anapolon 50; Nastenon; Pardroyd; Pavisoid; Plenastril; Protanabol; Synasteron

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Triethanolamine is widely used as an ingredient in emulsifiers, thickeners, wetting agents, detergents, and alkalinizing agents in cosmetic products; as a chemical intermediate for anionic and nonionic surfactants and surface active agents in household cleaning agents, textiles, herbicides, pharmaceutical ointments, and other products; as a vulcanization accelerator in the manufacture of rubber; and in many other industrial applications. The National Cancer Institute nominated triethanolamine for study because of its widespread use in cosmetics and other consumer products, its high potential for worker exposure due to its many industrial uses, and its potential for conversion to the carcinogen N -nitrosodiethanolamine. Dermal application was chosen as the route of exposure to mimic the principal means of human exposure to triethanolamine and because considerable systemic exposure is achieved with this route. Male and female F344/N rats and B6C3F1 mice received triethanol amine (purity 98% or greater) by dermal application for 13 weeks or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, Drosophila melano gaster, and mouse peripheral blood erythrocytes. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were topically administered 0, 125, 250, 500, or 1,000 mg triethanolamine per kilogram body weight in acetone or 2,000 mg/kg neat triethanolamine, 5 days per week, for 13 weeks. All rats survived to the end of the study. Final mean body weights and weight gains of males and females administered 2,000 mg/kg and the mean body weight gain of females administered 1,000 mg/kg were significantly less than those of the vehicle controls. Clinical observations included irritation, scaliness, and crustiness of the skin at the site of application for males and females. Males also had discoloration, and two males administered 2,000 mg/kg had ulceration at the site of application. Changes in clinical pathology parameters were minor and consistent with inflammation at the site of application. Kidney weights were generally greater in males and females administered 500, 1,000, or 2,000 mg/kg than in the vehicle controls. Microscopic lesions attributed to triethanolamine administration included acanthosis and inflammation at the site of application, nephropathy in females, and hypertrophy of the pituitary gland pars intermedia in males and females. These lesions generally occurred with dose-related increases in incidence and severity in males and females. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were topically administered 0, 250, 500, 1,000, or 2,000 mg triethanolamine per kilogram body weight in acetone or 4,000 mg/kg neat triethanolamine, 5 days per week, for 13 weeks. All mice survived to the end of the study. The final mean body weight and weight gain of males in the 250 mg/kg group were less than those of the vehicle controls. Clinical findings were observed only in mice in the 4,000 mg/kg groups and included scaliness, irritation, and discoloration at the site of triethanolamine application for males and females and skin erosion at this site in one male. The absolute kidney and liver weights of males and females administered 4,000 mg/kg were greater than those of the vehicle controls; relative kidney weights of males administered 1,000 mg/kg or greater and females in all dosed groups were also greater than those of the vehicle controls. Microscopic examination of the skin of dosed mice indicated acanthosis and inflammation at the site of application. Acanthosis occurred in all dosed groups and in one vehicle control female; the severity increased with increasing dose in males and females. Inflammation was observed in males and females in the 4,000 mg/kg groups and in one female in the 2,000 mg/kg group. 2-YEAR STUDY IN RATS: Based on the presence of acanthosis and inflammation at the site of application at the higher doses in the 13-week study, triethanolamine doses selected for the 2-year study in rats were 32, 63, and 125 mg/kg for malesr males and 63, 125, and 250 mg/kg for females. Groups of 60 male and 60 female rats were topically administered triethanolamine in acetone 5 days per week for 103 weeks. Ten male and ten female rats from each group were evaluated at 15 months for organ weights and histopathology. Survival, Body Weights, Clinical Findings, and Organ Weights: The survival rate of females in the 250 mg/kg group was slightly less than that of the vehicle controls. The mean body weight of females administered 250 mg/kg ranged from 9&amp;percnt; to 12&amp;percnt; less than that of the vehicle controls between weeks 73 and 93. Male and female rats receiving triethanolamine had irritated skin at the site of application; in dosed females, the site of application also had a crusty appearance. The number of animals in which these findings were observed increased with increasing dose. At the 15-month interim evaluation, the absolute left and right kidney weights and relative right kidney weight of females administered 250 mg/kg were significantly greater than those of the vehicle controls. Pathology Findings: The incidence of acanthosis at the site of application in males administered 125 mg/kg and the incidences of acanthosis, inflammation, and ulceration in dosed females were greater than in the vehicle controls at the 15-month interim evaluation and at the end of the 2-year study. Males in the 125 mg/kg group also had greater incidences of inflammation and ulceration than the vehicle controls, and females receiving 125 or 250 mg/kg had greater incidences of epidermal erosion than the vehicle controls at 2 years. There were no skin neoplasms at or away from the site of application that were considered related to treatment with triethanolamine. At the end of the study, renal tubule adenomas were observed in seven dosed males and in one vehicle control female and one female in the 63 mg/kg group. One male in the 125 mg/kg group and one female in the 250 mg/kg group had renal tubule hyperplasia. Extended (step-section) evaluation of the kidneys of all male rats revealed additional renal tubule adenomas in one vehicle control male, one male in the 32 mg/kg group, two males in the 63 mg/kg group, and three males in the 125 mg/kg group (including one male from the 15-month interim evaluation). An oncocytoma was also identified in one male in the 32 mg/kg group. Hyperplasia was identified in eight additional vehicle control males and in 19 additional dosed males. The total incidences (combined standard and extended evaluations) of renal tubule adenoma in dosed male rats were slightly greater than the vehicle control incidence (vehicle control, 1/50; 32 mg/kg, 2/50; 63 mg/kg, 6/49; 125 mg/kg, 4/50). The total incidence of hyperplasia in dosed and vehicle control males was similar (9/50, 8/50, 7/49, 6/50). The severity of hyperplasia in males in the 32 and 125 mg/kg groups was greater than that in the vehicle controls. 2-YEAR STUDY IN MICE: Based on dose-related inflammation at the site of application in the 13-week study, triethanolamine doses selected for the 2-year study in mice were 200, 630, and 2,000 mg/kg for males and 100, 300, and 1,000 mg/kg for females. Groups of 60 male and 60 female mice were topically administered triethanolamine in acetone 5 days per week for 103 weeks. Ten male and ten female mice from each group were evaluated at 15 months for organ weights and histopathology. Survival, Body Weights, Clinical Findings, and Organ Weights: Survival rates of all dosed groups of males and females were similar to those of the vehicle controls. The mean body weight of males administered 2,000 mg/kg ranged from 8&amp;percnt; to 10&amp;percnt; less than that of the vehicle controls from week 69 through the end of the study. Clinical findings included irritation and discoloration of the skin at the site of application for most males in the 2,000 mg/kg group and a few females in the 1,000 mg/kg group; males administered 200 or 630 mg/kg also had skin irritation. At the 15-month interim evaluation, the right kidney weights of male mice that received 630 or 2,000 mg/kg and the left kidney weights of males that received 2,000 mg/kg were significantly greater than those of the vehicle controls. Pathology Findings: Acanthosis and inflammation of the skin were observed at the site of application in male and female mice at the 15-month interim evaluation and at the end of the 2-year study. In males in the 2,000 mg/kg group, the incidences of both lesions were significantly greater than those in the vehicle controls at both time points; however, the severities of acanthosis and inflammation did not increase with dose. At the end of the study, the incidence of inflammation in females in the 1,000 mg/kg group was significantly greater than that in the vehicle controls. One vehicle control male and two males in each of the 630 and 2,000 mg/kg groups had ulcers at the site of application. At the 15-month interim evaluation, hepatocellular carcinomas were observed in dosed and vehicle control males and hepatocellular adenomas in dosed and vehicle control males and females; however, the incidences were not dose related. Nonneoplastic lesions observed at 15 months included foci of cellular alteration in a few dosed males and females; eosinophilic foci were also observed in two vehicle control females. At the end of the 2-year study, females in the 1,000 mg/kg group had significantly greater incidences of hepatocellular adenoma and multiple adenomas and a greater combined incidence of hepatocellular adenoma and carcinoma than the vehicle controls (adenoma: vehicle control, 22/50; 100 mg/kg, 22/50; 300 mg/kg, 24/50; 1,000 mg/kg, 40/50; multiple adenomas: 11/50, 9/50, 13/50, 29/50; combined adenoma and carcinoma: 23/50, 26/50, 28/50, 41/50). Females in the 300 mg/kg group had significantly greater incidences of hepatocellular carcinoma (1/50, 4/50, 7/50, 5/50) and eosinophilic foci (9/50, 10/50, 18/50, 16/50) than the vehicle controls. Incidences of hepatocellular adenoma and multiple adenomas in males in the 2,000 mg/kg group were significantly greater than those in the vehicle controls (adenoma: vehicle control, 27/50; 200 mg/kg, 27/50; 630 mg/kg, 29/50; 2,000 mg/kg, 37/50; multiple adenomas: 17/50, 18/50, 17/50, 29/50). Three males in the 2,000 mg/kg group had hepatoblastomas, and males in this group also had significantly greater incidences of hepatocellular neoplasms (combined) (adenoma, carcinoma, and hepatoblastoma: 31/50, 34/50, 33/50, 42/50) and eosinophilic foci (10/50, 17/50, 11/50, 23/50) than the vehicle controls. Male mice had a pattern of nonneoplastic liver lesions along with silver-staining helical organisms within the liver which suggested an infection with Helicobacter hepaticus. With polymerase chain reaction-based assays and culture, the presence of an organism compatible with H. hepaticus was confirmed. An increased incidence of hepatocellular neoplasms in male mice has been shown to be associated with H. hepaticus infection when hepatitis is also present. Therefore, interpretation of the increased incidence of hepatocellular neoplasms in mice was confounded. GENETIC TOXICOLOGY: Triethanolamine was not mutagenic in any of the in vitro or in vivo short-term tests performed by the NTP. It did not induce mutations in Salmonella typhimurium, and no induction of sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells exposed to triethanolamine was noted. These in vitro tests were conducted with and without S9 metabolic activation. Triethanolamine did not induce sex-linked recessive lethal mutations in germ cells of adult male Drosophila melanogaster exposed by feeding or injection. No increase in the frequency of micronucleated erythrocytes was observed in peripheral blood samples of male and female mice that received dermal applications of triethanolamine for 13 weeks. CONCLUSIONS: Under the conditions of these dermal studies, there was equivocal evidence of carcinogenic activity of triethanolamine in male F344/N rats based on a marginal increase in the incidence of renal tubule cell adenoma. There was no evidence of carcinogenic activity in female F344/N rats receiving 63, 125, or 250 mg triethanolamine per kilogram body weight. The study in male and female B6C3F1 mice was considered inadequate, because the presence of a Helicobacter hepaticus infection complicated inter pretation of the relationship between triethanolamine administration and liver neoplasms in these animals. Dosed rats and mice had varying degrees of acanthosis and inflammation, dosed rats had ulceration, and dosed female rats had epidermal erosion at the site of skin application. Synonyms: Nitrilo-2,2',2"-triethanol; 2,2',2"-nitrilotriethanol; 2,2',2"-nitrilotrisethanol; TEA; triaethanolamin-NG; triethanolamin; triethylolamine; tri(hydroxyethyl)amine; 2,2',2"-trihydroxytriethylamine; trihydroxytriethylamine; tris(hydroxyethyl)amine; tris(2-hydroxyethyl)amine; triethylolamine; trolamine Trade Names: Daltogen; Sterolamide; Thiofaco T-35

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Isobutyl nitrite is used to a limited extent as an intermediate in the syntheses of aliphatic nitrites. It is also an ingredient of various incenses or room odorizers and is used as a euphoric. The chemical has also been used as a jet propellant and in the preparation of fuels. Isobutyl nitrite was nominated by the Consumer Product Safety Commission to the NTP for toxicology and carcinogenicity studies because of its possible contribution to the high incidence of Kaposi's sarcoma among male homosexual acquired immune deficiency syndrome patients and because of the lack of available data on the potential carcinogenicity of isobutyl nitrite. Male and female F344/N rats and B6C3F1 mice were exposed to isobutyl nitrite (purity of 93% or greater) by inhalation for 16 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, Drosophila melanogaster, and mouse peripheral blood. 16-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were exposed to 0, 100, 200, 400, 600, or 800 ppm (approximately 420, 840, 1,700, 2,500, or 3,300 mg/m(3)) isobutyl nitrite by inhalation for 6 hours per day, 5 days per week for a total of 12 exposures during a 16-day period. All males and females exposed to 600 or 800 ppm and one 400 ppm female died on the first day of the study. Final mean body weights and mean body weight gains of 400 ppm males and females were significantly lower than those of the controls. Clinical findings observed in 400 ppm males and females included ocular discharge, lethargy, hunched posture, and rough coats. Absolute and relative lung weights of all exposed groups of males and of 200 and 400 ppm females were less than those of the controls. Chemical-related hyperplasia of the bronchial epithelium was observed in 200 and 400 ppm males and females and hyperplasia of the nasal turbinate epithelium was observed in rats exposed to 400 ppm or less. Hemosiderin pigmentation was observed in the spleen of 200 and 400 ppm males and females and bone marrow hematopoietic hyperplasia was observed in rats exposed to 400 ppm or less. 16-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were exposed to 0, 100, 200, 400, 600, or 800 ppm (approximately 420, 840, 1,700, 2,500, or 3,300 mg/m(3)) isobutyl nitrite by inhalation for 6 hours per day, 5 days per week for a total of 12 exposures during a 16-day period. Three males and four females exposed to 800 ppm died before the end of the study. Final mean body weights and mean body weight gains of 600 and 800 ppm males and females were significantly lower than those of the controls. Mice exposed to 400 ppm or greater were lethargic and exhibited hunched posture and rough coats. Absolute and relative lung weights of 600 and 800 ppm males and the relative lung weight of 600 ppm females were significantly greater than those of the controls. Chemical-related hyperplasia of the bronchiolar epithelium was observed in all exposed groups of males and females. Lymphocytic atrophy of the spleen and thymus was observed in males and females exposed to 400 ppm or greater. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were exposed to 0, 10, 25, 75, 150, or 300 ppm (approximately 42, 105, 315, 630, or 1,260 mg/m(3)) isobutyl nitrite by inhalation for 6 hours per day, 5 days per week for 13 weeks. All rats survived to the end of the study. Final mean body weights and mean body weight gains of 300 ppm males and females were significantly lower than those of the controls, as was the mean body weight gain of 150 ppm females. Clinical findings observed during the study included ruffled fur in 300 ppm males and females, hypoactivity in 300 ppm males, and hyperactivity in 150 and 300 ppm females. A very mild chemical-related methemoglobinemia and anemia occurred in male and female rats in the 75, 150, and 300 ppm groups. Hematopoietic hyperplasia occurred in the bone marrow of all exposed groups of males and females and was considered to be a secondary response to the anemia and methed methemoglobinemia. There was minimal hemosiderin pigment accumulation in the spleens of males and females exposed to 75 ppm or greater, mild to moderate epithelial cell hyperplasia of the nasal mucosa was observed in 300 ppm males and females, and minimal hyperplasia occurred in 150 ppm males and females. Hyperplasia of the bronchial epithelium was observed in 300 ppm males and females. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were exposed to 0, 10, 25, 75, 150, or 300 ppm (approximately 42, 105, 315, 630, or 1,260 mg/m(3)) isobutyl nitrite by inhalation for 6 hours per day, 5 days per week for 13 weeks. There were no chemical-related deaths. Final mean body weights and mean body weight gains of 150 and 300 ppm females were significantly less than those of the controls. Final mean body weights and mean body weight gains of exposed groups of males were similar to those of the controls. There were no chemical-related clinical findings. A very mild chemical-related methemoglobinemia occurred in male and female mice in the 150 and 300 ppm groups. A very mild anemia occurred in the 300 ppm groups. In the lung, increased incidences of mild to moderate hyperplasia of the bronchiolar epithelium occurred in males and females exposed to 300 ppm. Minimal hyperplasia occurred in males exposed to 75 ppm or greater and in females exposed to 150 ppm. Minimal epithelial cell hyperplasia of the nasal mucosa was observed in 300 ppm males. Increased hematopoiesis of the spleen, secondary to the hematotoxicity, occurred in males exposed to 75 ppm or greater and in females exposed to 150 or 300 ppm. Increased hemosiderosis of the spleen occurred in males exposed to 300 ppm and in females exposed to 75 ppm or greater. 2-YEAR STUDY IN RATS: Based on the low final mean body weights, anemia, and the mild to moderate nasal mucosal lesions and the hyperplastic bronchial lesions observed in 300 ppm males and females, isobutyl nitrite exposure concentrations selected for the 2-year inhalation study in rats were 37.5, 75, and 150 ppm. Groups of 56 male and 56 female rats were exposed to 0, 37.5, 75, or 150 ppm (equivalent to 0, 158, 315, or 630 mg/m(3)) isobutyl nitrite by inhalation for 6 hours per day, 5 days per week, for 103 weeks. Ten male and 10 female rats from each group were evaluated at 15 months for clinical pathology and histopathology. Survival, Body Weights, Clinical Findings, Hematology, and Clinical Chemistry: Survival rates of exposed groups of rats were greater than those of the controls, and the survival rates of 75 and 150 ppm males were significantly greater than that of the control. Mean body weights of 150 ppm males and females were 3&amp;percnt; to 11&amp;percnt; lower than those of the controls throughout the course of the study. There were no clinical findings considered to be related to isobutyl nitrite exposure. A very mild methemoglobinemia and anemia occurred in male and female rats exposed to 75 or 150 ppm. Pathology Findings: Incidences of alveolar/bronchiolar adenoma and alveolar/bronchiolar adenoma or carcinoma (combined) occurred with significant positive trends in exposed males and females, and the incidences of these neoplasms in 75 ppm males and in 150 ppm males and females were significantly greater than those in the controls. The incidence of alveolar/bronchiolar carcinoma was significantly greater in 150 ppm male rats than that in the controls. The incidences of alveolar epithelial hyperplasia were also increased in 75 and 150 ppm males and in all exposed groups of females. The incidences of mononuclear cell leukemia in exposed groups of males and females were significantly less than those in the controls. 2-YEAR STUDY IN MICE: Based on the low final mean body weight of 300 ppm females and the mild to moderate bronchiolar hyperplasia observed in 300 ppm males and females, isobutyl nitrite exposure concentrations selected for the 2-year inhalation study in mice were 37.5, 75, and 150 ppm. Groups of 60 male and 60 female mice were exposed to 0, 37.5, 75, or 150 ppm (equivalent to 0, 158, 315, or 630 mg/m(3)) isobutyl nitrite by inhalation for 6 hours per day, 5 days per week, for 103 weeks. As many as 10 male and 10 female mice from each group were evaluated at 15 months for clinical pathology and histopathology. Survival, Body Weights, Clinical Findings, and Hematology and Clinical Chemistry: Survival rates of exposed groups of males were similar to those of the controls. Survival rates of exposed groups of females were greater than those of the controls, and the survival rate in 37.5 ppm females was significantly greater than that of the controls. Mean body weights of exposed groups of males and of 37.5 and 75 ppm females were similar to those of the controls throughout the study. Mean body weights of 150 ppm females were lower than those of the controls from week 20 until the end of the study. There were no biologically significant clinical findings noted in the 2-year study in mice. A very mild methemoglobinemia and anemia occurred in male and female mice exposed to 75 or 150 ppm. Pathology Findings: Incidences of alveolar/bronchiolar adenoma and alveolar/bronchiolar adenoma or carcinoma (combined) occurred with significant positive trends in exposed males and females, and the incidences of these neoplasms were significantly greater than those in the controls in 75 ppm males and in 150 ppm males and females. Incidences of alveolar epithelial hyperplasia were significantly increased in 75 and 150 ppm male and female mice. Thyroid gland follicular cell adenoma occurred with a significant positive trend in male mice; the incidences of thyroid gland follicular cell hyperplasia were increased in all exposed groups of males, and the incidences in males exposed to 37.5 or 150 ppm were significantly greater than those in the controls. Incidences of serous exudate and olfactory epithelium atrophy in the nose of 150 ppm females were significantly greater than those in the controls. Incidences of minimal to mild hemosiderin pigment in the spleen of 75 and 150 ppm male mice were significantly greater than those in the controls. GENETIC TOXICOLOGY: Isobutyl nitrite was found to be mutagenic in vitro and in vivo. It induced base-pair substitution mutations in Salmonella typhimurim strains TA100 and TA1535 and sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells. Positive responses in the S. typhimurium tests required S9 activation, but isobutyl nitrite induced chromosomal effects in cultured Chinese hamster ovary cells with and without S9. In vivo, no induction of sex-linked recessive lethal mutations was noted in the germ cells of male Drosophila melanogaster exposed to isobutyl nitrite via feeding or injection. However, significant increases in micronucleated normochromatic erythrocytes were observed in the peripheral blood of male and female mice treated with isobutyl nitrite for 90 days by inhalation. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was clear evidence of carcinogenic activity of isobutyl nitrite in male and female F344/N rats based on the increased incidences of alveolar/bronchiolar adenoma and alveolar/bronchiolar adenoma or carcinoma (combined). There was some evidence of carcinogenic activity of isobutyl nitrite in male and female B6C3F1 mice based on the increased incidences of alveolar/bronchiolar adenoma and alveolar/bronchiolar adenoma or carcinoma (combined) in males and females. The increased incidence of thyroid gland follicular cell adenoma in male mice may have been related to isobutyl nitrite exposure. Exposure of rats and mice to isobutyl nitrite by inhalation for 2 years resulted in increased incidences of alveolar epithelial hyperplasia (male and female rats and mice), thyroid gland follicular cell hyperplasia and splenic hemosiderin pigmentation (male mice), and serous exudate and atrophy of the olfactory epithelium of the nose (female mice). Exposure of rats to isobutyl nitrite by inhalation for 2 years resulted in decreased incidences of mononuclear cell leukemia in males and females.

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Pentachloroanisole is a chlorinated aromatic compound which is widely distributed at low levels in the environment and in food products. Formation of pentachloroanisole in the environment may result from the degradation of structurally related, commercially important, ubiquitous chlorinated aromatic compounds such as pentachlorophenol and pentachloronitrobenzene which are known rodent toxins or carcinogens. Toxicology and carcinogenesis studies were conducted by administering pentachloroanisole (&gt;99% pure) in corn oil by gavage to groups of male and female F344/N rats and B6C3F1 mice for 16 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium strains, mouse lymphoma cells, and Chinese hamster ovary cells. 16-DAY STUDIES IN RATS: Groups of five male and five female F344/N rats were administered pentachloroanisole in corn oil by gavage once per day, 5 days per week, for 16 days at doses of 0, 100, 125, 150, 175, or 200 mg/kg body weight. Deaths occurred during days 2 and 3 in rats receiving doses of 125 mg/kg or greater; these deaths were considered directly related to pentachloroanisole administration. No biologically significant changes in mean body weight gains or final body weights were noted in the 100 mg/kg groups of rats. Because of the high early mortality rate, valid comparisons of body weight differences in other dose groups could not be made. Inactivity was noted in all dose groups. Rats administered doses of 125 mg/kg or greater also exhibited dyspnea. 16-DAY STUDIES IN MICE: Groups of five male and five female B6C3F1 mice were administered pentachloroanisole in corn oil by gavage once per day, 5 days per week, for 16 days at doses of 0, 100, 175, 250, 325, or 400 mg/kg. Deaths occurred during days 2 and 3 in mice receiving doses of 175 mg/kg or greater; these deaths were considered directly related to chemical administration. No biologically significant changes in mean body weight gains or final body weights were noted in 100 mg/kg males or 100 or 175 mg/kg females. Because of the high early mortality rate, valid comparisons of body weight differences in other dose groups could not be made. Inactivity was noted in dosed mice. 13-WEEK STUDIES IN RATS: Groups of 10 male and 10 female rats were administered pentachloroanisole in corn oil by gavage once per day, 5 days per week, for 13 weeks at doses of 0, 40, 80, 120, 140, or 180 mg/kg body weight. Most rats receiving doses of 120 mg/kg or greater died during the first week of the study as a direct result of pentachloroanisole administration. Mean body weight gains of males administered 40 or 80 mg/kg and of females administered 40, 80, or 120 mg/kg pentachloroanisole were significantly lower than those of the controls. Most dosed rats exhibited temporary inactivity for several hours after dosing. Relative liver and kidney weights of males administered 40 or 80 mg/kg and absolute and/or relative liver and kidney weights of females administered 40 to 120 mg/kg were significantly greater than those of the controls. Lesions observed in males administered 80 mg/kg or more and in females administered 120 mg/kg or more included pulmonary congestion, hemorrhage, and/or edema, meningeal congestion, and hepatocellular necrosis, glycogen depletion, and degeneration of biliary epithelium in the liver. 13-WEEK STUDIES IN MICE: Groups of 10 male and 10 female mice were administered pentachloroanisole in corn oil by gavage once per day, 5 days per week, for 13 weeks at doses of 0, 40, 80, 120, 140, or 180 mg/kg body weight. Most mice administered doses of 120 mg/kg or higher died during the first week of the study as a direct result of pentachloroanisole administration. Mean body weight gains of females administered 40 to 140 mg/kg were significantly greater than that of the controls, but those of dosed males were similar to that of the controls. Most dosed mice exhibited temporary inactivity for several hours after dosing. Absolute and relative liver weights of males administered 80 mg/kg, absolute and relative liver weights of femats of females administered 40 to 180 mg/kg, and absolute and relative kidney weights of females administered 80 to 180 mg/kg pentachloroanisole were also significantly greater than those of the controls. Lesions observed in males administered 40 mg/kg or more and in females administered 80 mg/kg or more included pulmonary congestion and/or edema, adrenal congestion, lymphoid depletion of lymph nodes and thymus, hepatocellular cytomegaly and karyomegaly, and pigment accumulation in hepatocytes and Kupffer cells. 2-YEAR STUDIES IN RATS: Based on the chemical-related mortality and liver lesions seen in the 16-day and 13-week studies, doses selected for the 2-year studies were 0, 10, 20, and 40 mg/kg for males and 0, 20, and 40 mg/kg for females. Groups of 70 male and 70 female rats were administered pentachloroanisole in corn oil by gavage 5 days per week for up to 2 years. At 9 and 15 months, up to 10 animals per group were selected for interim evaluations. Survival, Body Weights, and Clinical Findings: The survival of high-dose males was significantly decreased (vehicle control, 24/50; low-dose, 20/50; mid-dose, 24/50; high-dose, 14/50); most deaths in the high-dose group occurred at or before week 16. The majority of deaths in the mid- and high-dose groups may have been due to pentachloroanisole-related hyperthermia. The survival of dosed females was greater than that of the controls (29/50, 35/50, 44/50). Final mean body weights of mid- and high-dose males were 7&amp;percnt; and 10&amp;percnt; lower than that of the controls; final mean body weight of high-dose females was 11&amp;percnt; lower than that of the controls. Final mean body weights of other dose groups were similar to those of the vehicle controls. At the 9-month interim evaluation, mean rectal temperature of males administered 40 mg/kg was significantly greater than that of the controls. Relative liver and kidney weights of males and females administered 20 or 40 mg/kg were significantly greater than those of controls. At the 15-month interim evaluation, relative liver weights of dosed females and absolute liver weights of 40 mg/kg females were significantly greater than those of the controls, as were relative liver and kidney weights of 40 mg/kg males. Pathology Findings: In the 2-year studies, administration of pentachloroanisole to males was associated with significant increases in the incidences of benign adrenal medulla pheochromocytomas. The incidence of benign adrenal medulla pheochromocytomas was marginally increased in high-dose females and slightly exceeded the range of the historical controls. Incidences of adrenal medulla hyperplasia were increased in dosed female rats, but not in dosed males. The incidences of pancreatic adenomas and focal hyperplasia were decreased in dosed males. The incidences of mammary gland fibroadenomas and uterine stromal polyps and sarcomas (combined) were decreased in high-dose females. Treatment-related increased incidences of intracytoplasmic pigmentation occurred in renal tubule epithelium, olfactory epithelium, and hepatocytes of males and females. Congestion and hemorrhage of the lungs, lymph nodes, thymus, adrenal cortex, and meninges, as well as hepatocellular centrilobular necrosis occurred almost exclusively in mid- and high-dose males that died or were killed moribund before the end of the studies. 2-YEAR STUDIES IN MICE: Based on the chemical-related mortality and liver lesions seen in the 16-day and 13-week studies, doses selected for the 2-year studies were 0, 20, and 40 mg/kg. Groups of 70 male and 70 female mice were administered pentachloroanisole in corn oil by gavage 5 days per week for up to 2 years. At 9 and 15 months, up to 10 animals per group were selected for interim evaluations. Survival, Body Weights, and Clinical Findings: The survival of dosed males was similar to that of the controls; survival of high-dose females was lower than that of the controls (24/50, 25/50, 16/50). The decreased survival of the high-dose females was attributed primarily to ovarian abscesses which were observed after moribund sacrifice. At the 9-month interim evaluation, the mean body weight of males administered 40 mg/kg was significantly lower than that of the vehicle controls. Absolute and relative liver weights of females and the relative liver weight of males administered 40 mg/kg were significantly greater than those of the controls. Final mean body weights of low- and high-dose males were 11&amp;percnt; and 17&amp;percnt; lower than that of the controls. Final mean body weights of dosed females were similar to that of the controls. There were no clinical findings attributed to pentachloroanisole administration. Pathology Findings: Centrilobular hepatocyte cytomegaly and pigment accumulation in hepatocytes and Kupffer cells were seen in dosed mice, but not in controls at the 9- and 15-month interim evaluations. In the 2-year studies, the incidence of benign pheochromocytomas was significantly increased in high-dose males. Dosed males also exhibited increased incidences of adrenal medulla hyperplasia and hypertrophy. The incidences of hemangiosarcomas of the liver were significantly increased in dosed males. Increased incidences of hepatocellular cytologic alteration, biliary tract hyperplasia, and Kupffer cell pigmentation occurred in dosed males and females; the incidences of mixed cell foci were also increased in dosed males. Cytologic alteration encompassed hepatocellular cytomegaly, karyomegaly, hepatocyte degeneration and necrosis, and multinucleated giant cell formation, and was considered an advanced stage of the pathologic process observed at 13 weeks. GENETIC TOXICOLOGY: Pentachloroanisole was mutagenic in Salmonella typhimurium strains TA98 and TA1537 in the absence but not in the presence of exogenous metabolic activation (S9). No clear mutagenic activity was observed in TA100 with hamster S9, without S9, or in TA1535 with or without S9. An equivocal response was observed in TA100 with rat S9. Pentachloroanisole was positive for induction of trifluorothymidine resistance in mouse lymphoma L5178Y cells with S9; the response observed without S9 was weak and inconsistent. In cytogenetic tests with Chinese hamster ovary cells, pentachloroanisole induced sister chromatid exchanges, but not chromosomal aberrations, with and without S9. TOXICOKINETICS: Male and female F344/N rats and B6C3F1 mice were administered 10, 20, or 40 mg/kg pentachloroanisole by gavage or 10 mg/kg pentachloroanisole intravenously (Appendix H). A rapid elimination of pentachloroanisole and a rapid formation of its main metabolite, pentachlorophenol, were seen in both species after an intravenous or an oral dose of pentachloroanisole. The area under the concentration-versus-time curve of pentachloroanisole increased with dosage in each species but the dose proportionality was lost above 20 mg/kg. No sex-related differences were found in the rate of absorption of pentachloroanisole from the GI tract, in the area under the concentration-versus-time curve, or in the overall rate elimination of pentachloroanisole. However, in female rats the area under the concentration-versus-time curve of pentachlorophenol was significantly larger than in male rats. No such difference was observed in mice. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was some evidence of carcinogenic activity of pentachloroanisole in male F344/N rats based on increased incidences of benign pheochromocytomas of the adrenal medulla. There was equivocal evidence of carcinogenic activity of pentachloroanisole in female F344/N rats based on marginally increased incidences of benign pheochromocytomas of the adrenal medulla. There was some evidence of carcinogenic activity of pentachloroanisole in male B6C3F1 mice based on increased incidences of benign pheochromocytomas of the adrenal medulla and hemangiosarcomas of the liver. There was no evidence of carcinogenic activity of pentachloroanisole in female B6C3F1 mice given doses of 20 or 40 mg/kg. Pentachloroanisole administration was associated with increased incidences of adrenal medulla hyperplasia in female rats and increased incidences of pigmentation in the renal tubule epithelium, olfactory epithelium, and hepatocytes of male and female rats. In addition, decreased incidences of pancreatic adenomas and focal hyperplasia in male rats and decreased incidences of mammary gland fibroadenomas and uterine stromal polyps and sarcomas (combined) in female rats were observed. Hyperthermia-related lesions in male rats receiving 20 or 40 mg/kg were considered indirectly related to pentachloroanisole administration. Pentachloroanisole administration was associated with increased incidences of adrenal medulla hyperplasia and hypertrophy and hepatocellular mixed cell foci in male mice. In male and female mice, nonneoplastic liver lesions associated with pentachloroanisole administration included hepatocellular cytologic alteration, Kupffer cell pigmentation, biliary tract hyperplasia, and subacute inflammation. Synonyms: 2,3,4,5,6-pentachloroanisole; methyl pentachlorophenate; methyl pentachlorophenyl ether; o-methylpentachlorophenol; pentachloromethoxybenzene; pentachlorophenyl methyl ether

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Nitromethane is used as a rocket and engine fuel; as a synthesis intermediate for agricultural fumigants, biocides, and other products; as a solvent; and as an explosive in mining, oil-well drilling, and seismic exploration. It has been detected in air, in surface and drinking water, and in cigarette smoke. Nitromethane was studied because of the potential for widespread human exposure and because it is structurally related to the carcinogens 2-nitropropane and tetranitromethane. Male and female F344/N rats and B6C3F1 mice received nitromethane (purity 98% or greater) by inhalation for 16 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and peripheral blood erythrocytes of mice. 16-DAY STUDY IN RATS: Groups of five male and five female rats were exposed to 0, 94, 188, 375, 750, or 1,500 ppm nitromethane by inhalation, 6 hours per day, 5 days per week, for 16 days. All rats survived until the end of the study. The mean body weight gain of male rats in the 1,500 ppm group was slightly but significantly less than that of the controls; the final mean body weights and mean body weight gains of exposed females were similar to those of the controls. Clinical findings in all male and female rats in the 1,500 ppm groups included increased preening, rapid breathing, hyperactivity early in the study, and hypoactivity and loss of coordination in the hindlimbs near the end of the study. The relative liver weights of all exposed groups of male rats and the absolute and relative liver weights of females exposed to 375 ppm or greater were significantly greater than those of the controls. Minimal to mild degeneration of the olfactory epithelium was observed in the nose of males and females exposed to 375 ppm or greater. Sciatic nerve degeneration was present in all male and female rats exposed to 375 ppm or greater; rats exposed to 750 or 1,500 ppm also had reduced myelin around sciatic axons. 16-DAY STUDY IN MICE: Groups of five male and five female mice were exposed to 0, 94, 188, 375, 750, or 1,500 ppm nitromethane by inhalation, 6 hours per day, 5 days per week, for 16 days. All mice survived to the end of the study. The final mean body weights and weight gains of exposed males and females were similar to those of the controls. Clinical findings included hypoactivity and tachypnea in male and female mice in the 1,500 ppm groups. Absolute and relative liver weights of male mice in the 750 and 1,500 ppm groups and female mice in all exposed groups and the relative liver weight of males in the 375 ppm group were significantly greater than those of the controls. Degeneration of the olfactory epithelium of the nose was observed microscopically in all males and females exposed to 375 ppm or greater; this lesion was of minimal severity in males and minimal to mild severity in females. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were exposed to 0, 94, 188, 375, 750, or 1,500 ppm nitromethane by inhalation, 6 hours per day, 5 days per week, for 13 weeks. All rats survived to the end of the study. The final mean body weight and weight gain of male rats in the 1,500 ppm group were significantly less than those of the controls. Clinical findings included hindlimb paralysis in rats in the 750 and 1,500 ppm groups. Inhalation exposure of rats to nitromethane resulted in an exposure concentration-dependent, microcytic, responsive anemia; anemia was most pronounced in males and females exposed to 375 ppm or greater. The presence of schistocytes, Heinz bodies, and spherocytes and increased mean cell hemoglobin concentration and methemoglobin concentration were evidence that a hemolytic process was occurring; this hemolytic process could have accounted, in part, for the anemia. Thrombocytosis accompanied the anemia and would be consistent with a reactive bone marrow or could have been due to the erroneous inclusion of small erythrocyte fragments as part of the platelet count. On day 23, transient decreases in serum triiodothyronine, thyroxine, and fr and free thyroxine were observed in male rats exposed to 375 ppm or greater and female rats exposed to 750 or 1,500 ppm. There was little or no pituitary response to the thyroid hormone decreases, as evidenced by the lack of significantly increased concentrations of thyroid-stimulating hormone in exposed rats. No biologically significant differences in organ weights were observed. The forelimb and hindlimb grip strengths of males in the 1,500 ppm group were significantly less than those of the controls. The hindlimb grip strengths of females in the 750 and 1,500 ppm groups were also significantly less than the control value. Minimal to mild hyperplasia of the bone marrow was observed microscopically in male rats in the 750 and 1,500 ppm groups and in females exposed to 188 ppm or greater. Nasal lesions in exposed males and females included olfactory epithelial degeneration in males and females exposed to 375 ppm or greater and in one female exposed to 188 ppm and respiratory epithelial hyaline droplets and goblet cell hyperplasia in males and females in the 750 and 1,500 ppm groups; the severity of nasal lesions in males and females was minimal to mild. Males and females exposed to 375 ppm or greater had minimal to mild degeneration of the sciatic nerve and the lumbar spinal cord. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were exposed to 0, 94, 188, 375, 750, or 1,500 ppm nitromethane by inhalation, 6 hours per day, 5 days per week, for 13 weeks. All mice survived to the end of the study. The final mean body weights and weight gains of exposed mice were generally similar to those of the controls. There were no treatment-related clinical findings. The absolute right kidney weights of all groups of exposed male mice except the 1,500 ppm group and of females exposed to 188 ppm or greater and the relative right kidney weights of all groups of exposed males and of females in the 750 and 1,500 ppm groups were significantly greater than those of the controls. The absolute liver weight of male mice in the 750 ppm group and the relative liver weights of males exposed to 375 ppm or greater were significantly greater than those of the controls. Olfactory epithelial degeneration and respiratory epithelial hyaline droplets were observed microscopically in all male and female mice exposed to 375 ppm or greater. Degeneration also occurred in females in the 188 ppm group, and hyaline droplets occurred in females in the 94 and 188 ppm groups. The average severity of the nasal lesions ranged from minimal to mild in males. In females, the average severity of olfactory epithelial degeneration ranged from minimal to mild and the severity of respiratory epithelial hyaline droplets ranged from minimal to moderate. All males and nine females in the 1,500 ppm groups also had minimal extramedullary hematopoiesis of the spleen. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female rats were exposed to 0, 94, 188, or 375 ppm nitromethane by inhalation, 6 hours per day, 5 days per week, for 103 weeks. Survival,Body Weights, and Clinical Findings: There were no significant differences in survival rates between exposed and control male or female rats. The mean body weight of females in the 375 ppm group was slightly greater than that of the control group; the mean body weights of exposed males were generally similar to the mean body weight of the controls throughout the study. Clinical findings were consistent with incidences of mammary gland neoplasms in females exposed to 188 or 375 ppm; no hindlimb paralysis, as occurred in rats in the 13-week study, was observed in male or female rats in the 2-year study. Pathology Findings: The incidences of mammary gland fibroadenoma and fibroadenoma, adenoma, or carcinoma (combined) in female rats in the 188 and 375 ppm groups were significantly greater than those in the controls. Additionally, the incidences of mammary gland carcinoma in the 375 ppm group were significantly greater than those in the controls. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice were exposed to 0, 188, 375, or 750 ppm nitromethane by inhalation, 6 hours per day, 5 days per week, for 103 weeks. Survival,Body Weights, and ClinicalFindings The survival rate of females in the 750 ppm group was marginally greater than that of the controls. The mean body weights of exposed females were generally slightly greater than the mean body weights of the controls during the study but were generally similar to the mean body weight of the controls at the end of the study. The mean body weights of exposed males were similar to those of the controls throughout the study. Clinical findings included swelling around the eyes and exophthalmos in exposed males and females; these findings were coincident with harderian gland neoplasms. Pathology Findings: The incidences of harderian gland adenoma and adenoma or carcinoma (combined) in exposed mice increased with increasing exposure concentration and were significantly greater in males and females in the 375 and 750 ppm groups than those in the controls. The incidences of harderian gland carcinoma in males and females in the 375 and 750 ppm groups were also slightly greater than those in the controls. Female mice in the 188 and 750 ppm groups had significantly greater incidences of hepatocellular adenoma and hepatocellular adenoma or carcinoma (combined) than the controls. The incidences of liver eosinophilic focus increased with increasing exposure concentration, and the incidences in the 375 and 750 ppm groups were significantly greater than the control incidence. The incidences of alveolar/bronchiolar carcinoma in male mice in the 750 ppm group and female mice in the 375 ppm group were significantly greater than those in the controls. Females in the 750 ppm group also had a significantly greater incidence of alveolar/bronchiolar adenoma or carcinoma (combined) and a slightly greater incidence of alveolar/bronchiolar adenoma than the controls. Females in the 375 ppm group had a significantly greater incidence of cellular infiltration of histiocytes in the lung than the controls. The incidences of degeneration and metaplasia of the olfactory epithelium and hyaline degeneration of the respiratory epithelium were significantly greater in exposed male and female mice than those in the controls. Additionally, males in the 375 and 750 ppm groups had significantly greater incidences of inflammation of the nasolacrimal duct than did the controls. GENETIC TOXICOLOGY: Nitromethane was not mutagenic in any tests performed by the NTP. It did not induce mutations in Salmonella typhimurium, with or without S9 metabolic activation, and no induction of sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells exposed to nitromethane was noted with or without S9. No increase in the frequency of micronucleated erythrocytes was observed in peripheral blood samples of male and female mice at the end of the 13-week inhalation study of nitromethane. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was no evidence of carcinogenic activity of nitromethane in male F344/N rats exposed to 94, 188, or 375 ppm. There was clear evidence of carcinogenic activity of nitromethane in female F344/N rats based on increased incidences of mammary gland fibroadenomas and carcinomas. There was clear evidence of carcinogenic activity of nitromethane in male B6C3F1 mice based on increased incidences of harderian gland adenomas and carcinomas. There was clear evidence of carcin ogenic activity in female B6C3F1 mice, based on increased incidences of liver neoplasms (primarily adenomas) and harderian gland adenomas and carcinomas. Increased incidences of alveolar/bronchiolar adenomas and carcinomas in male and female mice exposed to nitromethane were also considered to be related to chemical administration. Exposure to nitromethane by inhalation for 2 years resulted in increased incidences of nasal lesions including degeneration and metaplasia of the olfactory epithelium and degeneration of the respiratory epithelium in male and female mice. Synonym: Nitrocarbol

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Tricresyl phosphate is an organophosphate plasticizer widely used in vinyl plastics and as a fire retardant additive for hydraulic fluids. Toxicology and carcinogenesis studies were conducted by administering a mixed isomer preparation of 79% tricresyl phosphate esters (consisting of 21% tri- m-cresyl phosphate, 4% tri- p-cresyl phosphate, less than 1% tri- o-cresyl phosphate, and other unidentified tricresyl phosphate esters) by gavage to groups of F344/N rats and B6C3F1 mice for 16 days and 13 weeks, and in feed to groups of F344/N rats and B6C3F1 mice for 13 weeks and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells. 16-DAY GAVAGE STUDY IN RATS: Groups of 10 male and 10 female rats received tricresyl phosphate in corn oil by gavage at doses of 0, 360, 730, 1,450, 2,900, or 5,800 mg/kg body weight, 5 days per week, for a total of 13 or 14 doses in a 16-day period. One female receiving 1,450 mg/kg and five males and eight females receiving 2,900 mg/kg died before the end of the study. Final mean body weights of male and female rats that received 1,450, 2,900, or 5,800 mg/kg were significantly lower than those of the controls. Necrosis of the mandibular lymph node, spleen, and thymus occurred primarily in rats receiving 2,900 and 5,800 mg/kg. Diffuse aspermatogenesis occurred in the testes of male rats that received 2,900 and 5,800 mg/kg. Changes in neurobehavioral parameters in groups that received 1,450, 2,900, or 5,800 mg/kg were confounded by mortality and reduced body weights and were not attributed to a direct neurotoxic response. 16-DAY GAVAGE STUDY IN MICE: Groups of 10 male and 10 female mice received tricresyl phosphate in corn oil by gavage at doses of 0, 360, 730, 1,450, 2,900, or 5,800 mg/kg body weight, 5 days per week, for a total of 13 or 14 doses in a 16-day period. Five males and all females that received 1,450 mg/kg, all mice that received 2,900 mg/kg, and four males and one female that received 5,800 mg/kg died before the end of the study. Final mean body weights of male mice that received 1,450 and 5,800 mg/kg were significantly lower than that of the controls. Final mean body weights of female mice that received 360, 730, or 5,800 mg/kg were significantly greater than that of the controls. Necrosis of the mandibular lymph node, thymus, and spleen occurred primarily in mice receiving 2,900 and 5,800 mg/kg. Hindlimb grip strengths of male mice that received 360 and 1,450 mg/kg and male and female mice that received 730 and 5,800 mg/kg were significantly lower than those of the controls at the end of the study. 13-WEEK GAVAGE STUDY IN RATS: Groups of 10 male and 10 female rats received tricresyl phosphate in corn oil by gavage at doses of 0, 50, 100, 200, 400, or 800 mg/kg body weight. All rats survived to the end of the study. Final mean body weights of male rats receiving 200, 400, and 800 mg/kg were significantly lower than that of the controls. Cytoplasmic vacuolization of the adrenal cortex occurred in all dosed groups and the severity increased with dose. Ovarian interstitial cell hypertrophy occurred in all dosed groups of females. Atrophy of the seminiferous tubules occurred in male rats that received 400 and 800 mg/kg. There were no biologically significant changes in neurobehavioral parameters in rats. 13-WEEK GAVAGE STUDY IN MICE: Groups of 10 male and 10 female mice received tricresyl phosphate in corn oil by gavage at doses of 0, 50, 100, 200, 400, or 800 mg/kg body weight. All mice survived to the end of the study. Final mean body weights of male mice receiving 200 mg/kg and of male and female mice receiving 400 and 800 mg/kg were significantly lower than those of the controls. Cytoplasmic vacuolization of the adrenal cortex occurred in all dosed groups of mice and the severity increased with dose. Ovarian interstitial cell hypertrophy was present in all dosed groups of female mice. Multifocal degeneration of the spinal cord occurred in males and females that received 100, 200, 400, and 800 mg/kg, and multifocal degenerg/kg, and multifocal degeneration of the sciatic nerve occurred in males that received 200, 400, and 800 mg/kg and females that received 100, 200, 400, and 800 mg/kg. Hindlimb grip strengths of male mice that received 200, 400, or 800 mg/kg were significantly lower than that of the controls at the end of the study. 13-WEEK FEED STUDY IN RATS: Groups of 10 male and 10 female rats were fed diets containing 0, 900, 1,700, 3,300, 6,600, or 13,000 ppm of tricresyl phosphate. All rats survived to the end of the study. Final mean body weights of males and females exposed to 6,600 and 13,000 ppm and females exposed to 3,300 ppm were significantly lower than those of controls. Feed consumption by male and female rats exposed to 13,000 ppm was lower than that by controls during the first week of the study. Dietary levels of 900, 1,700, 3,300, 6,600 or 13,000 ppm tricresyl phosphate were estimated to deliver daily doses of 55, 120, 220, 430, or 750 mg/kg body weight (males) and 65, 120, 230, 430, or 770 mg/kg (females). There were no biologically significant changes in neurobehavioral parameters in rats. Cytoplasmic vacuolization of the adrenal cortex occurred in all exposed groups of rats. Hyperplasia of ovarian interstitial cells and inflammation of the ovarian interstitium occurred in all exposed groups of females. Renal papillary edema and renal papillary necrosis occurred in 13,000 ppm males and females and in 6,600 ppm females. Basophilic hypertrophy of the pituitary gland pars distalis and atrophy of the seminiferous tubules occurred in 6,600 and 13,000 ppm males. Dose selection for the 2-year study in rats was based on lower mean body weights; toxic responses observed in the kidney, pituitary gland, and testis of males and the kidney of females exposed to 6,600 and 13,000 ppm; the presence of cytoplasmic vacuolization of the adrenal cortex in exposed males and females; and the occurrence of ovarian interstitial cell hyperplasia in females exposed to 900 and 1,700 ppm. 13-WEEK FEED STUDY IN MICE: Groups of 10 male and 10 female mice were fed diets containing 0, 250, 500, 1,000, 2,100, or 4,200 ppm of tricresyl phosphate. All mice survived to the end of the study. Mean body weights of 4,200 ppm males and of females exposed to 2,100 and 4,200 ppm were lower than those of controls throughout the study. Feed consumption by females exposed to 1,000, 2,100, or 4,200 ppm was lower than that by controls during week 12. Dietary levels of 250, 500, 1,000, 2,100, or 4,200 ppm tricresyl phosphate were estimated to deliver average daily doses of 45, 110, 180, 380, or 900 mg/kg body weight (males) and 65, 130, 230, 530, or 1,050 mg/kg (females). Interpretation of grip strength changes observed in groups receiving 2,100 or 4,200 ppm were confounded by the reduced body weights of these groups. Cytoplasmic vacuolization of the adrenal cortex occurred in all exposed groups of male and female mice with the exception of 250 ppm males. Papillary hyperplasia of the gallbladder mucosa occurred in male mice exposed to 500 ppm or more and in female mice exposed to 1,000 ppm or more. Axonal degeneration occurred in males and females exposed to 2,100 and 4,200 ppm and females exposed to 1,000 ppm. Renal tubule regeneration occurred in all 4,200 ppm male mice. Dose selection for the 2-year study in mice was based on the presence of axonal degeneration at concentrations of 1,000 ppm or more and cytoplasmic vacuolization of the adrenal cortex at concentrations of 500 ppm or more in males and in all exposed groups of females. 2-YEAR FEED STUDY IN RATS: Groups of 95 male and 95 female rats were fed diets containing 0, 75, 150, or 300 ppm of tricresyl phosphate. An additional group of 95 male and 95 female rats were fed diets containing 600 ppm of tricresyl phosphate for 22 weeks and then received only control feed. After 3, 9, and 15 months of chemical exposure, up to 15 males and 15 females per group were evaluated for forelimb and hindlimb grip strength, then necropsied and evaluated for histopathologic lesions. Survival, Mean Body Weights, and Feed Consumption: Survival of exposed rats was similar to that of controls. The final mean body weights of all exposed groups of males and females were similar to those of the controls. Feed consumption by exposed groups of male and female rats was similar to that by the controls. Dietary levels of 75, 150, or 300 ppm tricresyl phosphate were estimated to deliver average daily doses of 3, 6, or 13 mg/kg body weight (males) and 4, 7, or 15 mg/kg (females). Pathology Findings: There were no chemical-related increased incidences of neoplasms in rats. Cytoplasmic vacuolization of the adrenal cortex occurred in 600 ppm males and 150, 300, and 600 ppm females at the 3-month interim evaluation. At 9 and 15 months, cytoplasmic vacuolization occurred only in female rats, primarily in the 300 ppm group. Cytoplasmic vacuolization of the adrenal cortex and ovarian interstitial cell hyperplasia occurred in female rats exposed to 300 ppm throughout the 2-year study and the incidence and severity were significantly increased at the end of the study. 2-YEAR FEED STUDY IN MICE: Groups of 95 male and 95 female mice were fed diets containing 0, 60, 125, or 250 ppm of tricresyl phosphate. After 3, 9, and 15 months of chemical exposure, up to 15 males and 15 females per group were evaluated for forelimb and hindlimb grip strength, then necropsied and evaluated for histopathologic lesions. Survival, Mean Body Weights, and Feed Consumption: Survival of exposed groups of male and female mice was similar to that of the controls. The final mean body weights of males and females receiving tricresyl phosphate were similar to those of controls. Feed consumption by exposed groups of male and female mice was similar to that by the controls. Dietary levels of 60, 125, or 250 ppm tricresyl phosphate were estimated to deliver average daily doses of 7, 13, or 27 mg/kg body weight (males) and 8, 18, or 37 mg/kg (females). Pathology Findings: There were no chemical-related increased incidences of neoplasms in mice. Ceroid pigmentation of the adrenal cortex occurred in all groups of mice throughout most of the 2-year study, with the exception of 60 and 125 ppm females at the 3-month interim evaluation; however, the severity was markedly increased in female mice receiving 250 ppm. Incidences of clear cell foci, fatty change, and ceroid pigmentation of the liver were significantly increased in male mice that received 125 or 250 ppm. GENETIC TOXICOLOGY: Tricresyl phosphate was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537, nor did it induce chromosomal aberrations or sister chromatid exchanges in cultured Chinese hamster ovary cells. These in vitro assays were all conducted with and without exogenous metabolic activation (S9). CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of tricresyl phosphate in male or female F344/N rats that received 75, 150, or 300 ppm. There was no evidence of carcinogenic activity of tricresyl phosphate in male or female B6C3F1 mice that received 60, 125, or 250 ppm. Nonneoplastic lesions associated with exposure to tricresyl phosphate included cytoplasmic vacuolization of the adrenal cortex and ovarian interstitial cell hyperplasia in female rats, increased incidences of clear cell focus, fatty change, and ceroid pigmentation of the liver in male mice, and increased severity of ceroid pigmentation of the adrenal cortex in female mice.

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p-Nitrobenzoic acid is produced in large volumes for organic synthesis and as an intermediate in the manufacture of pesticides, dyes, and industrial solvents. Groups of male and female F344/N rats and B6C3F1 mice were exposed to p-nitrobenzoic acid (&gt;99% pure) in feed for 14 days, 13 weeks, or 2 years for toxicity and carcinogenicity studies. Genetic toxicology studies were conducted in in vitro assays with Salmonella typhimurium and cultured Chinese hamster ovary cells, and in studies of erythrocyte micronucleus formation in mice in the 13-week study. 14-DAY STUDY IN RATS: Groups of five male and five female rats were given 0, 2,500, 5,000, 10,000, 20,000, or 40,000 ppm p-nitrobenzoic acid in feed for 14 days. All rats survived until the end of the study. Male and female rats given 20,000 and 40,000 ppm lost weight. The final mean body weights of 10,000, 20,000, and 40,000 ppm males were 82%, 60%, or 52% that of the controls, and the final mean body weights of 10,000, 20,000, and 40,000 ppm females were 87%, 68%, and 65% that of the controls. There were no clinical findings that were characteristic of organ-specific toxicity. Absolute and relative spleen weights were significantly increased in rats exposed to 10,000, 20,000, and 40,000 ppm. There were decreases in erythrocyte count and hemoglobin and hematocrit values and increases in reticulocyte count, nucleated erythrocytes, and methemoglobin concentration that were most pronounced in the 20,000 and 40,000 ppm groups. Congestion of the spleen occurred in 10,000 ppm males and in 20,000 and 40,000 ppm females. Hypertrophy of the follicular epithelium of the thyroid gland was present in male and female rats exposed to 10,000, 20,000, or 40,000 ppm p-nitrobenzoic acid, while follicular hyperplasia was observed in the 40,000 ppm males and females. Atrophy of the testis was observed in 20,000 and 40,000 ppm males. Other lesions observed in 20,000 and 40,000 ppm rats included atrophy of the thymus in males and atrophy of the ovary, bone marrow, and thymus in females. 14-DAY STUDY IN MICE: Groups of five male and five female mice were given 0, 2,500, 5,000, 10,000, 20,000, or 40,000 ppm p-nitrobenzoic acid in feed for 14 days. Three males and two females given 40,000 ppm died during the study. All other animals survived until the end of the study. Male mice given 20,000 and 40,000 ppm and females given 20,000 ppm lost weight. Mean body weight gains of 20,000 and 40,000 ppm males and 10,000, 20,000, and 40,000 ppm females were significantly lower than those of the controls. There were no clinical findings related to organ-specific toxicity although lethargy and ataxia were observed in 40,000 ppm mice. Relative liver weights were significantly increased in 20,000 and 40,000 ppm males and females and in 10,000 ppm females. Absolute and relative thymus weights of 20,000 and 40,000 ppm males and of 10,000, 20,000, and 40,000 ppm females were reduced. No significant differences in hematology parameters occurred in exposed mice. Testicular degeneration was observed in three 20,000 ppm and two 40,000 ppm males. Bone marrow hemorrhage and atrophy occurred in 40,000 ppm females. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were given 0, 630, 1,250, 2,500, 5,000, or 10,000 ppm pnitrobenzoic acid in feed for 13 weeks resulting in approximate daily doses of 40, 70, 160, 310, or 660 mg/kg to males and 40, 80, 170, 340, or 680 mg/kg to females. All rats survived until the end of the study. Mean body weight gains and final mean body weights were significantly less than those of the controls in 2,500, 5,000, and 10,000 ppm males and in 5,000 and 10,000 ppm females. There were no clinical findings related to organ-specific toxicity. Differences in spleen weights and hematology parameters characteristic of regenerative anemia were observed in males and females, primarily in groups given 10,000 ppm. The absolute and relative spleen weights were significantly increased in 10,000 ppm males and females and the relative spleen weights were significantly increased in 5,000 ppm males hts were significantly increased in 5,000 ppm males and females. Methemoglobin, Heinz bodies, and reticulocyte counts were increased and erythrocyte counts, hemoglobin, and hematocrit values were decreased in 10,000 ppm males and females. Congestion, pigmentation, and accumulation of macrophages in the spleen and pigmentation in the kidney occurred in 2,500, 5,000, and 10,000 ppm males. Congestion and pigmentation of the spleen occurred in 10,000 ppm females. A yellowish brown pigment (hemosiderin) in the spleen and kidney was associated with hemolytic anemia. Mild cytoplasmic hyaline droplet accumulation was present in renal tubule epithelial cells in 10,000 ppm males while karyomegaly was present in male and female rats exposed to 2,500, 5,000, and 10,000 ppm p-nitrobenzoic acid. A chemical-related testicular lesion, consisting of atrophy of the seminiferous tubules, occurred in 10,000 ppm males. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were given 0, 1,250, 5,000, 10,000, or 20,000 ppm pnitrobenzoic acid in feed for 13 weeks resulting in approximate daily doses of 170, 330, 670, 1,900, or 4,000 mg/kg body weight to males and 240, 460, 970, 2,500, or 4,900 mg/kg to females. All mice survived until the end of the study, except one 1,250 ppm female that was killed accidentally. Final mean body weights and mean body weight gains of all exposed males and of 5,000, 10,000, and 20,000 ppm females were significantly lower than those of the controls. No clinical findings or differences in organ weights or histopathology related to organ-specific toxicity were observed in exposed mice. 2-YEAR STUDY IN RATS: Groups of 60 male and 60 female rats were given 0, 1,250, 2,500, or 5,000 ppm p-nitrobenzoic acid in feed for 2 years. Ten males and 10 females from each exposure group were evaluated at 15 months. Survival, Body Weights, Feed Consumption, and Clinical Findings: Two-year survival rates of 1,250 and 2,500 ppm males were similar to that of the controls. Two-year survival of 5,000 ppm males was marginally greater than that of the controls and was attributed in part to a decrease in the severity of nephropathy and a decrease in the incidence of mononuclear cell leukemia. Survival of exposed females was similar to that of the controls. Mean body weights of 5,000 ppm males were 2&amp;percnt; to 8&amp;percnt; lower than those of the controls through week 80. Final mean body weights of exposed males were similar to that of the controls. Mean body weights of 5,000 ppm females were 2&amp;percnt; to 9&amp;percnt; lower than those of the controls during the first year of the study and were 10&amp;percnt; to 16&amp;percnt; lower during the second year of the study. Final mean body weights of exposed females were 97&amp;percnt; (1,250 ppm), 92&amp;percnt; (2;500 ppm), and 84&amp;percnt; (5,000 ppm) that of the controls. Feed consumption by exposed males and females was similar to that by the controls. Dietary levels of 1,250, 2,500, or 5,000 ppm p-nitrobenzoic acid delivered approximately 50, 100, or 210 mg/kg body weight per day to males and 60, 125, or 250 mg/kg per day to females. There were no clinical findings attributable to organ-specific toxicity. Pathology Findings: There were increases in the incidences of clitoral gland adenoma and of clitoral gland adenoma or carcinoma (combined) (4/50, 14/49, 15/49, 15/50) in exposed females. The incidences of clitoral gland adenoma or carcinoma (combined) in the exposed groups (29&amp;percnt; to 31&amp;percnt;) exceeded the historical control mean incidence (11&amp;percnt;) and range (2&amp;percnt; to 21&amp;percnt;) in female F344/N rats in recent 2-year NTP feed studies. The increased incidences of clitoral gland neoplasms were considered to be some evidence of carcinogenic activity in female rats exposed to p-nitrobenzoic acid. The incidences of hyperplasia of the clitoral gland in exposed females were marginally lower than that of the controls (10/50, 6/49, 6/ 49, 7/50). There was a chemical-related decrease in the severity of nephropathy in male rats. Male rat kidneys were examined using both single and step-section analyses, and the incidences of renal tubule neoplasms were not statistically greater than those of the controls. Mild hyaline droplet accumulation was observed in renal tubule epithelial cells in 10,000 ppm males in the 13-week study, but this effect was not severe enough to lead to a chemical-related neoplastic response in the 2-year study as has been observed with other chemicals. At the 15-month interim evaluation, hematologic parameters characteristic of a mild regenerative anemia and significant differences in spleen weights were noted in 5,000 ppm females. These differences included decreases in erythrocyte count, hemoglobin, and hematocrit, increases in spleen weights, and hemosiderin accumulation in splenic macrophages. At 2 years, significant decreases in the incidences of mononuclear cell leukemia were observed in 5,000 ppm males and 2,500 and 5,000 ppm females (males: 29/50, 35/50, 26/50, 2/50; females: 17/50, 11/50, 3/50, 0/50). While the mechanism for this decrease is unknown, decreases in the incidence of mononuclear cell leukemia have also been observed in 2year studies with other amine/nitro compounds. 2-YEAR STUDY IN MICE: Groups of 60 male and 60 female mice were given 0, 1,250, 2,500, or 5,000 ppm p-nitrobenzoic acid in feed for 2 years. Ten males and 10 females from each exposure group were evaluated at 15 months. Survival, Body Weights, Feed Consumption, and Clinical Findings: Two-year survival rates of exposed mice were similar to those of the controls. Mean body weights of 5,000 ppm males were 6&amp;percnt; to 12&amp;percnt; lower than those of the controls after week 17, and mean body weights of 5,000 ppm females were 12&amp;percnt; to 24&amp;percnt; lower than those of the controls after week 16. The final mean body weight of 5,000 ppm females was 19&amp;percnt; less than that of the controls; final mean body weights of males were similar to that of the controls. Feed consumption by exposed mice was similar to that by the controls. Dietary levels of 1,250, 2,500, or 5,000 ppm p-nitrobenzoic acid delivered approximately 150, 300, or 675 mg/kg per day to males and 170, 365, or 905 mg/kg per day to females. There were no clinical findings of organ-specific toxicity. No chemical-related effects on hematology parameters were noted at the 15-month interim evaluation. Pathology Findings: There were no increases or decreases in neoplasms in male or female mice that were considered to be related to chemical administration. GENETIC TOXICOLOGY: p-Nitrobenzoic acid was mutagenic in Salmonella typhimurium strain TA100 with and without S9. No mutagenic activity was noted in strains TA98, TA1535, or TA1537, with or without S9. p-Nitrobenzoic acid induced sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells in the absence of S9; with S9, results of both tests were negative. In vivo, no increase in micronuclei was observed in peripheral blood erythrocytes of male or female mice administered p-nitrobenzoic acid in dosed feed for 13 weeks. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of p-nitrobenzoic acid in male F344/N rats exposed to 1,250, 2,500, or 5,000 ppm. There was some evidence of carcinogenic activity of p-nitrobenzoic acid in female F344/N rats based on increases in the incidences of clitoral gland adenoma and of clitoral gland adenoma or carcinoma (combined). There was no evidence of carcinogenic activity of p-nitrobenzoic acid in male or female B6C3F1 mice exposed to 1,250, 2,500, or 5,000 ppm. There were chemical-related decreases in the incidences of mononuclear cell leukemia in exposed male and female rats. p-Nitrobenzoic acid caused mild hematologic toxicity in female rats. Synonyms: 4-Nitrobenzoic acid; nitrodracylic acid; p-nitrobenzenecarboxylic acid; p-carboxynitrobenzene

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3,4-Dihydrocoumarin was nominated by the Food and Drug Administration and the National Cancer Institute for study because of its widespread use as a flavoring agent in beverages, gelatins, puddings, candy, and other food items; as a fragrance in perfumes, creams, and cosmetics; and because of interest in the structure-activity relationships of the coumarin derivatives. Toxicity and carcinogenicity studies were conducted by administering 3,4-dihydrocoumarin (99% pure) in corn oil by gavage to groups of male and female F344/N rats and B6C3F1 mice for 16 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and peripheral blood cells of mice. 16-DAY STUDY IN RATS: Groups of five male and five female rats received 3,4-dihydrocoumarin in corn oil by gavage at doses of 0, 190, 375, 750, 1,500, or 3,000 mg/kg body weight 5 days per week for a total of 12 doses in a 16-day period. All male and female rats given 3,000 mg/kg, and four male rats and five female rats given 1,500 mg/kg died. Body weight gains and final mean body weights of rats receiving 190, 375, or 750 mg/kg were similar to those of the controls. There were no clinical findings of organ-specific toxicity or evidence of impaired blood coagulation. 16-DAY STUDY IN MICE: Groups of five male and five female mice received 3,4-dihydrocoumarin in corn oil by gavage at doses of 0, 140, 280, 560, 1,125, or 2,250 mg/kg body weight 5 days per week for a total of 12 doses in a 16-day period. All mice given 2,250 mg/kg died. Body weight gains and final mean body weights of mice receiving 140, 280, 560, and 1,125 mg/kg were similar to those of the controls. There were no clinical findings of organ-specific toxicity or evidence of impaired blood coagulation. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats received 3,4-dihydrocoumarin in corn oil by gavage at doses of 0, 75, 150, 300, 600, or 1,200 mg/kg body weight 5 days per week for 13 weeks. Two male rats and five female rats given 1,200 mg/kg died. The body weight gain and final mean body weight of male rats that received 1,200 mg/kg were significantly lower than those of the controls, but the final mean body weights of other dosed groups of male rats and all dosed groups of female rats were similar to or slightly greater than those of the controls. Platelet counts were significantly lower in males and females receiving 600 and 1,200 mg/kg and in females receiving 300 mg/kg. Hemoglobin and hematocrit values and erythrocyte counts were significantly lower in males that received 300 mg/kg or more. The absolute and relative liver and kidney weights of males and females receiving 600 and 1,200 mg/kg were significantly greater than those of the controls. Hepatocellular hypertrophy was observed in rats given 300, 600, and 1,200 mg/kg. The high dose selected for the 2-year study was 600 mg/kg, which was below the level at which mortality, lower final mean body weights, and treatment-related liver lesions were observed. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice received 3,4-dihydrocoumarin in corn oil by gavage at doses of 0, 100, 200, 400, 800, or 1,600 mg/kg body weight 5 days per week for 13 weeks. Eight male and five female mice receiving 1,600 mg/kg died. Deaths in other groups were attributed to dosing accidents. Final mean body weights of dosed male and female mice were similar to those of the controls, and there were no treatment-related changes in any hematologic parameters. The absolute and relative liver weights of males and females that received 1,600 mg/kg and the relative kidney weight of males that received 1,600 mg/kg were significantly greater than those of the controls. No treatment-related lesions were noted. The high dose selected for the 2-year study was 600 mg/kg, which was below the level at which mortality, lower final mean body weights, and treatment-related liver lesions were observed. 2-YEAR STUDY IN RATS: Groups of 60 male and 60 female rats received 3,4-dihydrocoumarin in corn oil by gavage at age at doses of 0, 150, 300, or 600 mg/kg body weight. After 15 months, up to 10 animals from each group were evaluated. Survival, Body Weights, and Clinical Findings: Survival rates of dosed male rats were lower than that of the controls (O mg/kg, 28/51; 150 mg/kg, 12/50; 300 mg/kg, 8/50; 600 mg/kg, 2/50) but survival rates of dosed female rats were similar to that of the controls (31/50, 21/51, 26/50, 23/51). The decreased survival in dosed male rats was attributed to a chemical-related increase in the severity of nephropathy. The final mean body weight of male rats receiving 600 mg/kg was lower than that of the controls, but the final mean body weights of other dosed groups of male rats and all dosed groups of female rats were similar to those of the controls. No clinical findings related to chemical administration were observed. Hematology and Clinical Chemistry: At the 15-month interim evaluation, the hemoglobin concentrations, mean erythrocyte volumes, or mean erythrocyte hemoglobin concentrations in the 300 and 600 mg/kg female rats were slightly, but significantly, lower than those of the controls. In males, only the hemoglobin concentration in the 600 mg/kg group was significantly lower. Serum levels of alkaline phosphatase, alanine aminotransferase, sorbitol dehydrogenase, or g-glutamyltransferase in the 300 and 600 mg/kg male rats were significantly higher than those in the controls. In females, alkaline phosphatase and g-glutamyltransferase levels were significantly higher in the 600 mg/kg group. Pathology Findings: The principal lesions associated with the administration of 3,4-dihydrocoumarin to rats occurred in the kidney and forestomach. There was a chemical related increase in the severity of nephropathy in all dosed male rats and in 300 and 600 mg/kg female rats. There was a corresponding increased incidence of parathyroid gland hyperplasia, probably as a result of compromised renal function. In the standard evaluation of single kidney sections, renal tubule adenomas were observed in one 150 and two 600 mg/kg males and one each in the control, 150, and 300 mg/kg females. Transitional cell carcinomas were also observed in two 600 mg/kg male rats. However, an extended evaluation of step sections identified significantly higher incidences of focal hyperplasia and adenoma in the 600 mg/kg males than in controls (hyperplasia: 0/50, 5/48, 6/47, 8/50; adenoma: 1/50,1/48, 3/47, 6/50). The incidence of forestomach ulcers in all groups of dosed male rats was significantly greater than that of the controls (4/47, 14/48, 20/50, 16/46). STOP-EXPOSURE EVALUATION: A group of 40 male rats received 600 mg/kg 3,4-dihydrocoumarin in corn oil by gavage for 9 months, when 20 of the animals were necropsied and evaluated. The remainder of the male rats received only the corn oil vehicle until they died or until the end of the study. Similarly, a group of 30 male rats received 600 mg/kg 3,4-dihydrocoumarin in corn oil by gavage for 15 months, when 10 of the rats were necropsied and evaluated. The remaining 20 rats received only corn oil until the end of the study. A group of 20 vehicle control male rats was necropsied at 9 months, and another 10 vehicle control male rats were necropsied at 15 months. The severity of nephropathy in male rats of the stop-exposure groups was significantly greater than that of males examined at the 9- and 15-month interim evaluations. This was expected because nephropathy is a progressive degenerative disease that naturally increases in severity with age. 2-YEAR STUDY IN MICE: Groups of 70 male and 70 female mice received 3,4-dihydrocoumarin in corn oil by gavage at doses of 0, 200, 400, or 800 mg/kg body weight. After 15 months, five to 10 animals from each group were evaluated. Additional groups of 8 to 10 animals were evaluated for clinical pathology after 15 months. Survival, Body Weights, and Clinical Findings Survival rates of dosed male and female mice were similar to those of the controls (males: O mg/kg, 42/50; 200 mg/kg, 39/51; 400 mg/kg, 34/51; 800 mg/kg, 38/50; females: 36/51, 39/50, 41/50, 28/52). Final mean body weights of dosed male and female mice were similar to those of the controls. No clinical findings were noted that were related to chemical administration. Hematology and Clinical Chemistry: There were no differences in hematology or clinical chemistry parameters that were considered to be chemical related. Pathology Findings: The principal neoplasms associated with the administration of 3,4-dihydrocoumarin to mice occurred in the liver. There were significantly increased incidences of hepatocellular adenomas in all groups of dosed female mice. Further, the incidences of multiple hepatocellular adenomas in dosed female mice were greater than that of the controls (control, 0/51; 200 mg/kg, 6/50; 400 mg/kg, 9/50; 800 mg/kg, 9/52). However, there was no corresponding increased incidence of hepatocellular carcinoma in dosed female mice (3/51, 2/50, 4/50, 6/52), and the incidences of hepatocellular adenoma or carcinoma were similar between dosed and control male groups (adenoma: 29/50, 23/51, 36/51, 31/50; carcinoma: 11/50, 11/51, 11/51, 6/50). The incidence of alveolar/bronchiolar adenoma in the 200 and 400 mg/kg male mice was marginally greater than that of the controls (8/50,15/50,15/51,10/50). However, these neoplasms were not considered chemical related because the increased incidence was slight and there was no corresponding increased incidence in the 800 mg/kg group. The incidence of alveolar/bronchiolar neoplasms in female mice was similar between the dosed and control groups (adenoma: 2/51, 5/50, 1/48, 3/51; carcinoma: 0/51, 1/50, 0/48, 0/51). In the standard evaluation of single sections of kidney, focal hyperplasia and adenoma or carcinoma of the renal tubule were identified in several dosed male mice, but not in controls [adenoma or carcinoma (combined): 0/50,1/51, 2/51,1/49; hyperplasia: 2/50, 2/51, 5/51, 2/49]. In an extended evaluation of step sections, a few additional males with focal hyperplasia or renal tubule adenomas were identified in the dosed groups. However, the incidences of these lesions in dosed groups of male mice were not significantly greater than those of the controls, and did not increase with dose (hyperplasia: 0/50,1/51, 3/51, 1/49; renal tubule adenoma: 0/50, 0/51, 2/51, 1/49). Therefore, the low number of renal tubule neoplasms in male mice was not considered to be chemical related. GENETIC TOXICOLOGY: 3,4-Dihydrocoumarin did not induce gene mutations in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 with or without exogenous metabolic activation (S9). It induced sister chromatid exchanges but not chromosomal aberrations in cultured Chinese hamster ovary cells, with and without S9. No induction of micronuclei was noted in peripheral blood erythrocyte samples obtained from male and female B6C3F1 mice at the end of the 13-week toxicology study. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was some evidence of carcinogenic activity of 3,4-dihydrocoumarin in male F344/N rats based on increased incidences of renal tubule adenomas and focal hyperplasia. The transitional cell carcinomas in two 600 mg/kg males may also have been chemical related. There was no evidence of carcinogenic activity of 3,4-dihydrocoumarin in female F344/N rats receiving 150, 300, or 600 mg/kg. There was no evidence of carcinogenic activity of 3,4-dihydrocoumarin in male B6C3F1 mice receiving 200, 400, or 800 mg/kg. There was some evidence of carcinogenic activity in female B6C3F1 mice based on increased incidences of hepatocellular adenoma and hepatocellular adenoma or carcinoma (combined). 3,4-Dihydrocoumarin caused ulcers, hyperplasia, and inflammation of the forestomach, parathyroid gland hyperplasia, and increased severity of nephropathy in male rats. Synonyms: 1,2-benzodihydropyrone, 2H-1-benzopyran-2-one, 2-chromanone, 3,4-dihydro-2H-1-benzopyran-2-one, dihydrocoumarin, hydrocoumarin, o-hydroycinnamic acid, delta-lactone-hydrocinnamic acid, melilotin, melilotine, melilotol, 2-oxochroman

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o-Benzyl-p-chlorophenol is an aryl halide biocide with widespread use in hospitals and households as a broad-spectrum germicide in disinfectant solutions and soap formulations for general cleaning and disinfecting. Human exposure to o-benzyl-p-chlorophenol occurs by absorption through the skin and mucous membranes and by ingestion. Toxicity and carcinogenicity studies were conducted by administering o-benzyl-p-chlorophenol (approximately 97% pure) in corn oil by gavage to male and female F344/N rats and B6C3F1 mice for 16-days, 13-weeks, and 2-years. Clinical pathology parameters were evaluated during the 2-year rat study. Genetic toxicity studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, L5178Y mouse lymphoma cells, and cultured human lymphoblast cells. 16-DAY STUDY IN RATS: Groups of five male and five female rats were administered o-benzyl-p-chlorophenol in corn oil by gavage at doses of 0, 62.5, 125, 250, 500, or 1,000 mg/kg body weight 5 days a week over a 16-day period. Two 1,000 mg/kg female rats died and these deaths were attributed to chemical administration. The mean body weight gains of 1,000 mg/kg males and females were significantly lower than those of the controls. Clinical findings in 1,000 mg/kg males and females included diarrhea and rough hair coat. Absolute and relative kidney and liver weights of 250, 500, and 1,000 mg/kg males and 1,000 mg/kg females were significantly greater than those of the controls. Absolute and relative thymus weights of 500 and 1,000 mg/kg males and 250, 500, and 1,000 mg/kg females were significantly lower than those of the controls. At necropsy, dilatation of the cecum was observed in male and female rats; the incidence generally increased with dose. The dilated cecum of some dosed rats had necrosis of the mucosal epithelium. Mild to moderate nephropathy was observed in all 1,000 mg/kg male and female rats. Minimal nephropathy occurred in one rat receiving 62.5 mg/kg, two rats each from the 125 and 250 mg/kg groups, and seven rats in the 500 mg/kg groups. The incidence and severity of nephropathy increased with dose. 16-DAY STUDY IN MICE: Groups of five male and five female mice were administered o-benzyl-p-chlorophenol in corn oil by gavage at doses of 0, 62.5, 125, 250, 500, or 1,000 mg/kg body weight 5 days a week over a 16-day period. Deaths occurred only in the 1,000 mg/kg groups, in which three males and all females died. Mean body weight gains of dosed male and female mice were generally similar to those of the controls. Clinical findings in male and female high-dose mice included rough hair coat and postural changes. Absolute and relative liver weights of 500 and 1,000 mg/kg males and 500 mg/kg females (the highest dose group of females surviving) were significantly greater than those of the controls. Necropsy findings included dilatation of the cecum. Nephropathy occurred in 500 and 1,000 mg/kg mice (500 mg/kg, 2/10; 1,000 mg/kg, 6/10). 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were administered o-benzyl-p-chlorophenol in corn oil by gavage at doses of 0, 30, 60, 120, 240, or 480 mg/kg body weight 5 days a week for 13 weeks. No deaths were attributed to o-benzyl-p-chlorophenol administration; however, the deaths of five male rats were attributed to gavage trauma. Mean body weight gains of all dosed rats were generally similar to those of the controls. Clinical findings included yellow-red staining of the urogenital region hair coat of all dosed females. The albumin/globulin ratios in 120, 240, and 480 mg/kg male rats increased with dose and were the result of net decreases in total globulin. Administration of o-benzyl-p-chlorophenol caused no significant alterations in hematologic or urinalysis parameters. Absolute and relative kidney weights were significantly greater and the absolute and relative thymus weights were significantly lower in 480 mg/kg male and female rats and in 240 mg/kg female rats. No gross lesions related to compound administration were observed at necropsy. Nephropathy of mild to moderate derate severity occurred in 480 mg/kg male and female rats and in 240 mg/kg male rats. Few or no lesions occurred in other dosed rats and none occurred in controls. 13-WEEK STUDIES IN MICE: In the first 13-week study, groups of 10 male and 10 female mice were administered o-benzyl-p-chlorophenol in corn oil by gavage at doses of 0, 30, 60, 120, 240, or 480 mg/kg body weight 5 days a week for 13 weeks. Survival, mean body weight gains, and clinical findings of dosed animals were similar to those of the controls throughout the study. The Pathology Working Group confirmed that no microscopic lesions were observed that could definitively be associated with o-benzyl-p-chlorophenol administration. On the basis of these findings, a second 13-week study was performed using higher doses. In the second 13-week study, groups of 15 male and 15 female mice were administered o-benzyl-p-chlorophenol in corn oil by gavage at doses of 0, 500, 650, 800, or 1,000 mg/kg body weight 5 days a week for up to 13 weeks. Five male and five female mice from each group were evaluated after 2 weeks, with the remainder (up to 10 per sex) evaluated at the end of the study. One 500 mg/kg mouse, three 650 mg/kg mice, 14 mice receiving 800 mg/kg, and 19 mice administered 1,000 mg/kg died before the end of the study. Mean body weight gains of dosed male and female mice that received 500 or 800 mg/kg were lower than those of the controls. Absolute and relative liver weights of 800 mg/kg males and all surviving dosed females were significantly greater than those of the controls. Absolute and relative kidney weights of 500, 650, and 800 mg/kg male mice were slightly lower than those of the controls, and those of female mice were similar to those of the controls. The incidence and severity of nephropathy increased with time and with increasing dose of o-benzyl-p-chlorophenol. Significant nephropathy was present at all doses, with mild nephropathy present at the 500 mg/kg dose. Acute necrotizing, suppurative inflammation of the olfactory epithelium was noted in all dose groups, with severity increasing with dose. These lesions were considered to be directly related to the caustic nature of o-benzyl-p-chlorophenol following retrograde exposure after gavage, with the presence of foreign material likely due to retrograde migration of the chemical. 2-YEAR STUDY IN RATS: Groups of 80 male and 80 female rats were administered o-benzyl-p-chlorophenol in corn oil by gavage 5 days a week for 103 weeks. The doses were 0, 30, 60, or 120 mg/kg body weight for male rats and 0, 60, 120, or 240 mg/kg body weight for female rats. After 3 and 15 months, 7 to 10 male and 8 to 10 female rats were evaluated for organ weights and clinical pathology, and control and high-dose rats were evaluated for histopathology. Survival, Body Weights, and Clinical Findings: Survival of dosed male and female rats was similar to that of the controls. Mean body weights of dosed rats were generally similar to those of the controls. No chemical-related clinical findings were observed except yellow staining of the urogenital area hair coat in dosed female rats; staining was observed earlier in high-dose female rats. Pathology Findings: Severe, time- and dose-related nephropathy was observed in male and female rats, occurring as early as 3 months after the beginning of chemical administration (females). In male rats dosed for as long as 2 years, secondary hyperparathyroidism developed, with parathyroid gland hyperplasia, mineralization of the kidney and glandular stomach, and fibrous osteodystrophy occurring in the high-dose group. The severity of these lesions was greater in males. The kidney was the only organ in which chemical related increased incidences of neoplasms may have occurred. One renal tubule adenoma occurred in a control male rat, one renal tubule adenoma and one transitional cell carcinoma occurred in high-dose female rats, and one transitional cell carcinoma occurred in a mid-dose female. One renal tubule carcinoma was observed in a high-dose male rat. 2-YEAR STUDY IN MICE: Groups of 70 male and 70 female mice were administered o-benzyl-p-chlorophenol in corn oil by gavage at doses of 0, 120, 240, or 480 mg/kg body weight 5 days a week for 103 weeks. Ten male and 9 or 10 female mice were evaluated after 3 and 15 months for organ weights and histopathology; the remaining 50 male and 50 female mice were evaluated at the end of the study. Survival, Body Weights, and Clinical Findings: Survival of high-dose male and female mice was lower than that of the controls, which was associated in part with dose-related increases in the incidence and severity of nephropathy. The final mean body weights of all dosed males and mid- and high-dose females were lower than those of the controls. Chemical-related clinical findings included emaciation, abnormal posture, rough hair coat, and hypoactivity. Pathology Findings: Nephropathy occurred in most dosed males and females, and the incidence and severity increased with time and dose. Fibrous osteodystrophy of bone, mineralization of the glandular stomach, and squamous hyperplasia of the forestomach occurred in male and female mice. In the standard evaluation, the combined incidence of renal tubule adenoma and carcinoma was increased in 240 mg/kg male mice. Six renal tubule adenomas and three renal tubule carcinomas occurred in dosed male mice. No renal neoplasms occurred in female mice. Due to the marginal increase in renal neoplasia, and the small size of renal neoplasms, an extended evaluation of the kidney was conducted. No significant alteration in the neoplasm incidences were observed in female mice. However, a dose-related increased trend of renal tubule adenoma was observed in male mice. Combination of the extended evaluation with the original evaluation resulted in an increased incidence of renal tubule adenomas in the 480 mg/kg males and an increased incidence of renal tubule adenomas or carcinomas in both the 240 and 480 mg/kg males. GENETIC TOXICOLOGY: o-Benzyl-p-chlorophenol did not induce gene mutations in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 and did not induce sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells. These tests were performed with and without exogenous metabolic activation (S9). Positive results were obtained, however, in gene mutation tests conducted with LS178Y mouse Lymphoma cells and TK6 human lymphoblast cells in the absence of S9. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was no evidence of carcinogenic activity of o-benzyl-p-chlorophenol in male F344/N rats receiving 30, 60, or 120 mg/kg body weight. There was equivocal evidence of carcinogenic activity of o-benzyl-p-chlorophenol in female F344/N rats based on the occurrence of two rare renal transitional cell carcinomas. There was some evidence of carcinogenic activity of o-benzyl-p-chlorophenol in male B6C3F1 mice based on increased incidences of renal tubule adenoma and renal tubule adenoma or carcinoma (combined). There was no evidence of carcinogenic activity of o-benzyl-p-chlorophenol in female B6C3F1, mice receiving 120, 240, or 480 mg/kg. o-Benzyl-p-chlorophenol was nephrotoxic for male and female F344/N rats and B6C3F1 mice. The severity of nephropathy was increased in male and female rats and the incidence and severity of nephropathy was increased in male and female mice. The incidence and severity of nephropathy increased with length of treatment. Other lesions considered to be associated with the nephropathy and the secondary hyperparathyroidism in male rats and in male and female mice included fibrous osteodystrophy and soft tissue mineralization. Increased incidences of squamous cell hyperplasia of the forestomach were observed in mice. Synonyms: 2-benzyl-4-chlorophenol, 4-chloro-2-benzylphenol, 4-chloro-2-(phenylmethyl)phenol, 4-chloro-alpha-phenol o-cresol, p-chloro-o-benzylphenol, 2-hydroxy-5-chlorodiphenylmethane Trade names: Bio-Clave, Chlorophene, Clorofene, Clorophene, Ketolin H, Nipacide BCPR, Preventol BPR, Santophen 1, Septiphene

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Primary Objective: To evaluate the efficacy and safety of oral administration of imatinib combined with the Best Conventional Care (BCC) versus placebo plus BCC in hospitalized patients with COVID-19. Addition of imatinib to the BCC will provide a superior clinical outcome for patients with COVID-19 compared with BCC plus placebo. This hypothesis is on the basis of 1) intralysosomal entrapment of imatinib will increase endosomal pH and effectively decrease SARS-CoV-2/cell fusion, 2) kinase inhibitory activity of imatinib will interfere with budding/release or replication of SARS-CoV-2, and 3) because of the critical role of mechanical ventilation in the care of patients with ARDS, imatinib will have a significant clinical impact for patients with critical COVID-19 infection in Intensive Care Unit (ICU). This is an individual patient-level randomized, double-blind, placebo-controlled, two-parallel arm phase 3 study to evaluate the safety and efficacy of imatinib for the treatment of hospitalized adults with COVID-19. Participants will be followed for up to 60 days from the start of study drug administration. This trial will be conducted in accordance with the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines of the International Conference on Harmonization. Inclusion Criteria: Patients may be included in the study only if they meet all of the following criteria: 1) Ability to understand and willingness to sign a written informed consent document. Informed consent must be obtained prior to participation in the study. For patients who are too unwell to provide consent such as patients on invasive ventilator or extracorporeal membrane oxygenation (ECMO), their Legally Authorized Representative (LAR) can sign the informed consent, 2) Hospitalized patients ≥18 years of age, 3) Positive reverse transcriptase-polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 in the respiratory tract sample (oropharyngeal, nasopharyngeal or bronchoalveolar lavage (BAL)) by Center for Disease Control or local laboratory within 7 days of randomization, 4) Women of childbearing potential must agree to use at least one primary form of contraception for the duration of the study. Patients meeting any of the following criteria are not eligible for the study: 1) Patients receiving any other investigational agents in a clinical trial. Off-label use of agents such as hydroxychloroquine is not an exclusion criterion, 2) Pregnant or breastfeeding women, 3) Patients with significant liver or renal dysfunction at the time of screening as defined as: 3.1) Direct bilirubin &gt;2.5 mg/dL, 3.2) AST, ALT, or alkaline phosphatase &gt;5x upper limit of normal, 3.3) eGFR ≤30 mL/min or requiring renal replacement therapy, 4) Patients with significant hematologic disorder at screen as defined as: 4.1) Absolute neutrophil count (ANC) &lt;500/μL, 4.2) Platelet &lt;20,000/μL, 4.3) Hemoglobin &lt;7 g/dL, 5) Uncontrolled underlying illness including, but not limited to, symptomatic congestive heart failure, unstable angina pectoris, uncontrolled active seizure disorder, or psychiatric illness/social situations that per site Principal Investigator's judgment would limit compliance with study requirements, 6) Known allergy to imatinib or its component products, 7) Any other clinical conditions that in the opinion of the investigator would make the subject unsuitable for the study. Both men and women of all races and ethnic groups are eligible for this trial. University of Maryland Medical Center, Baltimore, MD is the initiating site. The study may be opened in other centers on the basis of the accrual rate or the magnitude of the COVID-19 pandemic. Imatinib: All doses of imatinib should be administered with a meal and a large glass of water. Imatinib can be dissolved in water or apple juice for patients having difficulty swallowing. In this study, patients with confirmed positive COVID-19 tests receive imatinib for a total of 14 days; 400 mg orally daily Days 1-14. Imatinib 400 mg tablets will be encapsulated using size 000 capsules and cellulose microcrystalline filler. For patients on ventilator or ECMO, imatinib will be given as oral suspension (40 mg/mL). To make the oral suspension, imatinib tablets will be crushed and mixed in Ora-sweet solution to yield a concentration of 40 mg/mL suspension by pharmacy. Additionally, in the absence of supportive microbiological testing results, we confirm that the in-use stability period for the prepared imatinib suspensions will be 24 hours at room temperature or 7 days at refrigerated conditions. The pharmacy staff will follow the American Society Health-System Pharmacists (ASHP) guidelines for handling hazardous drugs. Placebo: The matching placebo will be packaged by Investigational Drug Service Pharmacy at University of Maryland Medical Center. The placebos will be prepared using size 000 capsules and cellulose microcrystalline filler. Imatinib 400 mg capsules and placebo capsules will be identical form and color. For patients on ventilator or ECMO, placebo will be given as oral suspension with similar process for making imatinib suspension. Concomitant Medications/supportive care: In both arms, patients can receive concomitant available local standard of care antipyretics, antibacterials, antivirals, antifungals and anti-inflammatory including hydroxychloroquine at the discretion of the treating physician as necessary. For other drug-drug interactions particularly with CYP P450, the treating physician should consider the risk and benefit of drug administration based on available information. Co-administration of off-label immunomodulatory treatments for COVID-19 including but not limited to corticosteroids, sarilumab, clazakizumab, tocilizumab, and anakinra will be allowed but may affect interpretability of study outcomes. The timing, dosing, and duration of these treatments will be meticulously collected, including any of these treatments that may be used for participants who experience progression of COVID-19 disease after study enrollment. Two analyses will be performed, the primary analysis will compare the primary endpoint in the two trial arms irrespective of any other treatment; the second analysis will be stratified for co-administration of immunomodulatory drugs. The primary endpoint is the proportion of patients with a two-point improvement at Day 14 from baseline using the 8-category ordinal scale. The ordinal scale is an evaluation of the clinical status at the first assessment of a given study day. The scale is as follows: 1) Not hospitalized, no limitations on activities; 2) Not hospitalized, limitation on activities and/or requiring home oxygen; 3) Hospitalized, not requiring supplemental oxygen - no longer requires ongoing medical care; 4) Hospitalized, not requiring supplemental oxygen - requiring ongoing medical care (COVID-19 related or otherwise); 5) Hospitalized, requiring supplemental oxygen; 6) Hospitalized, on non-invasive ventilation or high flow oxygen devices; 7) Hospitalized, on invasive mechanical ventilation or ECMO; 8) Death. The secondary endpoints include: All-cause mortality at Day 28, All-cause mortality at Day 60, Time to a 2-point clinical improvement difference over baseline, Duration of hospitalization, Duration of ECMO or invasive mechanical ventilation (for subjects who are on ECMO or mechanical ventilation at Day 1), Duration of ICU stay (for subjects who are in ICU at Day 1), Time to SARS-CoV-2 negative by RT-PCR, Proportion of patients with negative oropharyngeal or nasopharyngeal swab for SARS-CoV-2 by RT-PCR on days 5, 10, 14, 21, and 28 after starting treatment, Proportion of subjects with serious adverse events, Proportion of subjects who discontinue study drug due to adverse events. The exploratory endpoints include: Determine the impact of treatment arms on IL-6 levels, Obtain blood/peripheral blood mononuclear cells (PBMCs) for storage to look at transcriptomics in severe disease, Association of major histocompatibility complex (MHC) with severity of illness, Mean change in the ordinal scale from baseline, Time to an improvement of one category from admission using an ordinal scale, Duration of hospitalization, Duration of new oxygen use, Number of oxygenation free days, Duration of new mechanical ventilation, Number of ventilator free days. Eligible patients will be uniformly randomized in 1:1 ratio to receive either imatinib or placebo for 14 days. Both groups will receive the BCC. The randomized treatment allocations use stratified, permuted block randomization with a variable block size; blocks are generated using a validated random number generator. In order to balance the severity of the respiratory illness between the two arms, randomization will be stratified based on radiographic findings and oxygen requirements: 1) Severe disease: evidence of pneumonia on chest X-ray or CT scan OR chest auscultation (rales, crackles), and SpO<sub2</sub ≤92% on ambient air or PaO<sub2</sub/FiO<sub2</sub &lt;300 mmHg, and requires supplemental oxygen administration by nasal cannula, simple face mask, or other similar oxygen delivery device; 2) Critical disease: requires supplemental oxygen delivered by non-rebreather mask or high flow cannula OR use of invasive or non-invasive ventilation OR requiring treatment in an intensive care unit, use of vasopressors, extracorporeal life support, or renal replacement therapy. The participants, caregivers, and the statistician are blinded to group assignment. The only people who are not blinded are Site Pharmacists. Blinding will be performed via a specific randomization process. Centralized, concealed randomization will be executed by the Primary Site's Pharmacist. Data on eligible consented cases will be submitted electronically on the appropriate on-study form to the pharmacy, where the patient is randomized to imatinib or placebo. Imatinib 400 mg capsules and placebo capsules will be identical form and color. For patients on ventilator or ECMO, placebo will be given as oral suspension with similar process for making imatinib suspension. The trial is designed as a double-blind, two-parallel arm, randomized controlled trial with a uniform (1:1) allocation ratio to: Arm A) Imatinib or Arm B) Placebo. Patients in both arms will receive the BCC per local institutional standards at the discretion of the treating physician. Group sample sizes of 102 in Arm A and 102 in Arm B achieve 80.6% power to detect a difference between the group proportions of 0.20. The proportion in Arm A (imatinib treatment arm) is assumed to be 0.30 under the null hypothesis and 0.50 under the alternative hypothesis. The proportion in Arm B (placebo control arm) is 0.30. The test statistic used is the two-sided Fisher's Exact Test. The significance level of the test is targeted at 0.05. The significance level actually achieved by this design is α=0.0385. The power of the test is calculated using binomial enumeration of all possible outcomes. The primary analysis will be conducted using an intention to treat principle (ITT) for participants who at least receive one dose of study drug or placebo. The sample size is not inflated for dropouts. All patients will be evaluable irrespective of the clinical course of their disease. Current protocol version is 1.2 from May 8, 2020. The recruitment started on June 15, 2020 and is ongoing. We originally anticipated that the trial would finish recruitment by mid 2021. We are aware of the enrollment requirement of approximately 200 patients, which is required to provide scientific integrity of the results. We are also aware of the fact that enrolling this number of patients in a single-site at University of Maryland Medical Center (UMMC) may take longer than expected, particularly taken into account other competing studies. For this reason, we are actively considering opening the protocol in other sites. After identification of other sites, we will fulfill all regulatory requirements before opening the protocol in other sites. ClinicalTrials.gov Identifier: NCT04394416 . First Posted: May 19, 2020; Last Update Posted: June 4, 2020. FDA has issued the "Study May Proceed" Letter for this clinical trial under the Investigational New Drug (IND) number 149239. The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

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An erratum was issued for: Involving Individuals with Developmental Language Disorder and their Parents/Carers in Research Priority Setting. The tables in the Representative Results section were updated. The tables in the Representative Results section were updated from: Participant (n=42) Topic Rating Identification Assessment/ diagnosis Bilingualism Lifelong impact Provision- primary Provision- secondary Provision- adults Intervention Working with others Raising awareness Technology 1 10 10 9 10 10 9 10 8 2 10 10 10 10 10 10 5 10 3 10 4 6 9 8 2 1 7 5 11 3 4 8 7 1 11 9 3 2 10 5 6 4 5 7 11 10 9 8 6 3 5 2 4 1 6 10 8 2 6 9 7 5 4 3 11 1 7 1 2 10 7 9 5 6 4 3 8 11 8 10 1 6 11 2 7 9 5 8 4 3 9 1 2 11 7 3 9 10 4 5 6 8 10 1 4 11 10 3 6 9 2 8 5 7 11 1 2 11 8 3 9 10 4 6 5 7 12 10 8 3 6 7 6 9 11 8 5 4 13 2 3 11 6 4 7 8 10 5 9 1 14 2 5 9 11 10 7 3 6 1 8 5 15 6 3 5 10 9 7 8 4 2 16 10 8 3 6 9 1 2 4 5 1 17 11 9 2 7 3 6 1 8 10 4 5 18 8 9 2 1 3 7 6 5 4 10 19 10 9 8 7 6 5 4 3 2 1 20 10 10 1 9 10 9 9 9 10 8 7 21 10 7 10 7 6 1 9 6 8 6 22 10 1 10 10 10 5 23 1 10 10 5 10 24 10 10 10 10 10 10 9 25 10 9 10 10 6 9 10 8 7 10 8 26 10 9 6 7 8 5 4 3 2 1 27 10 9 2 3 6 5 4 8 7 1 28 10 3 2 4 8 5 1 9 6 7 29 10 6 2 4 7 5 3 9 8 1 30 10 2 1 9 8 4 5 4 3 6 31 10 10 7 10 9 10 9 10 9 8 9 32 8 7 1 10 10 10 10 10 9 10 5 33 5 6 4 10 8 10 7 10 8 9 5 34 9 10 6 8 10 1 7 10 4 10 10 35 7 5 6 10 9 7 5 10 1 10 1 36 11 9 10 11 11 11 11 11 11 8 6 37 10 10 10 10 10 10 10 10 10 10 10 38 7 5 6 8 5 6 4 10 5 39 10 5 5 6 8 9 6 10 10 40 7 3 7 8 7 8 6 6 9 41 8 5 4 6 8 6 7 5 1 42 8 5 5 5 8 5 7 5 8 Corrector value 26 16 14 24 23 15 15 24 13 20 12 Table 3: Unadjusted and adjusted top ten research priorities lists. Table to show the top ten research priorities without adjustment (left column) and with adjustment (right column). * depict defined research areas which are not represented in the top ten of the other columns (i.e., where priorities were different). to: Participant (n=42) Topic Rating Identification Assessment/ diagnosis Bilingualism Lifelong impact Provision- primary Provision- secondary Provision- adults Intervention Working with others Raising awareness Technology 1 10 10 9 10 10 9 10 8 2 10 10 10 10 10 10 5 10 3 10 4 6 9 8 2 1 7 5 11 3 4 8 7 1 11 9 3 2 10 5 6 4 5 7 11 10 9 8 6 3 5 2 4 1 6 10 8 2 6 9 7 5 4 3 11 1 7 1 2 10 7 9 5 6 4 3 8 11 8 10 1 6 11 2 7 9 5 8 4 3 9 1 2 11 7 3 9 10 4 5 6 8 10 1 4 11 10 3 6 9 2 8 5 7 11 1 2 11 8 3 9 10 4 6 5 7 12 10 8 3 6 7 6 9 11 8 5 4 13 2 3 11 6 4 7 8 10 5 9 1 14 2 5 9 11 10 7 3 6 1 8 5 15 6 3 5 10 9 7 8 4 2 16 10 8 3 6 9 1 2 4 5 1 17 11 9 2 7 3 6 1 8 10 4 5 18 8 9 2 1 3 7 6 5 4 10 19 10 9 8 7 6 5 4 3 2 1 20 10 10 1 9 10 9 9 9 10 8 7 21 10 7 10 7 6 1 9 6 8 6 22 10 1 10 10 10 5 23 1 10 10 5 10 24 10 10 10 10 10 10 9 25 10 9 10 10 6 9 10 8 7 10 8 26 10 9 6 7 8 5 4 3 2 1 27 10 9 2 3 6 5 4 8 7 1 28 10 3 2 4 8 5 1 9 6 7 29 10 6 2 4 7 5 3 9 8 1 30 10 2 1 9 8 4 5 4 3 6 31 10 10 7 10 9 10 9 10 9 8 9 32 8 7 1 10 10 10 10 10 9 10 5 33 5 6 4 10 8 10 7 10 8 9 5 34 9 10 6 8 10 1 7 10 4 10 10 35 7 5 6 10 9 7 5 10 1 10 1 36 11 9 10 11 11 11 11 11 11 8 6 37 10 10 10 10 10 10 10 10 10 10 10 38 7 5 6 8 5 6 4 10 5 39 10 5 5 6 8 9 6 10 10 40 7 3 7 8 7 8 6 6 9 41 8 5 4 6 8 6 7 5 1 42 8 5 5 5 8 5 7 5 8 Corrector value 26 16 14 24 23 15 15 24 13 20 12 Table 1: Topic ratings from all iDLD/iDLDPC participants with corrector values. Corrector value = frequency of topic rated above 7 (identified as cut-off). Corrector values transform survey data to integrate iDLD/iDLDPC data. Ratings above cut-off are in bold-italic. Blank spaces indicate topics not discussed or rated by iDLD/iDLDPC. Research topic Survey score Topic Corrector Values Final score Specific characteristics of evidence-based DLD interventions which facilitate progress towards the goals of an individual with DLD 462 Intervention 486 24 Effective tools to assist accurate diagnosis of DLD in early years children with significant SLCN 418 Assessment/diagnosis 434 16 Implementation of SLT recommendations in the classroom by teaching staff: confidence levels, capacity, capability and levels of success 441 Working with others 454 13 Effective ways of teaching self-help strategies to children with DLD 414 Intervention 438 24 Effective interventions for improving receptive language in terms of intervention characteristics and mode of delivery 434 Intervention 458 24 Impact of including speech, language and communication needs (SLCN)/ developmental language disorder (DLD) in teacher training course curriculums on referral rates and level of support for children with DLD 409 Working with others Identification 448 13 26 Effectiveness of a face-to-face versus indirect approach to intervention for individuals with DLD 417 Provision- primary Provision- secondary Provision- adult 470 23 15 15 Outcomes for individuals with DLD across settings (e.g. language provision, mainstream school), in relation to curriculum access, language development and social skills 415 Lifelong impact Provision- primary Provision- secondary 477 24 23 15 Impact of SLT interventions for adolescents and adults with DLD, on wider functional outcomes (e.g. quality of life, access to the curriculum, social inclusion and mental health) 392 Lifelong impact Intervention 440 24 24 Impact of targeted vocabulary interventions for individuals with DLD on curriculum access 410 Intervention 434 24 Table 2: Top ten research topics from survey with unadjusted scores, with application of corrector values and adjusted scores. Each defined research area is assigned to one or more topic, and adjusted proportionately. The final column indicates final score which is used to identify top ten highest scoring research priorities Rank Unadjusted top ten research priorities (Correctors  not applied, survey data only) Adjusted top ten research priorities (Corrector values applied) 1 Specific characteristics of evidence-based DLD interventions which facilitate progress towards the goals of an individual with DLD  Outcomes for individuals with DLD across settings (e.g. language provision, mainstream school), in relation to curriculum access, language development and social skills  2 Effective tools to assist accurate diagnosis of DLD in early years children with significant SLCN* Specific characteristics of evidence-based DLD interventions which facilitate progress towards the goals of an individual with DLD 3 Implementation of SLT recommendations in the classroom by teaching staff: confidence levels, capacity, capability and levels of success  Effectiveness of a face-to-face versus indirect approach to intervention for individuals with DLD 4 Effective ways of teaching self-help strategies to children with DLD Effective interventions for improving receptive language in terms of intervention characteristics and mode of delivery  5 Effective interventions for improving receptive language in terms of intervention characteristics and mode of delivery (402) Impact of including speech, language and communication needs (SLCN)/ developmental language disorder (DLD) in teacher training course curriculums on referral rates and level of support for children with DLD  6 Impact of including speech, language and communication needs (SLCN)/ developmental language disorder (DLD) in teacher training course curriculums on referral rates and level of support for children with DLD  Impact of SLT interventions for adolescents and adults with DLD, on wider functional outcomes (e.g. quality of life, access to the curriculum, social inclusion and mental health)* 7 Effectiveness of a face-to-face versus indirect approach to intervention for individuals with DLD Implementation of SLT recommendations in the classroom by teaching staff: confidence levels, capacity, capability and levels of success  8 Outcomes for individuals with DLD across settings (e.g. language provision, mainstream school), in relation to curriculum access, language development and social skills Effective ways of teaching self-help strategies to children with DLD 9 Impact of SLT interventions for adolescents and adults with DLD, on wider functional outcomes (e.g. quality of life, access to the curriculum, social inclusion and mental health) Impact of targeted vocabulary interventions for individuals with DLD on curriculum access 10 Impact of targeted vocabulary interventions for individuals with DLD on curriculum access Impact of teacher training (on specific strategies/ language support) on academic attainment in adolescents with DLD in secondary schools Table 3: Unadjusted and adjusted top ten research priorities lists. Table to show the top ten research priorities without adjustment (left column) and with adjustment (right column). * depict defined research areas which are not represented in the top ten of the other columns (i.e., where priorities were different).

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Primidone is used alone or with other anticonvulsants in the control of grand mal, psychomotor, and focal epileptic seizures. It may control grand mal seizures refractory to other anticonvulsant therapy. Primidone was nominated by the National Cancer Institute for 2-year toxicology and carcinogenicity studies due to its human use as an anticonvulsant. Male and female F344/N rats and B6C3F1 mice received primidone (greater than 99% pure) in feed for 14 days, 14 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and mouse bone marrow cells. 14-DAY STUDY IN RATS: Five male and five female rats were exposed to 0, 1,250, 2,500, 5,000, 10,000 or 20,000 ppm primidone (equivalent to average daily doses of approximately 120, 240, 500, 970, or 1,100 mg primidone/kg body weight to males and 120, 240, 500, or 900 mg/kg to females) in feed for 14 days. All 20,000 ppm females died before the end of the study as did one 10,000 ppm male and two 20,000 ppm males. The mean body weights of 10,000 ppm males and females and 20,000 ppm males were significantly less than those of the controls. Feed consumption by all exposed rats was generally similar to that by the controls. Males and females in the 10,000 and 20,000 ppm groups were observed to have eye discharge, ataxia, and abnormal posture and were thin and lethargic. 14-DAY STUDY IN MICE: Five male and five female mice were exposed to 0, 625, 1,250, 2,500, 5,000 or 10,000 ppm primidone (equivalent to average daily doses of approximately 100, 200, 400, or 800 mg/kg body weight to males and 100, 250, 500, or 900 mg/kg to females) in feed for 14 days. All mice in the 10,000 ppm groups and one male and one female mouse in the 5,000 ppm groups died on day 3 of the study. The mean body weights of mice in the 625, 1,250, 2,500, and 5,000 ppm groups were similar to those of the controls. Feed consumption by all exposed mice was generally similar to that by the controls. Males and females in the 10,000 ppm groups were observed to have abnormal posture, ataxia, and lethargy. 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were exposed to 0, 300, 600, 1,300, 2,500, or 5,000 ppm primidone (equivalent to average daily doses of approximately 20, 40, 100, 200, or 400 mg/kg) in feed for 14 weeks. All rats survived to the end of the study. The mean body weights of male and female rats in the 2,500 and 5,000 ppm groups were significantly less than those of the controls. Feed consumption by all exposed rats was generally similar to that by the controls. A minimal to mild exposure-related thrombocytosis occurred on day 22 and at week 14 in all exposed groups of male rats and in females in the 1,300 ppm or greater groups. A minimal decrease in hemoglobin concentration occurred in 2,500 and 5,000 ppm male and female rats on day 22 and at week 14. The incidences of centrilobular hepatocyte hypertrophy in male rats exposed to 600 ppm or greater and in female rats exposed to 1,300 ppm or greater were significantly greater than those in the controls. The severity of chronic nephropathy in male rats exposed to 1,300 ppm or greater increased with increasing exposure concentration. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were exposed to 0, 300, 600, 1,300, 2,500, or 5,000 ppm primidone (equivalent to average daily doses of approximately 50, 100, 200, 400, or 1,000 mg/kg to males and 60, 120, 220, 440, or 1,100 mg/kg to females) in feed for 14 weeks. Three male and two female mice in the 5,000 ppm group died during week 1 of the study. The final mean body weights of all exposed groups were similar to those of the controls. Feed consumption by male mice in the 5,000 ppm group was slightly greater than that by the controls; this may have been due to feed spillage. Male and female mice in the 5,000 ppm groups were ataxic and lethargic. Compared to controls, the estrous cycle lengths of females exposed to 1,300, 2,500, or 5,000 ppm were significantly longer. The liver weights of male and female mice exposed to 600 po 600 ppm or greater were significantly greater than those of the controls. The incidences of centrilobular hepatocyte hypertrophy in all exposed males and in females exposed to 600 ppm or greater and the incidences of cytoplasmic alteration of the adrenal gland and hematopoietic cell proliferation of the spleen in 2,500 and 5,000 ppm males and in 5,000 ppm females were significantly greater than in the controls. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female F344/N rats were exposed to 0, 600, 1,300, or 2,500 ppm primidone (equivalent to average daily doses of approximately 25, 50, or 100 mg/kg) in feed for 2 years. Survival, Body Weights, and Feed Consumption Survival of the 1,300 and 2,500 ppm males was sig nificantly less than that of the controls. The mean body weights of males and females in the 2,500 ppm groups were less than those of the controls, beginning at week 29 for males and week 17 for females; the mean body weights of 1,300 ppm males and females were less than those of the controls during the second year of the study. Feed consumption by all exposed groups of rats was generally similar to that by the controls. Pathology Findings Male rats exposed to primidone had increased inci dences of thyroid gland follicular cell neoplasms (adenoma and/or carcinoma). All exposed groups of male rats had follicular cell adenomas or carcinomas (combined) at incidences above the historical control range, with the highest incidence in the 1,300 ppm group. Hepatocyte cytoplasmic vacuolation and centrilobular hypertrophy were associated with primidone exposure in male and female rats. These changes were more severe in females than in males and the incidences in all exposed groups of females were significantly greater than those in the controls. Females in the 2,500 ppm group had an increased incidence of hepatocellular eosinophilic foci. In 2,500 ppm males, the incidence of renal tubule hyperplasia was greater than that in the controls in the standard evaluation. Additional hyperplasias were found in the extended evaluation, and the incidences in exposed groups of males were significantly greater than that in the controls. In the extended evaluation, the incidence of renal tubule adenoma in 2,500 ppm males was significantly increased. The incidence of adenoma or carcinoma (combined) in 2,500 ppm males in the combined standard and extended evaluations were marginally increased over those in the controls. Male rats had an exposure-related increase in the severity of chronic nephropathy, which probably accounted for the reduced survival in the 1,300 and 2,500 ppm groups. The incidences of kidney cysts were increased in 1,300 and 2,500 ppm males. Hyperparathyroidism, secondary to the loss of renal function, was present in many exposed male rats. The incidences of parathyroid gland hyperplasia in all groups of exposed males were significantly greater than that in the controls. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice were exposed to dietary levels of 0, 300, 600, or 1,300 ppm primidone (equivalent to average daily doses of approximately 30, 65, or 150 mg/kg to males and 25, 50, or 100 mg/kg to females) in feed for 2 years. Survival, Body Weights, Feed Consumption, and Clinical Findings Survival of the 1,300 ppm males was significantly less than that of the controls. During the second year of the study, the mean body weights of 1,300 ppm male and female mice were less than those of the controls. The final mean body weights of 600 ppm males and females were less than those of the controls. Feed consumption by all exposed groups of mice was similar to that by the controls. During the latter part of the study, a treatment-related increase in the number of animals with swelling of the abdominal area was observed; necropsy revealed that the swelling was due to liver nodules/masses. Pathology Findings The liver was a target organ in both male and female mice. The incidences and multiplicities of hepatocellular neoplasms (hepatocellular adenoma, hepatocellular carcinoma, and hepatoblastoma) in all exposed groups of males and females (except hepatoblastoma in females) were significantly greater than those in the controls. The incidences of hepatocellular adenoma or carcinoma (combined) and hepatocellular adenoma, hepatocellular carcinoma, or hepatoblastoma (combined) in all exposed groups exceeded the historical control ranges in 2-year NTP studies. The incidences of centrilobular hepatocyte hypertrophy were increased in exposed groups of males and females, and the severities increased with increasing exposure concentration. The incidences of cytoplasmic vacuolization were increased in all exposed groups of females and in 300 ppm males. Incidences of eosinophilic focus in all exposed groups of females were significantly greater than those in the controls. Proliferative changes occurred in the thyroid gland in an exposure-related manner in male and female mice. Incidences of follicular cell hyperplasia were increased in all exposed groups of males and in 600 and 1,300 ppm females, but incidences of follicular cell adenomas were increased only in male mice. GENETIC TOXICOLOGY: Primidone was mutagenic in Salmonella typhimurium strain TA1535 in the absence of S9 activation only; no mutagenicity was detected in strain TA98, TA100, or TA1537, with or without S9. Primidone did not induce sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells, with or without S9. The single in vivo study with primidone, a mouse bone marrow micronucleus test, also gave negative results. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was equivocal evidence of carcinogenic activity of primidone in male F344/N rats based on a marginal increase in thyroid gland follicular cell neoplasms, primarily adenomas, and a marginal increase in renal tubule neoplasms. There was no evidence of carcinogenic activity of primidone in female F344/N rats exposed to 600, 1,300, or 2,500 ppm. There was clear evidence of carcinogenic activity of primidone in male B6C3F1 mice based on the increased incidences of hepatocellular neoplasms, and the increased incidence of thyroid gland follicular cell adenomas was also considered to be chemical related. There was clear evidence of carcinogenic activity of primidone in female B6C3F1 mice based on the increased incidences of hepatocellular neoplasms. Exposure of rats to primidone resulted in increased incidences of hepatocyte cytoplasmic vacuolization and centrilobular hypertrophy in males and females and eosinophilic foci in females. The increased severity of nephropathy and increased incidence of renal tubule hyperplasia in male rats were related to primidone exposure. Exposure of male mice to primidone resulted in hepatocyte centrilobular hypertrophy and thyroid gland follicular cell hyperplasia. Exposure of female mice to primidone resulted in hepatocyte centrilobular hypertrophy and cytoplasmic vacuolization, eosinophilic focus, and thyroid gland follicular cell hyperplasia. Synonyms: 5-Aethyl-5-phenyl-hexahydropyrimidin-4,6-dion; 2-deoxyphenobarbital; 2-desoxyphenobarbital; desoxyphenobarbitone; 5-ethyldihydro-5-phenyl-4,6 (1H,5H)-pyrimidinedione; 5-ethylhexahydro-4,6-dioxo-5-phenylphrimidine; 5-ethylhexahydro-5-phenylpyrimidine-4,6-dione; 5-ethyl-5-phenylhexahydropyrimidine-4,6-dione Trade names: Cyral; Hexadiona; Hexamidine; Lepimidin; Lepsiral; Majsolin; Midone; Milepsin; Misodine; Misolyne; Mizodin; Mizolin; Mylepsin; Mylepsinum; Mysedon; Mysoline; Prilepsin; Primacione; Primaclone; Primacone; Primakton; Primadon; Prysoline; Pyrimidone; ROE 101; Sertan

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Emodin is a naturally occurring anthraquinone present in the roots and bark of numerous plants of the genus Rhamnus. Extracts from the roots, bark, and/or dried leaves of buckthorn, senna, cascara, aloe, frangula, and rhubarb have been used as laxatives since ancient times and currently are widely used in the preparation of herbal laxative preparations. Anthraquinone glycosides are poorly absorbed from the gastrointestinal tract but are cleaved by gut bacteria to produce aglycones (such as emodin) that are more readily absorbed and are responsible for the purgative properties of these preparations. There is extensive exposure to emodin and other anthraquinones resulting from the use of herb-based stimulant laxatives. Reports that 1,8-dihydroxyanthraquinone, a commonly used laxative ingredient, caused tumors in the gastrointestinal tract of rats raised the possibility of an association between colorectal cancer and the use of laxatives containing anthraquinones. Because emodin is a hydroxyanthraquinone structurally similar to 1,8-dihydroxyanthraquinone, is present in herbal laxatives, and was reported to be mutagenic in bacteria, it was considered a potential carcinogen and was selected for in-depth evaluation. Male and female F344/N rats and B6C3F1 mice were exposed to emodin (at least 94% pure) in feed for 16 days, 14 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, rat and mouse bone marrow cells, and mouse peripheral blood erythrocytes. 16-DAY STUDY IN RATS: Groups of five male and five female rats were fed diets containing 0, 600, 2,000, 5,500, 17,000, or 50,000 ppm emodin (equivalent to average daily doses of approximately 50, 170, 480, 1,400, or 3,700 mg emodin/kg body weight to males and 50, 160, 460, 1,250, or 2,000 mg/kg to females) for 15 (males) or 16 (females) days. Three female rats died before the end of the study. Mean body weights of males and females exposed to 5,500 ppm or greater were significantly less than those of the controls. Feed consumption by males and females receiving 17,000 or 50,000 ppm was decreased throughout the study. Macroscopic lesions were present in the kidney of rats exposed to 17,000 or 50,000 ppm. 16-DAY STUDY IN MICE: Groups of five male and five female mice were fed diets containing 0, 600, 2,000, 5,500, 17,000, or 50,000 ppm emodin (equivalent to average daily doses of approximately 120, 400, 1,200, or 3,800 mg/kg to males and 140, 530, 1,600, or 5,000 mg/kg to females; 50,000 ppm equivalents were not calculated due to high mortality) for 15 (males) or 16 (females) days. All mice exposed to 50,000 ppm died before the end of the study. Mice in the 17,000 ppm groups lost weight during the study. Feed consumption by 5,500 ppm females was greater than that by the controls throughout the study. Macroscopic lesions were present in the gallbladder and kidney of mice exposed to 17,000 ppm. 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were fed diets containing 0, 312.5, 625, 1,250, 2,500, or 5,000 ppm emodin (equivalent to average daily doses of approximately 20, 40, 80, 170, or 300 mg/kg to males and females) for 14 weeks. Mean body weights of males exposed to 2,500 ppm or greater and females exposed to 1,250 ppm or greater were significantly less than those of the controls. During the first week of the study, feed consumption by males exposed to 2,500 or 5,000 ppm and females exposed to 5,000 ppm was less than that by the controls. Feed consumption by these groups was similar to that by the controls for the remainder of the study. In rats exposed to 2,500 or 5,000 ppm, there were increases in platelet counts in males and females and segmented neutrophil counts in females. Total serum protein and albumin concentrations were decreased in females exposed to 2,500 or 5,000 ppm. Relative kidney weights of rats exposed to 1,250 ppm or greater and relative lung weights of rats exposed to 625 ppm or greater were significantly increased compared to the control groups. Relative liver weights were incree increased in females exposed to 625 ppm or greater. The estrous cycle length wassignificantly increased in females exposed to 1,250 or 5,000 ppm. All male rats exposed to 1,250 ppm or greater and all exposed female rats had pigment in the renal tubules; and the severity of pigmentation generally increased with increasing exposure concentration. The incidences of hyaline droplets in the cortical epithelial cytoplasm were increased in all groups of exposed males and in females exposed to 312.5, 625, or 1,250 ppm. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were fed diets containing 0, 312.5, 625, 1,250, 2,500, or 5,000 ppm emodin (equivalent to average daily doses of approxi mately 50, 100, 190, 400, or 800 mg/kg to males and 60, 130, 240, 500, or 1,100 mg/kg to females) for 14 weeks. All mice survived to the end of the study. Mean body weights of males exposed to 2,500 or 5,000 ppm were significantly less than those of the controls. Feed consumption by exposed groups was generally similar to that by the controls. Relative kidney weights of male mice exposed to 1,250 ppm or greater, relative lung weights of males exposed to 625 ppm or greater, and relative liver weights of female mice exposed to 625 ppm or greater were increased. The incidences and severities of nephropathy were increased in males and females exposed to 1,250 ppm or greater. The incidences of renal tubule pigmentation were significantly increased in males exposed to 625 ppm or greater and in females exposed to 1,250 ppm or greater. 2-YEAR STUDY IN RATS: Groups of 65 male and 65 female rats were fed diets containing 0, 280, 830, or 2,500 ppm emodin (equivalent to average daily doses of approximately 110, 320, or 1,000 mg/kg to males and 120, 370, or 1,100 mg/kg to females) for 105 weeks. Ten male and ten female rats from each group were necropsied at 6 months. Blood samples from five male and five female rats in each group were evaluated at 3, 6, and 12 months for plasma emodin concentrations; these rats were necropsied at 12 months. Survival, Body Weights, and Feed Consumption: Survival of exposed males and females was similar to that of the controls. The mean body weights of rats in the 2,500 ppm groups were less than those of the controls beginning at week 2 of the study. Feed consumption by exposed groups was similar to that by the controls throughout the study. Pathology Findings: Three Zymbal's gland carcinomas were observed in female rats exposed to 2,500 ppm. This incidence exceeded the range observed for current historical controls and was considered an equivocal finding. At the 6- and 12-month interim evaluations and at 2 years, emodin-related increases in the incidences of renal tubule hyaline droplets occurred in all exposed groups. The incidences of renal tubule pigmentation were significantly increased in all exposed groups of males at 2 years. There were negative trends in the incidences of mononuclear cell leukemia in male and female rats, and the incidences in the 2,500 ppm groups were significantly decreased. In females exposed to 2,500 ppm, the incidence was below the historical control range; the incidence in males exposed to 2,500 ppm was at the lower end of the historical control range. 2-YEAR STUDY IN MICE: Groups of 60 male mice were fed diets containing 0, 160, 312, or 625 ppm emodin (equivalent to average daily doses of approximately 15, 35, or 70 mg/kg) for 105 weeks. Groups of 60 female mice were fed diets containing 0, 312, 625, or 1,250 ppm emodin (equivalent to average daily doses of approximately 30, 60, or 120 mg/kg) for 105 weeks. Ten male and ten female mice from each group were necropsied at 12 months. Survival, Body Weights, and Feed Consumption Survival and mean body weights of exposed males and females were similar to those of the controls. No differences in feed consumption were noted between exposed and control groups. Pathology Findings: Low incidences of renal tubule adenoma and carcinoma occurred in exposed male mice; these incidences included one carcinoma each in the 312 and 625 ppm groups. Renal tubule neoplasms are rare in male mice, and their presence in these groups suggested a possible association with emodin exposure. At the 12-month interim evaluation, the severity of nephropathy was slightly increased in males exposed to 625 ppm. Also at 12 months, the severity of nephropathy increased from minimal in the lower exposure groups to mild in females exposed to 1,250 ppm; the incidence in this group was significantly increased compared to the control group. At 2 years, the severities of nephropathy were slightly increased in males exposed to 625 ppm and females exposed to 1,250 ppm. The incidences of nephropathy were significantly increased in all exposed groups of females. At the 12-month interim evaluation, the incidences of renal tubule pigmentation were significantly increased in all exposed groups of males and in females exposed to 625 or 1,250 ppm. The severities increased with increasing exposure concentration. At 2 years, the incidences of renal tubule pigmentation were significantly increased in all exposed groups; severities increased with increasing exposure concentration. GENETIC TOXICOLOGY: Emodin was mutagenic in Salmonella typhimurium strain TA100 in the presence of S9 activation; no mutagenicity was detected in strain TA98, with or without S9. Chromosomal aberrations were induced in cultured Chinese hamster ovary cells treated with emodin, with and without S9. Three separate in vivo micronucleus tests were performed with emodin. A male rat bone marrow micronucleus test, with emodin administered by three intraperitoneal injections, gave negative results. Results of acute-exposure (intraperitoneal injection) micronucleus tests in bone marrow and peripheral blood erythrocytes of male and female mice were negative. In a peripheral blood micronucleus test on mice from the 14-week study, negative results were seen in male mice, but a weakly positive response was observed in similarly exposed females. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of emodin in male F344/N rats exposed to 280, 830, or 2,500 ppm. There was equivocal evidence of carcinogenic activity of emodin in female F344/N rats based on a marginal increase in the incidence of Zymbal's gland carcinoma. There was equivocal evidence of carcinogenic activity of emodin in male B6C3F1 mice based on a low incidence of uncommon renal tubule neoplasms. There was no evidence of carcinogenic activity of emodin in female B6C3F1 mice exposed to 312, 625, or 1,250 ppm. Exposure of rats to emodin resulted in increased incidences of renal tubule hyaline droplets and pigmentation in males, increased incidences of renal tubule hyaline droplets in females, and increased severities of renal tubule pigmentation in males and females. Emodin exposure resulted in increased incidences of renal tubule pigmentation in male and female mice and increased incidences of nephropathy in female mice. Incidences of mononuclear cell leukemia decreased in male and female rats exposed to 2,500 ppm. Synonyms: Archin; C.I. 75440; C.I. Natural Green 2; C.I. Natural Yellow 14; emodol; frangulic acid; frangula emodin; 6-methyl- 1,3,8-trihydroxyanthraquinone; Persian Berry Lake; rheum emodin; schuttgelb; 1,3,8-trihydroxy-6-methyl-9,10- anthracenedione; 1,3,8-trihydroxy-6-methylanthraquinone; 4,5,7-trihydroxy-2-methylanthraquinone.

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Methyleugenol is used as a flavoring agent in jellies, baked goods, nonalcoholic beverages, chewing gum, candy, pudding, relish, and ice cream. It is also used as a fragrance in perfumes, creams, lotions, detergents, and soaps. Methyleugenol has also been used as an insect attractant in eradication programs and as an anesthetic in rodents. Methyleugenol was nominated for testing because of its widespread use and because of its structural resemblance to safrole, a known carcinogen, and isosafrole and estragole. Male and female F344/N rats and B6C3F1 mice received methyleugenol (approximately 99% pure) in 0.5% methylcellulose by gavage for 14 weeks or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and mouse peripheral blood erythrocytes. 14-WEEK STUDY IN RATS: Groups of 9 or 10 male and 10 female F344/N rats were administered 0, 10, 30, 100, 300, or 1,000 mg methyleugenol/kg body weight in 0.5% methylcellulose by gavage 5 days per week for 14 weeks. A water control group of 10 male and 10 female rats received deionized water by gavage. All rats survived until the end of the study. The final mean body weights of 300 and 1,000 mg/kg males and of all dosed groups of females were significantly less than those of the vehicle controls. Erythrocyte microcytosis was demonstrated by decreased mean cell volumes in 300 mg/kg males and 1,000 mg/kg males and females. There was evidence of a thrombocytosis at all time points, demonstrated by increased platelet counts in the 100 mg/kg or greater groups. The serum activities of alanine aminotransferase and sorbitol dehydrogenase were increased in the 100 mg/kg or greater rats at various time points, suggesting hepatocellular injury. Additionally, bile acid concentrations were generally increased in the 300 and 1,000 mg/kg groups at all time points, consistent with cholestasis or altered hepatic function. A hypoproteinemia and hypoalbuminemia, evidenced by decreased total protein and albumin concentrations, occurred in rats in the 300 and 1,000 mg/kg groups at all time points. Liver weights of 100, 300, and 1,000 mg/kg males and 300 and 1,000 mg/kg females and testis weights of 1,000 mg/kg males were significantly increased. Increased incidences of liver lesions occurred in 300 and 1,000 mg/kg males and females and hepatocellular adenoma occurred in one 1,000 mg/kg male. The incidences of atrophy and chronic inflammation of the mucosa of the glandular stomach were significantly increased in rats administered 300 or 1,000 mg/kg. Increased incidences of adrenal gland cortical hypertrophy and/or cytoplasmic alteration in the submandibular gland occurred in the 100 mg/kg or greater groups. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice received methyleugenol in 0.5% methylcellulose by gavage at doses of 0, 10, 30, 100, 300, or 1,000 mg/kg, 5 days per week for 14 weeks. A water control group of 10 male and 10 female mice received deionized water by gavage. All but one male and all females receiving 1,000 mg/kg died before the end of the study. The mean body weight gains of mice in the 300 mg/kg groups were significantly less than those of the vehicle controls. The only clinical finding was toxicity manifested as generalized morbidity in mice administered 1,000 mg/kg. Liver weights of 30, 100, and 300 mg/kg males and of 300 mg/kg females were significantly increased. Male mice administered 10 or 30 mg/kg had significantly lower cauda epididymis, epididymis, and testis weights; males receiving 100 mg/kg had significantly lower spermatozoal concentrations. Increased incidences of liver lesions occurred in 1,000 mg/kg males and 300 and 1,000 mg/kg females. The incidences of lesions of the glandular stomach were increased in one or more groups administered 30 mg/kg or greater. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female rats received methyleugenol in 0.5% methylcellulose by gavage at doses of 37, 75, or 150 mg/kg, 5 days per week for 105 weeks; groups of 60 male and 60 female rats received the 0.5% me60 female rats received the 0.5&amp;percnt; methylcellulose vehicle only. Stop-exposure groups of 60 male and 60 female rats received 300 mg/kg in 0.5&amp;percnt; methylcellulose by gavage for 52 weeks followed by just the 0.5&amp;percnt; methylcellulose vehicle for the remaining 53 weeks of the study. Special study groups of 10 male and 10 female rats administered 36, 75, 150, or 300 mg/kg were designated for toxicokinetic studies. Survival and Body Weights: All 150 and 300 mg/kg males died before the end of the study, and survival of 150 mg/kg females was slightly less than that of the vehicle controls. Mean body weights of all dosed groups of rats were less than those of the vehicle controls throughout most of the 2-year study. Pathology Findings: Chemical-related liver neoplasms occurred in all dosed groups of rats and included hepatocellular adenoma, hepatocellular carcinoma, hepatocholangioma, and hepatocholangiocarcinoma; at 2 years, there were positive trends in the incidences of hepatocellular adenoma, carcinoma, and adenoma or carcinoma (combined) in core study rats and in the numbers of rats with multiple liver neoplasms. Nonneoplastic lesions included eosinophilic and mixed cell foci, hepatocellular hypertrophy, oval cell hyperplasia, cystic degeneration, and bile duct hyperplasia (females); the incidences of these lesions in dosed groups of male and female rats were increased at 6 months, 12 months, and/or 2 years. Chemical-related neoplasms and nonneoplastic lesions of the glandular stomach included benign and malignant neuroendocrine tumors in the 150 and 300 mg/kg groups and females in the 75 mg/kg group. In all dosed groups of rats at all time points, the incidences of mucosal atrophy were significantly greater than in the vehicle controls. Neuroendocrine cell hyperplasia was observed in females at 6 months and males and females at 12 months and at 2 years. In core study female rats, there was a positive trend in the incidences of squamous cell papilloma or carcinoma (combined) of the forestomach, and the incidence in the 150 mg/kg group exceeded the historical control range. The incidences of renal tubule proliferative lesions in male rats were suggestive of a neoplastic effect in the kidney. Therefore, additional step sections of the kidneys of male rats were prepared. The incidences of renal tubule hyperplasia and adenoma in the extended evaluation and the combined incidences of standard and step sections in the 75, 150, and 300 mg/kg groups were greater than those in the vehicle controls. The incidences of nephropathy were increased in all dosed groups of females, and the increase was significant in the 300 mg/kg group. In dosed groups of male rats, there was a positive trend in the incidences of malignant mesothelioma, and the incidences were significantly greater in 150 and 300 mg/kg males than in the vehicle controls. The incidences of mammary gland fibroadenoma in 75 and 150 mg/kg males were significantly increased. The incidences of fibroma of the subcutaneous tissue in 37 and 75 mg/kg males and the combined incidences of fibroma or fibrosarcoma in 37, 75, and 150 mg/kg males were significantly increased. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice received methyleugenol in 0.5&amp;percnt; methylcellulose by gavage at doses of 0, 37, 75, or 150 mg/kg for 105 weeks. Special study groups of 10 male and 10 female mice administered 37, 75, or 150 mg/kg were designated for toxicokinetic studies. Survival and Body Weights: Survival of all dosed groups of male mice was similar to that of the vehicle controls. Survival of dosed groups of females was significantly less. Mean body weights of dosed mice were generally less than those of the vehicle controls throughout the studies. Pathology Findings: Chemical-related increases in the incidences of liver neoplasms and nonneoplastic lesions in mice included hepatocellular adenoma and carcinoma, hepatoblastoma, hepatocholangiocarcinoma, eosinophilic foci, oval cell hyperplasia, bile duct hyperplasia, hemosiderin pigmentation, chronic active inflammation, and hematopoietic cell proliferation. In all dosed groups ofmales and females, the incidences of hepatocellular neoplasms and the multiplicity of neoplasms were generally greater than in the vehicle controls. The incidences of hepatoblastoma were significantly increased in all dosed groups of females and slightly increased in 150 mg/kg males. Hepatocholangiocarcinoma was observed in 150 mg/kg females. The incidences of eosinophilic foci, oval cell hyperplasia, portal hypertrophy, hepatocyte necrosis, hematopoietic cell proliferation, bile duct hyperplasia, and hemosiderin pigmentation were significantly increased in two or more dosed groups of male and/or female mice. The incidences of glandular ectasia, mucosal atrophy, chronic active inflammation, epithelial hyperplasia, and neuroendocrine cell hyperplasia of the glandular stomach were increased in one or more dosed groups of male and female mice. In addition, malignant neuroendocrine tumors were observed in the glandular stomach of two 150 mg/kg male mice; one male in this group had a carcinoma. TOXICOKINETIC STUDIES: Methyleugenol is rapidly absorbed following oral administration to rats and mice. The kinetic data are consistent with rapid clearance from the blood, metabolism in the liver, and excretion of the parent and various metabolites in the urine. GENETIC TOXICOLOGY: Methyleugenol was not mutagenic in S. typhimurium strain TA98, TA100, TA1535, or TA1537, with or without exogenous metabolic activation (S9). In cytogenetic tests with cultured Chinese hamster ovary cells, methyleugenol induced sister chromatid exchanges in the presence of S9, but no induction of chromosomal aberrations was noted in cultured Chinese hamster ovary cells following exposure to methyleugenol, with or without S9. In vivo, no increase in the frequency of micronucleated normochromatic erythrocytes was seen in male or female mice administered methyleugenol by gavage for 14 weeks. PHYSIOLOGICALLY BASED PHARMACOKINETIC MODEL: A physiologically based pharmacokinetic (PBPK) model resulting from intravenous and oral exposure was created to characterize tissue concentrations of methyleugenol in rats and mice. Data used to create the model were obtained from the literature or from current studies. The primary conclusions that can be reached from the PBPK model are: 1) absorption of oral doses of methyleugenol in rats and mice is rapid and complete, 2) distribution of methyleugenol to tissues is not hampered by capillary permeability, and 3) metabolism of methyleugenol is saturable and must have some extrahepatic component in the mouse. Model-based plasma methyleugenol concentrations were not found to be good dosimeters for evaluating neoplasm dose-response data. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was clear evidence of carcinogenic activity of methyleugenol in male and female F344/N rats based on the increased incidences of liver neoplasms and neuroendocrine tumors of the glandular stomach in male and female rats and the increased incidences of kidney neoplasms, malignant mesothelioma, mammary gland fibroadenoma, and subcutaneous fibroma and fibroma or fibrosarcoma (combined) in male rats. A marginal increase in the incidence of squamous cell neoplasms of the forestomach may have been related to methyleugenol administration in female rats. There was clear evidence of carcinogenic activity of methyleugenol in male and female B6C3F1 mice based on the increased incidences of liver neoplasms. Neuroendocrine tumors of the glandular stomach in male mice were also considered related to methyleugenol administration. In male and female rats and mice, methyleugenol administration caused significant increases in nonneoplastic lesions of the liver and glandular stomach. Synonyms: 1-Allyl-1,2-dimethoxybenzene; 4-allylveratrole; 4-allyl-1,2-dimethoxy-benzene; 1,2-dimethoxy-4-allylbenzene; 3,4-dimethoxyallylbenzene; ENT 21040; 1-(3,4-dimethoxyphenyl)-2-propene; eugenol methyl ether; 1,3,4-eugenol methyl ether; veratrole methyl ether.

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Hypothesis The hypotheses of all the four included studies share the common idea that it is possible to augment the effect of antidepressant drug treatment by applying different interventions and with each intervention attain a clinically meaningful better effect compared to a control condition, and with minor side effects, thus improving the short- and medium-term outcome in major depression. Procedures Study design The basic study design has been the double blind randomised controlled trial (RCT). In the light therapy study, all patients were treated with sertraline for the whole of the study duration. In the first five weeks of the study, patients were randomised to treatment with either 60 minutes of bright white or 30 minutes of dim red light (sham condition). In the four weeks follow-up period, patients were treated with sertraline alone. In the Pindolol study, all patients were treated with venlafaxine and randomised to augmentation with either active or placebo matching pindolol tablets. In the PEMF study patients were continued on ongoing medication and randomised to augmentation with active or inactive (sham) 30 minutes daily PEMF treatment on weekdays. In the Chronos study all patients were treated with duloxetine and randomized to either a combination of three wake therapies with daily bright light treatment and sleep time stabilisation (wake group) or to daily exercise of minimum 30 minutes as an active control intervention (exercise group). The Chronos study was divided into: (1) a one-week run-in phase where duloxetine were started (and continued for the whole 29 week study period), (2) a one-week inpatient intervention phase where patient in the wake group did three wake therapies (sleep abstinence for the whole night and the following day until evening) in combination with daily light therapy and guidance on sleep time stabilisation and patients in the exercise group started a daily exercise program, (3) a seven week continuation phase where patient in the wake group continued light therapy and sleep time stabilisation and patients in the exercise group continued an individual exercise program, and (4) a 20 week follow-up phase with the same treatment elements but where duloxetine dosage could be adjusted or changed to other antidepressants. Recruitment Patients recruited for these studies were allocated from general practitioners, psychiatric specialist practices and for the lesser part from open psychiatric wards. Only a few patients were re-cruited through advertisements (in the PEMF and Chronos studies).   Inclusion criteria Inclusion criteria were major depression according to the DSM-IV, including a depressive episode as part of a bipolar disorder. For the PEMF study, treatment resistance was a specific inclusion criterion. Duration of studies Study duration was nine weeks for the light therapy study, 19 days for the Pindolol study, five weeks for the PEMF study, and 29 weeks for the Chronos study. Assessments In all studies, assessments were done with clinician rated scales, patient self-assessment scales, including quality of life scales and a side effect scale. As clinician rated scales we used the Hamilton depression rating scale: the HAM-D17 and its 6 item subscale: the HAM-D6, the Bech Rafaelsen Melancholia scale (MES), and the Bech Rafaelsen Mania scale (MAS). As self-assessment scales we used the Major Depression Inventory (MDI), the Symptom Check-list (SCL-92), and the Preskorn scale. For side effects we used the UKU scale. Further scales used are mentioned in the specific study sections. Assessments in the light therapy study were done weekly for the first six weeks and finally after nine weeks; at four time points in the Pindolol study (baseline, days 6, 11 and 19), weekly for five weeks in the PEMF study and weekly for the first nine weeks of the Chronos study and thereafter every four weeks. The clinical setting for evaluation has been the Psychiatric Research Unit at Mental Health Centre North Zealand. For the Bright Light study, Pindolol and PEMF study patients were also seen at a psychiatric specialist practice in Copenhagen. Biochemical measures In the Light therapy study saliva cortisol was collected at baseline before start of light therapy and sertraline and blood was drawn for thyroid analysis. In the Chronos study saliva and 24 hour urine cortisol was collected in the patients randomised to the exercise group. Main results The main results from the Bright Light study covering the first five weeks of the study are given in the PhD thesis "Adjunctive bright light in nonseasonal major depression" defended and awarded on the 18 November 2004 at the University of Copenhagen. Results from the cortisol measurement and for the four weeks extension period were published in separate papers after the PhD thesis and are included in this thesis. Results from the Bright Light study Analysis of the saliva cortisol measurements taken at baseline of the study as cortisol awakening profiles (CAR) showed that patients responded differentially to light treatment according to their CAR levels (dichotomized to high or low about the mean). Thus, in the bright light group HAM-D17 scores were reduced by 15.7 (4.2) points for patients with a low CAR (below mean), and 11.4 (4.8) points for patients with a high CAR (above mean). In the dim light group the corresponding values were 11.1 (5.2) for patients with a low CAR and 11.3 (5.3) for patients with a high CAR. This interaction between CAR and treatment group was statistically significant (p = 0.006). Survival analysis, for the first five weeks of the study period, showed a statistically significant higher response rate (χ2= 9.6, p =0.002) and higher remission rate (χ2 = 12.5, p = 0.0004) for the bright light treated group versus the dim light treated group. At end of the five weeks of light treatment response rates were 66.7% versus 40.7 % and remission rates were 41.7 % versus 14.8 % for the bright versus dim light treated group. In the subsequent publication that covered the four weeks extension period where light treatment was discontinued, data showed that the attained differences in response and remission rates between groups were not sustained. The offset of effect was nearly complete after four weeks of continued treatment on sertraline only. Thus, at end-point, response rates were 79.2 % versus 75.9 % and remission rates were 60 .4 % versus 55.6% in the bright versus dim light groups. The conclusion reached was that bright light in non-seasonal depression should be used to achieve an earlier antidepressant response and that light therapy probably should be of longer duration. Results from the Pindolol study The results from the Pindolol study showed that pindolol did not augment the effect of venlafaxine for the whole sample. However, for those patients classified as slow metabolizers, based on their O-desmethylvenlafaxine/venlafaxine ratio (ODV/V), pindolol did augment the antidepressant effect. For patients classified as fast metabolizers, pindolol worsened the outcome. This interaction between ODV/V ratio and treatment group was statistically significant (p = 0.01). Results from the PEMF study The results from the PEMF Study showed that treatment with active versus sham PEMF augmented the effect of the ongoing anti-depressant medication treatment. Thus, patients in the active PEMF group attained a statistically significant greater score reduction from week one and at all subsequent assessments compared to the sham treated group (p &lt; 0.01). Response and remission rates in the active PEMF group were also larger than in the sham treated group with response rates at endpoint of 61.0 % versus 12.9 % (p &lt; 0.01) and remission rates of 33.9 % versus 4.1 % (p &lt; 0.05). Results from the Chronos study The Chronos study, published in three papers, covers a one-week intervention phase, a seven weeks continuation phase, and a 20 weeks follow-up phase. Results from the intervention week showed that patient treated in the wake group, from the day after the first wake therapy, had en clinically and statistically significant better antidepressant effect compared to the exercise group. On the HAM-D6 scale (which does not contains sleep items), patients in the wake group had a response rate after the first wake therapy of 58.7% versus 13.7% i the exercise group (p &lt;0.0001) and a remission rate of 38.6% versus 2.9% (p &lt;0.0001). After the second recovery sleep (the night after the second wake therapy = dag 5) patients in the wake group had a response rate of 75.0% versus 25.1% in the exercise group (p &lt;0.0001) and remission rates of 58.6% versus 6.0% (p &lt;0.0001). Results from the continuation phase showed, on the HAM-D17 scale which was used at all the following assessments, at week two response rates of 41.4% in the wake group and 12.8% in the exercise group (p = 0.003) and remission rates of 23.9% versus 5.4% (p = 0,004). This clinically relevant and statistically significant difference between the wake and exercise groups was maintained at all the subsequent assessments with response rates of 71.4% versus 47.3% (p = 0.04) and remission rates of 45.6% versus 23.1% (p = 0.04), at week nine. Results from the 20 weeks follow-up phase showed a continued better effect in the wake group at all visits with HAM-D17 depression scored at week 29 of 7.5 (SE = 0.9) in the wake group versus 10.1 (SE = 0.9), (p = 0.02) in the exercise group. Remission rates were higher in the wake group with endpoint rates of 61.9% versus 37.9% (p = 0.01) in the exercise group. Response rates was only numerically, but not statistically, higher in the wake group with 74.6% versus 64.4% in the exercise group (p = 0.22). The sleep diary data showed a statistically smaller day-to-day variation in sleep onset, sleep midpoint, sleep offset and sleep duration in the wake group compared to the exercise group as a sign of better day-to-day sleep-wake cycle control in the wake group (p &lt; 0.01). In the first nine weeks of the study patients in the wake group had a moderate sleep phase advance that diminished during the follow-up period. The hypothesised predictors for response to wake therapy were confirmed. Thus, in the wake group, a positive diurnal variation (morning worst, evening best) was associated with a better out-come, after the wake therapies, compared to a negative diurnal variation (morning best, evening worst). In the exercise group, the reverse was found, as a positive diurnal variation was associated with worse outcome, compared to a negative diurnal variation. This interaction between group and diurnal variation was statistically significant (p = 0.0004). The positive predictive value of response to the first wake therapy (i.e. maintaining response also at week two) was 56.3 % and the negative predictive value of non-response to the first wake therapy (i.e. maintaining no response also at week two) was 75.0 %. The impact of naps on depression severity was examined. In the wake group, patients who napped on the days after wake therapy compared to those patients not napping, had a more severe deterioration at the following assessment at week two (p = 0.02). Patients in the exercise group were able to perform exercise with a mean of 63.0 minutes/day (55.3) for the first eight weeks.

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Scopolamine hydrobromide trihydrate is used in ophthalmic preparations and as a preanesthetic sedative. Its major use is in transdermal patches for the treatment of motion sickness. Scopolamine hydrobromide trihydrate was selected for study because of considerable human exposure resulting from its use in prescription and over-the-counter preparations. Scopolamine was a suspect carcinogen because it contains an aliphatic epoxide moiety which may act as a biological alkylating agent. Male and female F344/N rats and B6C3F1 mice received scopolamine hydrobromide trihydrate (89% pure) in distilled water by gavage for 16 days, 14 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and mouse peripheral blood erythrocytes. 16-DAY STUDY IN RATS: Groups of five male and five female rats were administered 0, 75, 150, 300, 600, or 1,200 mg scopolamine hydrobromide trihydrate/kg body weight in distilled water by gavage for 16 days. All rats survived to the end of the study. The final mean body weights and body weight gains of males receiving 600 and 1,200 mg/kg and the mean body weight gain of males receiving 300 mg/kg were significantly lower than those of the control group. Clinical findings included bilateral pupillary dilation in all dosed animals and red eyelids in males and females receiving 1,200 mg/kg. There were no significant treatment-related gross or microscopic lesions. 16-DAY STUDY IN MICE: Groups of five male and five female mice were administered 0, 150, 250, 450, 900, or 1,800 mg scopolamine hydrobromide trihydrate/kg body weight in distilled water by gavage for 16 days. One male and two females receiving 1,800 mg/kg and one female receiving 150 mg/kg died during the study. The final mean body weights and body weight gains of dosed mice were similar to those of the control groups. Clinical findings related to scopolamine hydrobromide trihydrate administration included bilateral pupillary dilation and squinting in all dosed males and females. The relative liver weights of males receiving 1,800 mg/kg and of females in all dosed groups were significantly greater than those of the control groups. There were no significant treatment-related gross or microscopic lesions. 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were administered 0, 15, 45, 135, 400, or 1,200 mg scopolamine hydrobromide trihydrate/kg body weight in distilled water by gavage for 14 weeks. One female receiving 45 mg/kg, one male and one female receiving 135 mg/kg, six males and one female receiving 400 mg/kg, and eight males and seven females receiving 1,200 mg/kg died during the study. The final mean body weights and mean body weight gains of all dosed males and females were significantly lower than those of the control groups. Clinical findings included bilateral pupillary dilation in all dosed males and females and reddening of the eyes in 15 mg/kg males and 135, 400, and 1,200 mg/kg males and females. Hematocrit, hemoglobin concentration, and/or erythrocyte count in male and female rats receiving 45 mg/kg or greater were slightly higher than those of the control groups. In general, these changes were most prominent in rats in the 400 and 1,200 mg/kg groups. Higher hematocrit, hemoglobin concentration, and erythrocyte count were likely due to hemoconcentration from dehydration (relative erythrocytosis). A minimal to mild mature neutrophilia, evidenced by higher segmented neutrophil numbers than in the control group, occurred in all dosed male rats. Sperm morphology and vaginal cytology parameters in dosed rats were similar to those in the control groups. Nine male and five female dosed rats died from esophageal obstructions consisting of feed and bedding material in the posterior pharynx. Tracheal obstruction occurred concurrently with esophageal obstruction as a result of food build-up in the oropharyngeal region. This condition is considered to be secondary to the inhibitory effects of scopolamine hydrobromide trihydrate on salivary gland secretions and on esopon esophageal smooth muscle involved in swallowing. There were no other significant treatment-related gross or microscopic findings. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were administered 0, 15, 45, 135, 400, or 1,200 mg scopolamine hydrobromide trihydrate/kg body weight in distilled water by gavage for 14 weeks. One male receiving 135 mg/kg and two males and one female receiving 1,200 mg/kg died during the study. The final mean body weights and mean body weight gains of all dosed male groups and females receiving 45 mg/kg and above were significantly lower than those of the control groups. Clinical observations included bilateral pupillary dilation, hyperactivity, and hypoactivity. A minimal to mild mature neutrophilia, similar to that which occurred in the 14-week rat study, occurred in male mice receiving 45 mg/kg or greater. As in the rat study, there was no microscopic evidence of inflammation that could account for the neutrophilia. The estrous cycle length of 1,200 mg/kg females was significantly greater than that in the control group. There were no significant treatment-related gross or microscopic lesions. 2-YEAR STUDY IN RATS: Groups of 60 male and 60 female rats were administered 0, 1, 5, or 25 mg scopolamine hydrobromide trihydrate/kg body weight in distilled water by gavage for 104 weeks. Ten males and ten females from each dose group, excluding the 1 mg/kg female group, were evaluated at 15 months. Survival, Body Weights, Clinical Findings, and Ophthalmic Examination Findings: The survival rates of female rats receiving 1 and 25 mg/kg were significantly lower than that of the control group. Mean body weights of 1 and 5 mg/kg males and females were similar to those of the controls throughout the study. However, mean body weights of 25 mg/kg males and females were generally lower than those of the control groups after about week 25. Clinical findings included bilateral pupillary dilation in all dosed males and females. Ophthalmic examination revealed no significant findings. Hematology: Compared to controls, hematocrit was slightly higher in the 25 mg/kg male rats, similar to the effects observed in the 14-week study; this is consistent with dehydration resulting in hemoconcentration. Reticulocyte numbers in the 25 mg/kg female rats were slightly lower than those in the controls. This result is consistent with the lower body weights, and thus a decreased nutritional status, exhibited by these animals. Plasma Scopolamine Determinations: The serum scopolamine concentrations were 6 ng scopolamine/mL serum for the 5 mg/kg female sample and 12 and 28 ng/mL for the 25 mg/kg male and female samples, respectively. The amounts of scopolamine in the other serum samples were below the minimum detection limit (4 ng/mL) of the analysis method. Neurobehavioral Findings: Horizontal motor activity of 25 mg/kg females was significantly greater than that of the control group on days 90, 180, and 360. Startle response of 5 and 25 mg/kg females was significantly lower than that of the control group on day 90. On day 180, passive avoidance of 25 mg/kg males was significantly lower than that of the control group. Pathology Findings: The incidences of adenoma of the pituitary gland pars distalis decreased with increasing dose in both male and female rats; however, this trend was only significant in males (males: vehicle control, 19/49; 1 mg/kg, 17/49; 5 mg/kg, 13/50; 25 mg/kg, 10/50; females: 20/50, 13/60, 14/50, 10/50). The incidences of adenoma of the pituitary gland pars distalis in 25 mg/kg males and all groups of dosed females were below the NTP historical control range. The incidences of hyperplasia were not significantly different from those in the control groups. The incidences of mononuclear cell leukemia in 25 mg/kg males and females were significantly lower than those of the control groups (males: 33/50, 21/50, 26/50, 24/50; females: 20/50, 6/60, 13/50, 4/50). The incidence of mononuclear cell leukemia in females receiving 25 mg/kg was well below the NTP historical range. 2-YEAR STUDY IN MICE: Groups of 70 male and 70 female mice were administered 0, 1, 5, or 25 mg scopolamine hydrobromide trihydrate/kg body weight in distilled water by gavage for 104 to 105 weeks. Ten control animals and ten animals from each dose level were evaluated at 15 months. Survival, Body Weights, Clinical Findings, and Ophthalmic Examination Findings Survival of dosed males and females was similar to that of the controls. The mean body weights of males and females receiving 1 mg/kg were similar to those of the control groups throughout the majority of the study. The mean body weights of 5 mg/kg males and females were slightly lower than those of the controls. The mean body weights of males and females receiving 25 mg/kg were lower than those of the control groups after week 13. Clinical findings included bilateral pupillary dilation in all dosed male and female groups. Ophthalmic examination revealed no significant findings. Hematology: Hematocrit, hemoglobin concentration, and erythrocyte count in 25 mg/kg female mice were slightly lower than those in the control group. These results are consistent with development of a minimal normocytic, normochromic nonresponsive anemia. The anemia may be related to the lower body weights exhibited by these animals and are presumed to be due to a decreased nutritional status. Pathology Findings: The combined incidences of hepatocellular neoplasms (adenoma or carcinoma) occurred with a significant negative trend in males and females (males: vehicle control, 30/50; 1 mg/kg, 33/50; 5 mg/kg, 14/50; 25 mg/kg, 15/50; females: 22/51, 21/50, 16/50, 9/51). The combined incidences of hepatocellular neoplasms in 5 and 25 mg/kg males were within the NTP historical control range. The incidences of clear cell foci and eosinophilic foci in dosed male groups, and eosinophilic foci in 25 mg/kg females, were significantly lower than those of the control groups. The incidences of many spontaneously occurring nonneoplastic lesions were significantly lower in dosed mice than in the control groups and usually decreased with increasing dose. These included kidney nephropathy, alveolar epithelial hyperplasia, hyperplasia of the pancreatic islets, bone marrow myelofibrosis, hyperplasia of the pituitary gland pars distalis, cystic hyperplasia of the uterus, and hematopoietic cell proliferation of the spleen. The decreased incidences of these spontaneous lesions were most likely a result of lower body weights in dosed animals. GENETIC TOXICOLOGY: Scopolamine hydrobromide trihydrate did not induce mutations in any of five strains of Salmonella typhi murium, with or without S9 metabolic activation enzymes, nor did it induce sister chromatid exchanges in cultured Chinese hamster ovary cells, with or without S9. A weakly positive response was obtained, however, in a chromosomal aberrations test conducted in cultured Chinese hamster ovary cells with very high doses of scopolamine hydrobromide trihydrate in the presence of S9; without S9, no increase in aberrations was noted. Despite the evidence for chromosomal damage observed in vitro, no increase in the frequencies of micronucleated normochromatic erythrocytes was observed in peripheral blood samples of male or female mice exposed to scopolamine hydrobromide trihydrate for 14 weeks by gavage. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was no evidence of carcinogenic activity of scopolamine hydrobromide trihydrate in male or female F344/N rats or B6C3F1 mice administered 1, 5, or 25 mg/kg. Synonyms: Scopolamine hydrobromide, 6,7-epoxytropan-3-yl, euscopol, hydroscine hydrobromide, hyoscine bromide, (-)-hyoscine hydrobromide, hysco, isoscopil, scopolammonium bromide, (s)-tropate hydrobromide trihydrate, l&amp;alpha;-tropyl-a-scopine

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Talc ore may contain several other minerals including calcite, dolomite, magnesite, tremolite, anthophyllite, antigorite, quartz, pyrophyllite, micas, or chlorites. Talc products are sold in a multitude of grades which have physical or functional characteristics especially suited for particular applications, so occupational and consumer exposures to talc are complex. Epidemiology studies have suggested an association between non-fibrous talc and lung cancer risk. Talc was nominated by the National Institute of Occupational Safety and Health (NIOSH) for study by the NTP because of widespread human exposure and because of the lack of adequate information on its chronic toxicity and potential carcinogenicity. Toxicology and carcinogenicity studies of talc (non-asbestiform, cosmetic grade), a finely powdered hydrous magnesium silicate, were conducted by exposing groups of F344/N rats to aerosols for 6 hours per day, 5 days per week for up to 113 weeks (males) or 122 weeks (females). Groups of B6C3F1 mice were exposed similarly for up to 104 weeks. LIFETIME STUDY IN RATS: Groups of 49 or 50 male and 50 female rats were exposed to aerosols of 0, 6, or 18 mg/m(3) talc until mortality in any exposure group reached 80% (113 weeks for males and 122 weeks for females). These exposures were selected based on 4-week inhalation studies of the terminal lung talc burden in F344/N rats; concentrations greater than 18 mg/m(3) were expected to overwhelm lung clearance mechanisms and impair lung function. These exposure concentrations provided a dose equivalent of 0, 2.8, or 8.4 mg/kg per day for male rats and 0, 3.2, or 9.6 mg/kg per day for female rats. In a special study, additional groups of 22 male and 22 female rats were similarly exposed and examined for interim pathology evaluations or pulmonary function tests after 6, 11, 18, and 24 months and lung biochemistry and cytology studies after 24 months. The talc aerosols had a median mass aerodynamic diameter of 2.7 mm in the 6 mg/m(3) chamber and a median diameter of 3.2 mm in the 18 mg/m(3) chamber, with geometric standard deviations of 1.9 mm. However, there was a 7-week period beginning at study week 11 during which the chamber concentration for the 18 mg/m(3) rats varied from approximately 30 to 40 mg/m(3) because of difficulties with the aerosol concentration monitoring system. Further, there was a 12-week period beginning at approximately week 70 during which there were difficulties in generating the talc aerosol, and the chamber concentrations for rats and mice were substantially lower than the target concentrations. Survival, Body Weights, and Clinical Findings: The survival of male and female rats exposed to talc was similar to that of the controls. Mean body weights of rats exposed to 18 mg/m(3) were slightly lower than those of controls after week 65. No clinical findings were attributed to talc exposure. Pathology Findings: Absolute and relative lung weights of male rats exposed to 18 mg/m(3) were significantly greater than those of controls at the 6-, 11-, and 18-month interim evaluations and at the end of the lifetime study, while those of female rats exposed to 18 mg/m(3) were significantly greater at the 11-, 18-, and 24-month interim evaluations and at the end of the lifetime study. Inhalation exposure of rats to talc produced a spectrum of inflammatory, reparative, and proliferative processes in the lungs. Granulomatous inflammation occurred in nearly all exposed rats and the severity increased with exposure duration and concentration. Hyperplasia of the alveolar epithelium and interstitial fibrosis occurred in or near foci of inflammation in many exposed rats, while squamous metaplasia of the alveolar epithelium and squamous cysts were also occasionally seen. Accumulations of macrophages (histiocytes), most containing talc particles, were found in the peribronchial lymphoid tissue of the lung and in the bronchial and mediastinal Iymph nodes. In female rats, the incidences of alveolar/bronchiolar adenoma, carcinoma, and adenoma or carcinoma (combined) in the 18 mg/m(8 mg/m(3) group were significantly greater than those of controls. The incidences of pulmonary neoplasms in exposed male rats were similar to those in controls. Minor alterations attributed to talc exposure were also observed in the upper respiratory tract. Hyperplasia of the respiratory epithelium of the nasal mucosa in males and accumulation of cytoplasmic, eosinophilic droplets in the nasal mucosal epithelium in male and female rats occurred with a concentration-related increased incidence in the exposed groups. Adrenal medulla pheochromocytomas [benign, malignant, or complex (combined)] occurred with a significant positive trend in male and female rats, and the incidences in the 18 mg/m(3) groups were significantly greater than those of controls. Although adrenal medulla hyperplasia occurred with similar frequency among exposed and control females, the incidences of hyperplasia in exposed males were significantly lower than in controls. Lung Talc Burden: Lung talc burdens of male and female rats exposed to 6 mg/m(3) were similar and increased progressively from 6 to 24 months. Lung talc burdens of females exposed to 18 mg/m(3) also increased progressively from 6 to 24 months, while those of males exposed to 18 mg/m(3) remained about the same after 18 months. Lung burdens were generally proportional to exposure concentration at each interim evaluation. Pulmonary Function, Bronchoalveolar Lavage, and Lung Biochemistry: In exposed male and female rats there was a concentration-related impairment of respiratory function which increased in severity with increasing exposure duration. The impairment was characterized by reductions in lung volume (total lung capacity, vital capacity, and forced vital capacity), lung compliance, gas exchange efficiency (carbon monoxide diffusing capacity), and nonuniform intrapulmonary gas distribution. After 24 months, males exposed to 6 mg/m(3) talc had a significant increase in beta-glucuronidase and polymorphonuclear leukocytes; males exposed 18 mg/m(3) had significant increases in b -glucuronidase, lactate dehydrogenase, alkaline phosphatase, and total protein in bronchoalveolar lavage fluid. All exposed females had significantly increased a-glucuronidase, lactate dehydrogenase, alkaline phosphatase, total protein, and polymorphonuclear leukocytes; 18 mg/m(3) females also had significantly increased glutathione reductase. Viability and phagocytic activity of macrophages recovered from lavage fluid were not affected by talc exposure. Total lung collagen was significantly increased in rats at both exposure concentrations after 24 months, while collagenous peptides in lavage fluid and the percentages of newly synthesized protein from females, but not males, were also significantly increased at the 6 or 18 mg/m(3) levels. In addition, lung proteinase activity, primarily cathepsin D-like activity, was significantly greater in exposed males and females. Rats exposed to talc also had significant increases in collagenous peptides and acid proteinase in lung homogenates. 2-YEAR STUDY IN MICE: Groups of 47 to 49 male and 48 to 50 female mice were exposed to aerosols containing 0, 6, or 18 mg/m(3) talc for up to 104 weeks. These exposures were selected based on 4-week inhalation studies of the terminal lung talc burden in B6C3F1 mice; concentrations greater than 18 mg/m(3) were expected to overwhelm lung clearance mechanisms and impair lung function. These exposure concentrations provide a dose equivalent of 0, 2, or 6 mg/kg per day for male mice and 0, 1.3, or 3.9 mg/kg per day for female mice. In a special study, additional groups of 39 or 40 male and 39 or 40 female mice similarly exposed were examined for interim pathology evaluations, lung biochemistry, and cytology studies after 6, 12, and 18 months of exposure. The talc aerosols had a median mass aerodynamic diameter of 3.3 mm with a geometric standard deviation of 1.9 mm in the 6 mg/m(3) chamber, and a median diameter of 3.6 mm with a geometric standard deviation of 2.0 mm in the 18 mg/m(3) chamber. Further, there was a 12-week period beginning at approximately week 70 during which there were difficulties in generating the talc aerosol, and the chamber concentrations for rats and mice were substantially lower than the target concentrations. Survival, Body Weights, and Clinical Findings: Survival and final mean body weights of male and female mice exposed to talc were similar to those of the controls. There were no clinical findings attributed to talc exposure. Pathology Findings: Inhalation exposure of mice to talc was associated with chronic active inflammation and the accumulation of macrophages in the lung. In contrast to rats, hyperplasia of the alveolar epithelium, squamous metaplasia, or interstitial fibrosis were not associated with the inflammatory response in mice, and the incidences of pulmonary neoplasms in exposed and control groups of mice were similar. Accumulations of macrophages (histiocytes) containing talc particles were also present in the bronchial Iymph node. In the upper respiratory tract, cytoplasmic alteration, consisting of the accumulation of cytoplasmic eosinophilic droplets in the nasal mucosal epithelium, occurred with a concentration-related increased incidence in exposed male and female mice. Lung Talc Burden: Lung talc burdens of mice exposed to 6 mg/m(3) were similar between males and females and increased progressively from 6 to 24 months, except for males at 18 months. The lung talc burdens of mice exposed to 18 mg/m(3) were also similar between the sexes at each interim evaluation. Although the talc burdens of males and females increased substantially from 6 to 24 months, the values at 12 and 18 months were similar. Generally, lung burdens of mice exposed to 18 mg/m(3) were disproportionately greater than those of mice exposed to 6 mg/m(3), suggesting that clearance of talc from the lung was impaired, or impaired to a greater extent, in mice exposed to 18 mg/m(3) than in mice exposed to 6 mg/m(3). Bronchoalveolar Lavage and Lung Biochemistry: Increases in total protein, beta-glucuronidase, lactate dehydrogenase, glutathione reductase, total nucleated cells, and polymorphonuclear leukocytes in bronchoalveolar lavage fluid were observed primarily in mice exposed to 18 mg/m(3), although some parameters were also increased in mice exposed to 6 mg/m(3). The amount of collagenous peptides in lavage fluid and total lung collagen were increased in male and female mice exposed to 18 mg/m(3). Acid proteinase activity, principally cathepsin D-like activity, of lung homogenate supernatant fluid was also significantly increased in mice at the 18 mg/m(3) exposure concentration. CONCLUSIONS: Under the conditions of these inhalation studies, there was some evidence of carcinogenic activity of talc in male F344/N rats based on an increased incidence of benign or malignant pheochromocytomas of the adrenal gland. There was clear evidence of carcinogenic activity of talc in female F344/N rats based on increased incidences of alveolar/bronchiolar adenomas and carcinomas of the lung and benign or malignant pheochromocytomas of the adrenal gland. There was no evidence of carcinogenic activity of talc in male or female B6C3F1 mice exposed to 6 or 18 mg/m(3). The principal toxic lesions associated with inhalation exposure to the same concentrations of talc in rats included chronic granulomatous inflammation, alveolar epithelial hyperplasia, squamous metaplasia and squamous cysts, and interstitial fibrosis of the lung. These lesions were accompanied by impaired pulmonary function characterized primarily by reduced lung volumes, reduced dynamic and/or quasistatic lung compliance, reduced gas exchange efficiency, and nonuniform intrapulmonary gas distribution. In mice, inhalation exposure to talc produced chronic inflammation of the lung with the accumulation of alveolar macrophages. Synonyms: talcum; agalite; emtal 596; non-asbestiform talc; non-fibrous talc; steatite; hydrous magnesium silicate

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These 2 parallel studies (K031 and K032) aim to evaluate the safety of KB109 in addition to supportive self-care (SSC) compared with SSC alone in outpatients with mild to moderate coronavirus disease 2019 (COVID-19). KB109 is a novel synthetic glycan that was formulated to modulate the gut microbiome composition and metabolic output in order to increase beneficial short-chain fatty acid (SCFA) production in the gut. The K031 study is designed to evaluate the safety of KB109 and characterize its impact on the natural progression of COVID-19 in patients with mild to moderate disease. The K032 study is evaluating the effect of KB109 on the gut microbiota structure and function in this same patient population. Additionally, both studies are evaluating measures of health care utilization, quality of life (QOL), laboratory indices, biomarkers of inflammation, and serological measures of immunity in patients who received SSC alone or with KB109. Noteworthy aspects of these outpatient studies include study design measures aimed at limiting in-person interactions to minimize the risk of infection spread, such as use of online diaries, telemedicine, and at-home sample collection. K031 and K032 are randomized, controlled, open-label, clinical food studies. Inclusion Criteria: • Adults ≥18 years of age • Patients willing and able to give informed consent • Screening/randomization telemedicine visit within 2 days of testing positive test for COVID-19 ○ In K031 study, symptomatic patients at COVID-19 testing must report new or worsening symptoms at baseline that have not been present for more than 5 days ▪ Cardinal COVID-19 symptoms include fever, chills/repeated shaking with chills, cough, shortness of breath, headache, muscle pain, anosmia/ageusia, and sore throat. The 5 additional symptoms include gastrointestinal (GI) disturbance/symptoms (other than diarrhea), diarrhea, fatigue, nasal congestion, and chest tightness ○ In K031, at COVID-19 testing, pre-symptomatic patients must report new cardinal COVID-19 symptoms within 7 days of a positive test and they must be screened and randomized within 5 days of developing symptoms • Mild to moderate COVID-19 and self-reported outpatient management ○ In K032, mild to moderate COVID-19 was defined as having the following symptoms for no more than 72 hours before COVID-19 testing: a self- reported fever or cough (new or exacerbated) or presence of at least 2 of the following: anosmia, sore throat, or nasal congestion • Ability to adhere to the study visit schedule and other protocol requirements • Consistent internet or cell phone access with a data plan and access to a smartphone, tablet, or computer • The K031 and K032 studies are currently being conducted at 17 clinical institutions throughout the United States. • In the primary investigator's (PI) judgement, patients likely to require hospitalization for COVID-19 • Patients who are hospitalized for in-patient treatment or currently being evaluated for potential hospitalization at the time of informed consent for conditions other than COVID-19 • History of chronic lung disease with chronic hypoxia • History of documented cirrhosis or end-stage liver disease • Ongoing requirement for oxygen therapy • Shortness of breath in resting position • Diagnosis of sleep apnea requiring bilevel positive airway pressure (BIPAP)/continuous positive airway pressure (CPAP) • Female patients who are pregnant, trying to become pregnant, or lactating • Concurrent use of immunomodulatory agent within 12 months; systemic antibiotics, antifungals, or antivirals for treatment of active infection within 28 days; systemic immunosuppressive therapy within 3 months; or drugs or other compounds that modulate GI motility (eg, stool softeners, laxatives, or fiber supplements) taken currently, or within 7 days. Antacid (histamine 2 blockers and proton pump inhibitors) and antidiarrheal agents are not prohibited • History of GI surgery (6 months prior to randomization), including but not limited to bariatric surgery and bowel resection, or history of, or active GI disease(s) that may affect assessment of tolerability, including but not limited to inflammatory bowel disease, irritable bowel syndrome, autoimmune disease, or GI malignancy • Participation in an interventional clinical trial or use of any investigational agent within 30 days before randomization • Clinically significant or uncontrolled concomitant medical condition that would put the patient at risk or jeopardize the objectives of the study in the opinion of the PI • In the opinion of the PI, patient unlikely for any reason to be able to comply with study procedures • Contraindications, sensitivities, or known allergy to the use of the study product or its components INTERVENTION AND COMPARATOR: Patients will be randomized (1,1) to receive either SSC and KB109 or SSC alone. During SSC, patients should follow the steps as instructed by their healthcare provider to care for themselves and protect other people in the home and community from potentially contracting COVID-19. Management of COVID-19-related symptoms with over-the-counter cough, cold, and anti-pyretic medications by patients is permitted in accordance with the medications' respective drug facts label or as instructed by the patient's healthcare provider. Following randomization, patients assigned to receive KB109 and SSC will receive a Kaleido Biosciences, Inc at-home study kit including a thermometer, pulse oximeter, and KB109. During the Intake Period (days 1-14), KB109 will be reconstituted in water by the patient and consumed by the patient twice daily (at least 8 hours apart), following an up-titration dosing schedule: Days 1 to 2: 9 g twice daily for a total daily dose of 18 g Days 3 to 4: 18 g twice daily for a total daily dose of 36 g Days 5 to 14: 36 g twice daily for a total daily dose of 72 g During the intake period, patients will record their daily COVID-19-related symptoms, selected COVID-19 signs (as self-measured using the provided thermometer and pulse oximeter), responses to questions related to QOL measures, health care use measures, and concomitant medications taken in the previous 24 hours. Wellness visits by telephone will be conducted between days 1 and 14 to follow up on patient's health status and to ascertain compliance with KB109 and completion of questions. On day 14, all patients will undergo a telemedicine visit where the following will be conducted: abbreviated physical examination, assessment of safety and other protocol-specified measures of health, and an evaluation of whether follow-up treatment is recommended owing to a progression of COVID-19 symptoms. If feasible, blood samples for clinical chemistries, biomarkers and serological measure of immunity, and nasal/oropharyngeal swabs for quantitative viral load assessments will be collected. Beginning on day 15, patients in both groups will enter the follow-up period (days 15-35) where COVID-19 signs, symptoms, and health care use indices will be collected. Wellness visits by telephone will be conducted on days 21, 28, and 35 to follow-up on the patient's health status. On day 35, all patients will undergo a telemedicine visit where the same information as the day 14 telemedicine visit will be collected, including any blood samples. The primary outcome for the K031 and K032 studies is to evaluate the safety of KB109 in addition to SSC compared with SSC alone in outpatients with mild to moderate COVID-19 by assessing the number of patients experiencing KB109-related treatment-emergent adverse events (TEAEs) during the study. K031 will also evaluate duration of symptoms among outpatients with mild to moderate COVID-19. This will be as an assessment made during the intake and/or follow-up periods of the following: • Time to resolution of the 13 overall and the 8 cardinal COVID-19-related symptoms from day 1 until the day at which the composite score of the 13 overall and 8 cardinal COVID-19-related symptoms becomes 0 or 1 and remains at 0 or 1 for the rest of the intake period and for the follow-up period • Proportion of patients with a reduction from baseline in each of the 13 overall COVID-19-related symptoms • Proportion of patients in whom symptoms (present at baseline) become absent for each of the 13 overall COVID-19-related symptoms • Change from baseline in the overall composite score of the 13 overall COVID-19-related symptoms and the 8 cardinal COVID-19-related symptoms • Time to resolution of fever (defined as from day 1 until the day at which a patient's daily maximum temperature achieves and remains below 100.4°F without antipyretic medication) • Proportion of patients with oxygen saturation &lt;95% and &lt;98% on days 14 and 35 • Measures collected from the health care provider wellness visits • Proportion of patients experiencing hospital admissions (all cause and COVID-19-related) • Health care use K032 will evaluate the effect of KB109 in addition to SSC compared with SSC alone on the gut microbiota structure and function in outpatients with mild to moderate COVID-19. Before days 1, 14, and 35, microbiota structure (eg, magnitude of change in gut microbiome structure, composition of gut microbiome) will be analysed by methods such as nucleic acid sequencing and gut microbiome function will be analysed via levels of stool inflammatory biomarkers (eg, lipocalin) and gut microbiome metabolites (eg, SCFA). The health of outpatients with mild to moderate COVID-19 will be evaluated during the intake and follow- up periods by: measures of QOL; measures collected from the healthcare provider wellness visits; the proportion of patients experiencing hospital admissions; health care use, the proportions of patients with oxygen saturation &lt;95% and &lt;98%, and the proportion of patients with temperature below 100.4 °F without an anti-pyretic medication. Potential exploratory outcome measures may include: changes from baseline (day 1) in laboratory measures, specific biomarkers of infection, serology, inflammation (eg, D-dimer, lipocalin, cytokines, IgM/IgG sero-conversion, and neutralization assays), and viral load in outpatients with mild to moderate COVID-19 in the presence and absence of KB109. All patients deemed eligible for the studies will be randomized in a 1:1 ratio to KB109 in addition to SSC or SSC alone group using an interactive response technology system. Randomization will be stratified by study site/center, age groups (≥18-&lt;45 years, ≥45-&lt;65 years, ≥65 years), and comorbidity status (yes, no). These studies are open-label; therefore, no blinding is necessary. K031 will enroll approximately 350 to 400 (175-200 patients per group) whereas K032 will enroll approximately 50 patients (25 per group). K031 protocol version 4, December 9, 2020; recruitment started in August, 2020, and the study is estimated to be completed in March 2021. This study is active and enrollment was completed in January, 2021. K032 protocol version 2, June 30, 2020; recruitment is estimated to start in July, 2020. This study is recruiting and the study is estimated to be completed in March 2021. K031 is registered with the US National Library of Medicine, Identifier NCT04414124 as of June 4, 2020. K032 is registered with the US National Library of Medicine, Identifier NCT04486482 as of July 24, 2020. The full protocols are attached as additional files (Additional files 1 and 2), accessible from the ClinicalTrials.gov website. In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocols. The study protocols have been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional files 3 and 4).

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3'-Azido-3'-deoxythymidine (AZT) is the most widely used and evaluated chemotherapeutic agent for the treatment of persons with acquired immune deficiency syndrome (AIDS) and persons seropositive for human immunodeficiency virus (HIV). The National Cancer Institute nominated AZT for toxicity and carcinogenicity studies because of the impending large-scale use of AZT in the treatment of adult patients with AIDS or AIDS-related complex. alpha-Interferon A/D, which displays antiviral activity in mice, is a hybrid molecule composed of the N-terminal portion of human alpha-interferon A and the C-terminal portion of human alpha-interferon D. AZT and alpha-interferon A/D combination studies were conducted because in vitro studies of AZT and alpha-interferon have demonstrated that the combination is more effective in blocking HIV infection than either agent alone. Male and female B6C3F1 mice received AZT (approximately 98% pure) in 0.5% aqueous methylcellulose by gavage for 14 weeks or 2 years. In addition, male and female B6C3F1 mice received alpha-interferon A or alpha-interferon A/D by subcutaneous injection for 2 years, and male and female B6C3F1 mice received AZT in 0.5%% aqueous methylcellulose by gavage in combination with alpha-interferon A/D by subcutaneous injection for 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, mouse bone marrow erythrocytes, and mouse peripheral blood erythrocytes. 14-WEEK AZT STUDY: Groups of 10 male and 10 female mice received AZT in 0.5% methylcellulose by gavage at doses of 0, 50, 100, 200, 800, or 2,000 mg/kg daily for 14 weeks. Additional groups of 10 male and 10 female mice received AZT in 0.5% methylcellulose by gavage at doses of 0, 100, 800, or 2,000 mg/kg daily for 14 weeks and then were held without treatment for an additional 4 weeks before necropsy. One female receiving 100 mg/kg and two females receiving 200 mg/kg died during week 1 as a result of gavage trauma; one female receiving 2,000 mg/kg also died prior to the end of the 14-week dosing period. One female receiving 2,000 mg/kg in the recovery study also died from gavage trauma during week 1. The final mean body weights of dosed mice were similar to those of the vehicle control groups at the end of the dosing period and at the end of the recovery period. Female mice receiving 200, 800, or 2,000 mg/kg gained less weight than the vehicle controls during the 14-week dosing period. Exposure to AZT was toxic to the bone marrow, resulting in significant changes in the peripheral blood (decreased hematocrit values, erythrocyte counts, and hemoglobin concentrations, and increased mean cell volume and mean cell hemoglobin) and bone marrow (erythroid hypoplasia) characteristic of a dose- and time-dependent, minimal to moderate, poorly regenerative macrocytic anemia. At the end of the 4-week recovery period, the hematology parameters had returned to normal, indicating that the hematotoxicity was reversible. 2-YEAR STUDIES: AZT Groups of 95 male and 95 female mice received AZT in 0.5% methylcellulose by gavage at daily doses of 0, 30, 60, or 120 mg/kg body weight, administered as two equal doses at least 6 hours apart, 5 days per week for 105 weeks. Each group of 95 animals was composed of a core group of 50 animals for evaluation of carcinogenic response, a group of 30 animals for evaluation of hematology and bone marrow cellularity, and a group of 15 animals from which blood was drawn for determination of plasma AZT concentrations at week 54. alpha-Interferon A/D and AZT/alpha-Interferon A/D Studies Groups of 80 male and 80 female mice received AZT in 0.5% aqueous methylcellulose by gavage at daily doses of 0, 30, 60, or 120 mg/kg body weight, given in two equal doses, 5 days per week for 105 weeks. Those groups receiving AZT also received sub-cutaneous injections of 500 or 5,000 U alpha-interferon A/D three times per week for 105 weeks. Additional groups of 80 male and 80 female mice received subcutaneous injections of the vehicle, 500 U alpha-interferon A/D, 5,000 Uutaneous injections of the vehicle, 500 U &amp;alpha;-interferon A/D, 5,000 U &amp;alpha;-interferon A/D, or 5,000 U &amp;alpha;-interferon A, three times per week for 105 weeks. Each group of 80 animals was composed of a core group of 50 animals for evaluation of carcinogenic response and a group of 30 animals for evaluation of hematology and bone marrow cellularity. Because of the large number of animals involved, the 2-year studies were started in four phases and, for clarity, are presented as follows: the AZT study, the &amp;alpha;-interferon A/D study, the AZT/500 U &amp;alpha;-interferon A/D study, and the AZT/5,000 U &amp;alpha;-interferon A/D study. Design of the 2-year AZT, AZT/&amp;alpha;-Interferon A/D, and &amp;alpha;-Interferon A/D Studies AZT Dose AZT Study AZT/500 U &amp;alpha;-Interferon A/D Study AZT/5,000 U &amp;alpha;-Interferon A/D Study 500 or 5,000 U &amp;alpha;-Interferon A/D or 5,000 U &amp;alpha;-Interferon A Study Vehicle Control 95 male and 95 female micea 80 male and 80 female miceb 80 male and 80 female miceb 80 male and 80 female miceb 30 mg/kg AZT 95 male and 95 female mice 80 male and 80 female mice 80 male and 80 female mice none 60 mg/kg AZT 95 male and 95 female mice 80 male and 80 female mice 80 male and 80 female mice none 120 mg/kg AZT 95 male and 95 female mice 80 male and 80 female mice 80 male and 80 female mice none aFor the AZT study, there were 95 male and 95 female mice; these were divided into 50 males and 50 females in the core groups, 30 males and 30 females in the clinical pathology groups (hematology and bone marrow analyses only), and 15 males and 15 females for plasma AZT concentration determinations. bFor the &amp;alpha;-interferon A/D study and the AZT/&amp;alpha;-interferon A/D studies, there were 80 male and 80 female mice for each study; these were divided into 50 males and 50 females in the core groups and 30 males and 30 females in the clinical pathology groups (hematology and bone marrow analyses only). Survival and Body Weights Survival and mean body weights of mice exposed to AZT, &amp;alpha;-interferon A, &amp;alpha;-interferon A/D, or AZT plus &amp;alpha;-interferon A/D were generally similar to those of the vehicle control groups. Hematology and Bone Marrow Analyses All groups of male and female mice receiving AZT exhibited changes in peripheral blood and bone marrow characteristic of a dose- and time-dependent, minimal to mild, macrocytic, nonresponsive anemia. In females, these changes were evident throughout the study. In males, the macrocytic anemia had resolved by week 80 in the 30 mg/kg group; at study termination erythrocyte macrocytosis was present only in males receiving 60 or 120 mg/kg AZT or AZT plus &amp;alpha;-interferon A/D. There were no treatment-related alterations in hematology or bone marrow parameters in groups that received only &amp;alpha;-interferon A or A/D. Pathology Findings Incidences of squamous cell carcinoma and squamous cell papilloma or carcinoma (combined) of the vagina occurred with a positive trend and were significantly increased in groups of female mice receiving 60 or 120 mg/kg AZT alone or in combination with &amp;alpha;-interferon A/D. Epithelial hyperplasia was observed in all dosed groups of females, and the incidence was significantly increased in the 120 mg/kg AZT group. Three renal tubule adenomas and one renal tubule carcinoma were observed in male mice receiving 120 mg/kg AZT; the combined incidence in this group exceeded the range in historical controls. A renal tubule adenoma was observed in one male receiving 60 mg AZT/kg and 500 U &amp;alpha;-interferon A/D; how ever, none were observed in other groups. Evaluation of step sections revealed a few more renal tubule hyperplasias but no additional neoplasms. The incidence of harderian gland adenoma was increased in male mice receiving 120 mg/kg AZT and exceeded the range in historical controls. Harderian gland neoplasms were observed in other groups but did not follow a treatment-related pattern. Overall Incidences of Vaginal Neoplasms and Hyperplasia of the Vaginal Epithelium in Female Mice in the 2-Year Gavage Studies of AZT and AZT/&amp;alpha;-Interferon A/Da Vehicle Control 30 mg AZT/kg 60 mg AZT/kg 120 mg AZT/kg AZT alone 2/197 (1&amp;percnt;)b 1/197 0/49 (0&amp;percnt;) 3/49 5/45 (11%&amp;percnt;) 4/45 11/49 (22%&amp;percnt;) 11/49 500 U &amp;alpha;-Interferon A/D 0/49 (0%&amp;percnt;) 0/49 0/44 (0&amp;percnt;) 4/44 5/48 (10&amp;percnt;) 8/48 6/48 (13&amp;percnt;) 12/48 5,000 U &amp;alpha;-Interferon A/D 1/50 (2&amp;percnt;) 1/50 1/48 (2&amp;percnt;) 4/48 5/48 (10&amp;percnt;) 8/48 4/50 (8&amp;percnt;) 15/50 aData are presented as number of vaginal neoplasms/number of animals microscopically examined (first line) and number of vaginal hyperplasias/number of animals microscopically examined (second line) bCombined incidences of controls from the AZT alone study and the AZT/&amp;alpha;-interferon A/D studies; incidences in the vehicle control group from the AZT alone study are 0/50 (0%&amp;percnt;) (neoplasms) and 0/50 (hyperplasia) Overall Incidence of Harderian Gland Neoplasms in Male Mice in the 2-Year Gavage Studies of AZT and AZT/&amp;alpha;-Interferon A/Da Vehicle Control 30 mg AZT/kg 60 mg AZT/kg 120 mg AZT/kg AZT alone 13/200 (6%&amp;percnt;)b 5/50 (10%&amp;percnt;) 2/50 (4&amp;percnt;) 10/50 (20%&amp;percnt;) 500 U &amp;alpha;-Interferon A/D 3/50 (6&amp;percnt;) 3/50 (6&amp;percnt;) 1/50 (2%&amp;percnt;) 4/50 (8%&amp;percnt;) 5,000 U &amp;alpha;-Interferon A/D 3/50 (6&amp;percnt;) 9/50 (18%&amp;percnt;) 4/50 (8%&amp;percnt;) 4/50 (8&amp;percnt;) aData are presented as number of harderian gland neoplasms/number of animals necropsied bCombined incidences of controls from the AZT alone study and the AZT/&amp;alpha;-interferon A/D studies; incidence in the vehicle control group from the AZT alone study is 3/50 (6&amp;percnt;) Male mice had a pattern of nonneoplastic liver lesions along with silver-staining helical organisms within the liver consistent with an infection with Helicobacter hepaticus. An organism compatible with H. hepaticus was confirmed by polymerase chain reaction-restriction fragment length polymorphism-based assays. Detection of dose-related differences in neoplasm incidences in these studies was not considered to have been significantly impacted by the infection with H. hepaticus or its associated hepatitis. GENETIC TOXICOLOGY: AZT is mutagenic in vitro and in vivo. It induced gene mutations in Salmonella typhimurium strain TA102, with and without S9; no increases in mutations were noted in the other tested strains of S. typhimurium. AZT induced sister chromatid exchanges, but not chromosomal aberrations, in cultured Chinese hamster ovary cells, with and without S9. In vivo studies with male mice administered AZT by gavage showed highly significant increases in micronucleated erythrocytes in bone marrow and peripheral blood after exposure periods that ranged from 72 hours to 14 weeks. CONCLUSIONS: Under the conditions of these 2-year gavage studies there was equivocal evidence of carcinogenic activity of AZT in male mice based on increased incidences of renal tubule and harderian gland neoplasms in groups receiving AZT alone. There was clear evidence of carcinogenic activity of AZT in female mice based on increased incidences of squamous cell neoplasms of the vagina in groups that received AZT alone or in combination with &amp;alpha;-interferon A/D. Hematotoxicity occurred in all groups that received AZT. Treatment with AZT alone and AZT in combination with &amp;alpha;-interferon A/D resulted in increased incidences of epithelial hyperplasia of the vagina in all dosed groups of females. Synonyms: AZT; 3'-azido-2',3'-dideoxythymidine; azidodeoxythymidine; azidothymidine; 3'-azidothymidine; 3'-deoxy-3'-azidothymidine; 3'-deoxy-(8CI) (9CI); BW A509U; Compound S; ZDV; zidovudine Trade name: Retrovir&amp;reg;

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INTRODUCTION: It is known that the larvae of ascarids have migrating phase before they reach the intestine. Stewart (1916) reported the pulmonary migration of ascaris larvae in normal host. Beaver et al. (1952) demonstrated the ascaris larvae of animal origin from the biopsied human liver, and applied the term "visceral larva migrans" to the migration of larval nematodes in unsuitable hosts. Either in normal or abnormal host, the migrated larvae cause inflammatory changes in the tissues and produce corresponding symptoms. There have been a considerable number of anthelminthics for the ascaris adult worm, but very few reports concerning the migrating larvae. Smirnov (1932) found no larvicidal effect of santonin and chenopodium oil on the migrating phase. Snyder (1961) also reported that diethylcarbamazine did not relieve the symptoms of visceral larva migrans. Recently, thiabendazole has appeared as a broad spectrum anthelminthic and Brown (1961) reported that the chemical inhibited the development of helminth larvae affecting the migratory phases of roundworms and kidney worms in swine. The present study was designed to confirm the previous reports concerning the anthelminthic effect of thiabendazole and to examine the mechanism of its activity. MATERIALS: Animal: White mice, weighing 18-26 gms, were used regardliss of sex. Parasites: Eggs from the 3cm distal portion of uteri of Toxocara canis and Ascaris lumbricoides were sampled and cultured in 0.5% formalin solution under room temperature for 40-50 days. The embryonated eggs were used for the experiment. Virus: Infuenza A/swine/1957/12 N.I.H., U.S.A. December 20, 1965. Chemical: Thiabendazole; 2-4'-thiazolyle)-benzimidazole, Merck Sharp and Dohme Co. 50% aqueous suspension of the chemical was used for experiment. METHODS: White mice were infected each orally using the stomach tube with 500 eggs of canine-ascaris or 800-1,000 eggs of human ascaris according to the experimental purposes. The viral infection was done by inhalation of 2-3 drops of emulsion containing viurs, and the drug was given by stomach tube. The average dose was 250 mg/kg. Recovery of larvae from the tissues: The larvae in the brain were examined under the microscope by pressing the tissue between two slides. The tissues of liver, lung, and carcasses were macerated with Waring blendor. The macerated tissue was suspended in 20 cc freshly prepared artificial gastric juice (pepsin 1 gm, HCL 0.5 cc, NaCL 0.85 gm, distilled water 100 cc), and incubated over night at 37 degrees C. The sample was centrifuged and the sediments examined for larvae. Inthe first experiment, the fate of the migrating larvae after drug administration was determined in early observation group and late observation group. The early observation group: Three days after the infection of 500 eggs of Toxocara canis, 30 of the mice were diviede into two subgroups; having had a single dose and three doses of drug respectively. Four days after the first dose, the mice were sacrificed and the larvae in tissue were examined. The late observation group: The procedure was the same. The mice were sacrificed 14th day after drug administration. In the second experiment, 30 mice infected with 1,000 eggs of human ascaris each were divided into three groups. One group was control and two groups were group of drug administration. In one group the drug was given two days after the infection and the other in 6 days. Allthe mice were sacrificed on the 8th day after the infection. In the third experiment, 45 mice which were infected with 800 eggs of human ascaris each were divided into three groups. In one group the drug was given 24 hours before the infection and in the other 24 hours after the infection and control A mouse of each group was sacrificed every day for 15 days. In the fourth experiment 100 mice were divided into five groups, I, II, III, IV, V. Group I was infected with influenza virus only, and group II was infeted with 800 eggs of human ascaris only. Group III was infected with the influenza virus 7 days after the ascaris infection. Group IV was treated with a single dose of the drug 24 hours before the infection and the virus was infected 7 days later. Group V was treated with the same dose of drug 24 hours after the infection and virus was infected 7 days later. The fatality of each group was observed every day and also the pathological changes of the lungs in each mouse were examined. RESULT: 1)The number of larvae in the tissues of mice treated with thiabendazole was different according to the observation period and the the number of drug administration. In the early observation group: The number of larvae in the single dose group was 40.9 &amp;plusmn; 2.25 (mean &amp;plusmn; standard error) The number in organs were 12.8 &amp;plusmn; 1.69 in brain, 19.6 &amp;plusmn; 1.51 in liver and 8.5 &amp;plusmn; 0.88 in muscle. The number in the three doses group was 35.6 &amp;plusmn; 1.64. The number in organs were 9.6 &amp;plusmn; 0.87 in brain, 16.8 &amp;plusmn; 1.75 in liver and 9.2 &amp;plusmn; 0.82 in muscle. The average number of larvae from control mice was 85.7 &amp;plusmn; 7.45 and the average numbers from different parts of tissue; brain, liver and muscle were 19.7 &amp;plusmn; 1.93, 50.8 &amp;plusmn; 7.23 and 15.2 &amp;plusmn; 1.38 respectively. The average numbers of larvae of single dose group and three dose group were reduced in proportion of 52.2% and 58.5% respectively compared with that of control group. In the late observation group the number of larvae from the single dose group was 28.9 &amp;plusmn; 1.35. The numbers in organs were 8.6 &amp;plusmn; 0.42 in brain, 10.8 &amp;plusmn; 1.13 in liver and 9.5 &amp;plusmn; 0.87 in muscle. The number from the three doses group was 26.1 &amp;plusmn; 1.01, and the numbers in tissue were 11.3 &amp;plusmn; 0.72 in brain, 7.8 &amp;plusmn; 0.70 in liver and 19.6 &amp;plusmn; 1.45 in muscle. The reduction rates in single dose group and three doses group were 59.3% and 63.2% respectively compared with control group. 2) The numbers of the larvae were examined according to the time of drug administration. Tn the earlier group which were given 3 days after the infection, the numbers of the larvae were 3.5 &amp;plusmn; 0.66 in liver and 8.7 &amp;plusmn; 0.93 in lungs. But in the later group, the numbers were 7.4 &amp;plusmn; 1.04 in liver and 14.4 &amp;plusmn; 1.39 in lungs. In the control group, the numbers were 8.7 &amp;plusmn; 0.94 in liver and 31.9 &amp;plusmn; 1.48 in lungs. The reduction rate of the numbers of larvae from liver and lungs in the early drug administration group were 59.7% and 72.9% respectively. In the delayed drug administrating group, 14.9% and 54.9% were reduced in liver and lungs respectively compared with those of control group. 3) The numbers of the larvae in tissues were different according to the method of drug administration; the groups of durg administration before the infection and after the infection, and control group were 30.6 &amp;plusmn; 4.71, 35.9 &amp;plusmn; 4.86 and 52.0 &amp;plusmn; 6.73 respectively. The numbers of recovered larvae in the mice of drug given before and after infection were reduced to 42.3% and 31.1% as compared with the control group. The peak number of recoverd larvae was observed on the 7th to 8th day in the control group and the group of mice of drug administration before the infection, but on the group of mice of drug administration after the infection was appeared on the 8th to 10th day. The numbers of larvae from liver in the group of mice of drug administration before and after the infection, and control were 16.4 &amp;plusmn; 2.93, 19.9 &amp;plusmn; 3.16 and 25.8 &amp;plusmn; 4.02, respectively. The peak of the number in the liver appeared on the 9th day in the group of drug administration before infection, and in 10th day in the group of drug administration after infection, but in the control group the peak appeared on the 4th day after infection. The numbers of larvae from lungs were 71 &amp;plusmn; 1.54, 9.1 &amp;plusmn; 1.62 and 12.9 &amp;plusmn; 2.42 in the group of before, after and control respectively. The reduction rates were 44.9% and 29.4% as compared with control group. The peak of the number of recovered larvae was shown on the 9th day in the group before infection, in 10th day in the group after infection but in control group the peak appeared on the 8th and 9th day. The larvae in intestinal contents of the group of drug administration before and after infection were reduced 65.6% and 54.7% respectively as compared with control group. 4) The drug also effected the life span of the experimental animals. The group of ascaris infection alone showed the longest period of 13.1 &amp;plusmn; 0.90 days. The group was infected by virus alone showed 9.9 &amp;plusmn; 0.80 days. The group which was infected by ascaris and virus showed the shortest 3.8 &amp;plusmn; 0.40 days. However the groups IV and V which were treated with the drug before and after the infection had almost two times longer longivity than the combined infection group. The pathological findings of the lungs were also different according to the drug administration. The ascaris only group showed the light edematous changes and hemorrhagic spots. The viral group showed severe inflammation and edematous changes on whole lungs and the combined group showed severe inflammation and edema with massive hemorrhage on entire lung field. However the treated group showed much lighter changes than in the group of combined infection. CONCLUSION: The following results were obtained in the present study concerning the effectiveness of thiabendazole upon the larvae of the migrating stages. 1) In the early observation group: The average number of larvae of the group treated with single dose and the group treated with three doses were reduced in proportion of 52.2%, 58.5 % respectively compared with control group. 2) In the late observation group: The reduction rate in the group treated with singel dose and group treated with three doses were 59.3 % and 63.2 % respectively compared with control group. 3) The reduction rates of larvae from liver and lungs in the early drug administration group were 72.9 % and 59.7 % respectively, and 14.9 % and 54.8 % in the delayed drug administration group. 4) In the group of drug given before and after infection, the number of recovered larvae were reduced 42.2 % and 31.1 % respectively compared with the control group. 5) The peak number in organs was delayed 1 to 2 days in the treated group than that of control group. 6) The survival period of the infected mouse was prolonged by the drug administration. 7) The pathological changes were reduced by the administration of the drug. Through above results, it was concluded that thiabendazole reduced the number of migrating larvae and delayed the normal migration of the larvae in tissues and reduced the pathological changes in the tissues.

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We thank Dr Rahman Shiri (1) for his careful reading of our systematic review and meta-analysis on suicide among agricultural, forestry, and fishery workers (2). Our paper had the objective of providing a pooled effect size of suicide for this occupational group. Suicide is a crucial issue in public and occupational health. Suicide has a multifactorial etiology and recent systematic reviews and meta-analyses have pointed out the role of occupational exposures, mainly psychosocial work stressors, as risk factors for suicide (3, 4). Suicide is a very rare event in the general population and still more seldom in the working population. Indeed, unemployed and economically inactive people have a higher risk of suicide compared to employed people (5, 6). However, the total number of suicides is greater in the employed population than among the economically inactive or unemployed (6). Shiri's letter (1) questioned several aspects of our review and meta-analysis. One comment related to the single reference database used in our review and a suggestion that our review could not be considered to be systematic. The review was based on Medline because our main interest was in quantitative epidemiologic studies. This is the largest database for biomedical literature and we would argue the most pertinent. Furthermore, we checked the reference lists of the most recent papers and literature reviews, and Shiri did not report any paper that was missing. No review, whether searching one or more databases, can expect to be totally exhaustive. There may always be missing studies, especially if we consider grey literature. Thus we assert that our review was systematic, while acknowledging that it may not be perfectly comprehensive. Shiri suggested an absence of quality assessment of the studies included in our meta-analysis. First, quality was considered in the context of our comments in the discussion section. Second, as suggested by Rothman et al (7), quality assessment was replaced by regression analyses of the effect of each quality item (study characteristics, ie, study design, effect measure, reference group, and adjustment). Third, because most studies included in this review were based on objective data (census, administrative, or register data), they were free of many of the sources of bias that exist in studies where information on exposure and outcome must be collected from participants. Consequently, many of the items related to quality were not pertinent, such as response and follow-up rates, coverage and representativeness of the sample, selection, etc. Contrary to what Shiri suggested, all study designs can be informative in this topic because all of them are able to provide an unbiased estimate of the effect size. In addition, the prospective and case-control studies may have shortcomings. For example, we excluded five studies including three prospective and case-control studies in the sensibility analysis because the group of interest was defined on the basis of the exposure to chemicals (pesticides) rather than job title. Our choice to retain the least adjusted models was justified because aggregated data were used for the meta-analysis. Therefore, unless all included studies adjusted for the same covariates measured in the same way, adjusted estimates cannot be meaningfully provided in an aggregate data meta-analysis. In addition, as the objective was above all descriptive and not etiological or explanatory, and as it is the norm in the exploration of social inequalities in health (8), the results from the least (gender- and age-) adjusted models were in line with the objective. Indeed, including more adjustment variables could lead to overadjustment as they may be intermediate variables on the causal pathways between occupation and suicide. Our strategy was in line with previous meta-analyses on similar topics (9-11). Consequently, we would argue that our results are not likely to be largely due to confounding, contrary to the comment by Shiri. Indeed, the study of the contribution of underlying factors in explaining social inequalities in health outcomes is a fully-fledged topic of research (12-15), but this is relevant research to conduct after demonstrating that inequalities exist between social or occupational groups. Several of Shiri's comments were about statistical aspects of our analyses. First, it was suggested that we did not correctly extract the confidence intervals for the estimates of several studies. We disagree. We used the STATA metan suite of commands using log-transformed effect sizes and standard errors. Our figure 1 and the values of effect sizes and confidence intervals were provided by STATA, this explains why there may be small differences in these values compared with the results published in some studies. Using log-transformed effect sizes and confidence intervals, the analysis provided the same results. Second, our subgroup comparison was based on subsamples that were independent. As not all studies provided information for these subgroups, each subgroup was treated as a unit of analysis. This strategy allows the use of all relevant subgroups and comparisons between them (16). Third, we were also criticized for the use of random-effects models. Random-effects models are generally more plausible for meta-analysis based on studies from the published literature, because the fixed-effect model assumed that the entire corpus of literature has been obtained, ie, that every study has been or ever will be written on the topic has been included, which is an implausible assumption. We also assumed differences in effect size between studies and between subgroups, and the use of random-effects models was consistent with such an assumption. However, random-effects models produce wider confidence intervals compared to fixed-effect models (16). These models are thus more conservative, making our results all the more robust. One of Shiri's comments related to the reference group used in the studies for the comparison of agricultural, forestry, and fishery workers. Although we reported that the studies using a specific occupational group as reference group provided a higher effect size than the studies using other reference groups, we did not explicitly recognize and state in the paper that the results for Japan were based on two studies using a specific occupational group as reference; we concede that this may explain why we found a much more elevated effect size for Japan. Shiri's results (1) allow to conclude that the difference between Japan and the other geographic areas could be explained by the choice of reference group-we are grateful to him for raising this point. However, we would note that the effect size of suicide was still elevated and significant for agricultural, forestry, and fishery workers even after this change in the reference group for these two studies. Nevertheless, the choice of the optimal reference group is not obvious. If we consider the general population as the reference group, as unemployed people and economically inactive people (including people who may not be working due to illness or disability) are part of it and have a higher risk of suicide than employed people, the effect size provided by the nine studies using the general population as the reference is likely to be underestimated, which may contribute to an underestimation of the observed effect size of suicide among agricultural, forestry, and fishery workers in our study. The comparison was made in our paper with the other occupational groups (ie, the working population except the group of interest) as the reference, which was used by nine other studies, but this did not allow to determine the exact rank of the group of interest in the occupational hierarchy. Another relevant choice would have been to retain the group with the lowest suicide risk (for example, the high-skilled occupational group) as the reference, which would have led to a much higher effect size of suicide for agricultural, forestry, and fishery workers. To conclude, as statistical power in detecting differences between subgroups may be low in subgroup analyses and meta-regression, the absence of significant results according to subgroups found in our results cannot be interpreted as evidence that the effect size is the same across subgroups. Consequently, our meta-analysis reporting a significant excess of risk of suicide among agricultural, forestry, and fishery workers may also be a good incentive for more research among this group of workers to (i) confirm this observed excess of risk using differing methodological approaches to meta-analysis and (ii) explore the potential differences within this group and the underlying factors that may explain this excess of risk. References 1. Shiri R. Suicide among agricultural, forestry, and fishery workers. Scand J Work Environ Health - online first. https://doi.org/10.5271/sjweh.3697 2. Klingelschmidt J, Milner A, Khireddine-Medouni I, Witt K, Alexopoulos EC, Toivanen S, et al. Suicide among agricultural, forestry, and fishery workers: a systematic literature review and meta-analysis. Scand J Work Environ Health - online first. https://doi.org/10.5271/sjweh.3682 3. Milner A, Witt K, LaMontagne AD, Niedhammer I. Psychosocial job stressors and suicidality: a meta-analysis and systematic review. Occup Environ Med - online first. https://doi.org/10.1136/oemed-2017-104531 4. Leach LS, Poyser C, Butterworth P. Workplace bullying and the association with suicidal ideation/thoughts and behaviour: a systematic review. Occup Environ Med. 2017;74(1):72-9. https://doi.org/10.1136/oemed-2016-103726 5. Milner A, Page A, LaMontagne AD. Long-term unemployment and suicide: a systematic review and meta-analysis. PLoS One. 2013;8(1):e51333. https://doi.org/10.1371/journal.pone.0051333 6. Milner A, Morrell S, Lamontagne AD. Economically inactive, unemployed and employed suicides in Australia by age and sex over a 10-year period: what was the impact of the 2007 economic recession? Int J Epidemiol. 2014;43(5):1500-7. https://doi.org/10.1093/ije/dyu148 7. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology - Third Edition. Philadelphia: Wolters Kluwer Health - Lippincott Williams &amp; Wilkins; 2008. 8. Lundberg I, Hemmingsson T, Hogstedt C. Work and social inequalities in health in Europe. Brussels: P.I.E. Peter Lang SA; 2007. 9. Milner A, Spittal MJ, Pirkis J, Lamontagne AD. Suicide by occupation: systematic review and meta-analysis. Br J Psychiatry. 2013;203(6):409-16. https://doi.org/10.1192/bjp.bp.113.128405 10. Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 2003;157(2):98-112. https://doi.org/10.1093/aje/kwf182 11. Grittner U, Kuntsche S, Gmel G, Bloomfield K. Alcohol consumption and social inequality at the individual and country levels--results from an international study. Eur J Public Health. 2013;23(2):332-9. https://doi.org/10.1093/eurpub/cks044 12. Niedhammer I, Bourgkard E, Chau N. Occupational and behavioural factors in the explanation of social inequalities in premature and total mortality: a 12.5-year follow-up in the Lorhandicap study. Eur J Epidemiol. 2011;26(1):1-12. https://doi.org/10.1007/s10654-010-9506-9 13. Niedhammer I, Chastang JF, David S, Kelleher C. The contribution of occupational factors to social inequalities in health: findings from the national French SUMER survey. Soc Sci Med. 2008;67(11):1870-81. https://doi.org/10.1016/j.socscimed.2008.09.007 14. Chazelle E, Lemogne C, Morgan K, Kelleher CC, Chastang JF, Niedhammer I. Explanations of educational differences in major depression and generalised anxiety disorder in the Irish population. J Affect Disord. 2011;134(1-3):304-14. https://doi.org/10.1016/j.jad.2011.05.049 15. Niedhammer I, Lesuffleur T, Coutrot T, Chastang JF. Contribution of working conditions to occupational inequalities in depressive symptoms: results from the national French SUMER survey. Int Arch Occup Environ Health. 2016;89(6):1025-37.https://doi.org/10.1007/s00420-016-1142-6 16. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to meta-analysis: John Wiley &amp; Sons, Ltd. ISBN: 978-0-470-05724-7; 2009. https://doi.org/10.1002/9780470743386.

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Samples returned from Mars would be placed under quarantine at a Sample Receiving Facility (SRF) until they are considered safe to release to other laboratories for further study. The process of determining whether samples are safe for release, which may involve detailed analysis and/or sterilization, is expected to take several months. However, the process of breaking the sample tube seal and extracting the headspace gas will perturb local equilibrium conditions between gas and rock and set in motion irreversible processes that proceed as a function of time. Unless these time-sensitive processes are understood, planned for, and/or monitored during the quarantine period, scientific information expected from further analysis may be lost forever. At least four processes underpin the time-sensitivity of Mars returned sample science: (1) degradation of organic material of potential biological origin, (2) modification of sample headspace gas composition, (3) mineral-volatile exchange, and (4) oxidation/reduction of redox-sensitive materials. Available constraints on the timescales associated with these processes supports the conclusion that an SRF must have the capability to characterize attributes such as sample tube headspace gas composition, organic material of potential biological origin, as well as volatiles and their solid-phase hosts. Because most time-sensitive investigations are also sensitive to sterilization, these must be completed inside the SRF and on timescales of several months or less. To that end, we detail recommendations for how sample preparation and analysis could complete these investigations as efficiently as possible within an SRF. Finally, because constraints on characteristic timescales that define time-sensitivity for some processes are uncertain, future work should focus on: (1) quantifying the timescales of volatile exchange for core material physically and mineralogically similar to samples expected to be returned from Mars, and (2) identifying and developing stabilization or temporary storage strategies that mitigate volatile exchange until analysis can be completed. Executive Summary Any samples returned from Mars would be placed under quarantine at a Sample Receiving Facility (SRF) until it can be determined that they are safe to release to other laboratories for further study. The process of determining whether samples are safe for release, which may involve detailed analysis and/or sterilization, is expected to take several months. However, the process of breaking the sample tube seal and extracting the headspace gas would perturb local equilibrium conditions between gas and rock and set in motion irreversible processes that proceed as a function of time. <u<iUnless these processes are understood, planned for, and/or monitored during the quarantine period, scientific information expected from further analysis may be lost forever</i</u. Specialist members of the Mars Sample Return Planning Group Phase 2 (MSPG-2), referred to here as the Time-Sensitive Focus Group, have identified four processes that underpin the time-sensitivity of Mars returned sample science: (1) degradation of organic material of potential biological origin, (2) modification of sample headspace gas composition, (3) mineral-volatile exchange, and (4) oxidation/reduction of redox-sensitive materials (Figure 2). Consideration of the timescales and the degree to which these processes jeopardize scientific investigations of returned samples supports the conclusion that an SRF must have the capability to characterize: (1) sample tube headspace gas composition, (2) organic material of potential biological origin, (3) volatiles bound to or within minerals, and (4) minerals or other solids that host volatiles (Table 4). <u<iMost of the investigations classified as time-sensitive in this report are also sensitive to sterilization by either heat treatment and/or gamma irradiation (Velbel et al., 2022). Therefore, these investigations must be completed inside biocontainment and on timescales that minimize the irrecoverable loss of scientific information (i.e., several months or less; Section 5)</i.</u To that end, the Time-Sensitive Focus Group has outlined a number of specific recommendations for sample preparation and instrumentation in order to complete these investigations as efficiently as possible within an SRF (Table 5). Constraints on the characteristic timescales that define time-sensitivity for different processes can range from relatively coarse to uncertain (Section 4). Thus, future work should focus on: (1) quantifying the timescales of volatile exchange for variably lithified core material physically and mineralogically similar to samples expected to be returned from Mars, and (2) identifying and developing stabilization strategies or temporary storage strategies that mitigate volatile exchange until analysis can be completed. List of Findings <bFINDING T-1:</b Aqueous phases, and oxidants liberated by exposure of the sample to aqueous phases, mediate and accelerate the degradation of critically important but sensitive organic compounds such as DNA. <bFINDING T-2:</b Warming samples increases reaction rates and destroys compounds making biological studies much more time-sensitive. <bMAJOR FINDING T-3: Given the potential for rapid degradation of biomolecules, (especially in the presence of aqueous phases and/or reactive O-containing compounds) Sample Safety Assessment Protocol (SSAP) and parallel biological analysis are time sensitive and must be carried out as soon as possible.</b <bFINDING T-4:</b If molecules or whole cells from either extant or extinct organisms have persisted under present-day martian conditions in the samples, then it follows that preserving sample aliquots under those same conditions (<ii.e.,</i 6 mbar total pressure in a dominantly CO<sub2</sub atmosphere and at an average temperature of -80<sup°</supC) in a small isolation chamber is likely to allow for their continued persistence. <bFINDING T-5:</b Volatile compounds (<ie.g.,</i HCN and formaldehyde) have been lost from Solar System materials stored under standard curation conditions. <bFINDING T-6:</b Reactive O-containing species have been identified <iin situ</i at the martian surface and so may be present in rock or regolith samples returned from Mars. These species rapidly degrade organic molecules and react more rapidly as temperature and humidity increase. <bFINDING T-7:</b Because the sample tubes would not be closed with perfect seals and because, after arrival on Earth, there will be a large pressure gradient across that seal such that the probability of contamination of the tube interiors by terrestrial gases increases with time, the as-received sample tubes are considered a poor choice for long-term gas sample storage. This is an important element of time sensitivity. <bMAJOR FINDING T-8: To determine how volatiles may have been exchanged with headspace gas during transit to Earth, the composition of martian atmosphere (in a separately sealed reservoir and/or extracted from the witness tubes), sample headspace gas composition, temperature/time history of the samples, and mineral composition (including mineral-bound volatiles) must all be quantified. When the sample tube seal is breached, mineral-bound volatile loss to the curation atmosphere jeopardizes robust determination of volatile exchange history between mineral and headspace.</b <bFINDING T-9:</b Previous experiments with mineral powders show that sulfate minerals are susceptible to H<sub2</subO loss over timescales of hours to days. In addition to volatile loss, these processes are accompanied by mineralogical transformation. Thus, investigations targeting these minerals should be considered time-sensitive. <bFINDING T-10:</b Sulfate minerals may be stabilized by storage under fixed relative-humidity conditions, but only if the identity of the sulfate phase(s) is known <ia priori</i. In addition, other methods such as freezing may also stabilize these minerals against volatile loss. <bFINDING T-11:</b Hydrous perchlorate salts are likely to undergo phase transitions and volatile exchange with ambient surroundings in hours to days under temperature and relative humidity ranges typical of laboratory environments. However, the exact timescale over which these processes occur is likely a function of grain size, lithification, and/or cementation. <bFINDING T-12:</b Nanocrystalline or X-ray amorphous materials are typically stabilized by high proportions of surface adsorbed H<sub2</subO. Because this surface adsorbed H<sub2</subO is weakly bound compared to bulk materials, nanocrystalline materials are likely to undergo irreversible ripening reactions in response to volatile loss, which in turn results in decreases in specific surface area and increases in crystallinity. These reactions are expected to occur over the timescale of weeks to months under curation conditions. Therefore, the crystallinity and specific surface area of nanocrystalline materials should be characterized and monitored within a few months of opening the sample tubes. These are considered time-sensitive measurements that must be made as soon as possible. <bFINDING T-13:</b Volcanic and impact glasses, as well as opal-CT, are metastable in air and susceptible to alteration and volatile exchange with other solid phases and ambient headspace. However, available constraints indicate that these reactions are expected to proceed slowly under typical laboratory conditions (<ii.e.,</i several years) and so analyses targeting these materials are not considered time sensitive. <bFINDING T-14:</b Surface adsorbed and interlayer-bound H<sub2</subO in clay minerals is susceptible to exchange with ambient surroundings at timescales of hours to days, although the timescale may be modified depending on the degree of lithification or cementation. Even though structural properties of clay minerals remain unaffected during this process (with the exception of the interlayer spacing), investigations targeting H<sub2</subO or other volatiles bound on or within clay minerals should be considered time sensitive upon opening the sample tube. <bFINDING T-15:</b Hydrated Mg-carbonates are susceptible to volatile loss and recrystallization and transformation over timespans of months or longer, though this timescale may be modified by the degree of lithification and cementation. Investigations targeting hydrated carbonate minerals (either the volatiles they host or their bulk mineralogical properties) should be considered time sensitive upon opening the sample tube. <bMAJOR FINDING T-16: Current understanding of mineral-volatile exchange rates and processes is largely derived from monomineralic experiments and systems with high surface area; lithified sedimentary rocks (accounting for some, but not all, of the samples in the cache) will behave differently in this regard and are likely to be associated with longer time constants controlled in part by grain boundary diffusion. Although insufficient information is available to quantify this at the present time, the timescale of mineral-volatile exchange in lithified samples is likely to overlap with the sample processing and curation workflow (<ii.e.,</i 1-10 months; Table 4). This underscores the need to prioritize measurements targeting mineral-hosted volatiles within biocontainment.</b <bFINDING T-17:</b The liberation of reactive O-species through sample treatment or processing involving H<sub2</subO (<ie.g.,</i rinsing, solvent extraction, particle size separation in aqueous solution, or other chemical extraction or preparation protocols) is likely to result in oxidation of some component of redox-sensitive materials in a matter of hours. The presence of reactive O-species should be examined before sample processing steps that seek to preserve or target redox-sensitive minerals. Electron paramagnetic resonance spectroscopy (EPR) is one example of an effective analytical method capable of detecting and characterizing the presence of reactive O-species. <bFINDING T-18:</b Environments that maintain anoxia under inert gas containing &lt;&lt;1 ppm O<sub2</sub are likely to stabilize redox-sensitive minerals over timescales of several years. <bMAJOR FINDING T-19: MSR investigations targeting organic macromolecular or cellular material, mineral-bound volatile compounds, redox sensitive minerals, and/or hydrous carbonate minerals can become compromised at the timescale of weeks (after opening the sample tube), and scientific information may be completely lost within a time timescale of a few months. Because current considerations indicate that completion of SSAP, sample sterilization, and distribution to investigator laboratories cannot be completed in this time, these investigations must be completed within the Sample Receiving Facility as soon as possible.</b

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The prognosis of people with metastatic cutaneous melanoma, a skin cancer, is generally poor. Recently, new classes of drugs (e.g. immune checkpoint inhibitors and small-molecule targeted drugs) have significantly improved patient prognosis, which has drastically changed the landscape of melanoma therapeutic management. This is an update of a Cochrane Review published in 2000. To assess the beneficial and harmful effects of systemic treatments for metastatic cutaneous melanoma. We searched the following databases up to October 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers and the ASCO database in February 2017, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We considered RCTs of systemic therapies for people with unresectable lymph node metastasis and distant metastatic cutaneous melanoma compared to any other treatment. We checked the reference lists of selected articles to identify further references to relevant trials. Two review authors extracted data, and a third review author independently verified extracted data. We implemented a network meta-analysis approach to make indirect comparisons and rank treatments according to their effectiveness (as measured by the impact on survival) and harm (as measured by occurrence of high-grade toxicity). The same two review authors independently assessed the risk of bias of eligible studies according to Cochrane standards and assessed evidence quality based on the GRADE criteria. We included 122 RCTs (28,561 participants). Of these, 83 RCTs, encompassing 21 different comparisons, were included in meta-analyses. Included participants were men and women with a mean age of 57.5 years who were recruited from hospital settings. Twenty-nine studies included people whose cancer had spread to their brains. Interventions were categorised into five groups: conventional chemotherapy (including single agent and polychemotherapy), biochemotherapy (combining chemotherapy with cytokines such as interleukin-2 and interferon-alpha), immune checkpoint inhibitors (such as anti-CTLA4 and anti-PD1 monoclonal antibodies), small-molecule targeted drugs used for melanomas with specific gene changes (such as BRAF inhibitors and MEK inhibitors), and other agents (such as anti-angiogenic drugs). Most interventions were compared with chemotherapy. In many cases, trials were sponsored by pharmaceutical companies producing the tested drug: this was especially true for new classes of drugs, such as immune checkpoint inhibitors and small-molecule targeted drugs.When compared to single agent chemotherapy, the combination of multiple chemotherapeutic agents (polychemotherapy) did not translate into significantly better survival (overall survival: HR 0.99, 95% CI 0.85 to 1.16, 6 studies, 594 participants; high-quality evidence; progression-free survival: HR 1.07, 95% CI 0.91 to 1.25, 5 studies, 398 participants; high-quality evidence. Those who received combined treatment are probably burdened by higher toxicity rates (RR 1.97, 95% CI 1.44 to 2.71, 3 studies, 390 participants; moderate-quality evidence). (We defined toxicity as the occurrence of grade 3 (G3) or higher adverse events according to the World Health Organization scale.)Compared to chemotherapy, biochemotherapy (chemotherapy combined with both interferon-alpha and interleukin-2) improved progression-free survival (HR 0.90, 95% CI 0.83 to 0.99, 6 studies, 964 participants; high-quality evidence), but did not significantly improve overall survival (HR 0.94, 95% CI 0.84 to 1.06, 7 studies, 1317 participants; high-quality evidence). Biochemotherapy had higher toxicity rates (RR 1.35, 95% CI 1.14 to 1.61, 2 studies, 631 participants; high-quality evidence).With regard to immune checkpoint inhibitors, anti-CTLA4 monoclonal antibodies plus chemotherapy probably increased the chance of progression-free survival compared to chemotherapy alone (HR 0.76, 95% CI 0.63 to 0.92, 1 study, 502 participants; moderate-quality evidence), but may not significantly improve overall survival (HR 0.81, 95% CI 0.65 to 1.01, 2 studies, 1157 participants; low-quality evidence). Compared to chemotherapy alone, anti-CTLA4 monoclonal antibodies is likely to be associated with higher toxicity rates (RR 1.69, 95% CI 1.19 to 2.42, 2 studies, 1142 participants; moderate-quality evidence).Compared to chemotherapy, anti-PD1 monoclonal antibodies (immune checkpoint inhibitors) improved overall survival (HR 0.42, 95% CI 0.37 to 0.48, 1 study, 418 participants; high-quality evidence) and probably improved progression-free survival (HR 0.49, 95% CI 0.39 to 0.61, 2 studies, 957 participants; moderate-quality evidence). Anti-PD1 monoclonal antibodies may also result in less toxicity than chemotherapy (RR 0.55, 95% CI 0.31 to 0.97, 3 studies, 1360 participants; low-quality evidence).Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival (HR 0.63, 95% CI 0.60 to 0.66, 1 study, 764 participants; high-quality evidence) and progression-free survival (HR 0.54, 95% CI 0.50 to 0.60, 2 studies, 1465 participants; high-quality evidence). Anti-PD1 monoclonal antibodies may result in better toxicity outcomes than anti-CTLA4 monoclonal antibodies (RR 0.70, 95% CI 0.54 to 0.91, 2 studies, 1465 participants; low-quality evidence).Compared to anti-CTLA4 monoclonal antibodies alone, the combination of anti-CTLA4 plus anti-PD1 monoclonal antibodies was associated with better progression-free survival (HR 0.40, 95% CI 0.35 to 0.46, 2 studies, 738 participants; high-quality evidence). There may be no significant difference in toxicity outcomes (RR 1.57, 95% CI 0.85 to 2.92, 2 studies, 764 participants; low-quality evidence) (no data for overall survival were available).The class of small-molecule targeted drugs, BRAF inhibitors (which are active exclusively against BRAF-mutated melanoma), performed better than chemotherapy in terms of overall survival (HR 0.40, 95% CI 0.28 to 0.57, 2 studies, 925 participants; high-quality evidence) and progression-free survival (HR 0.27, 95% CI 0.21 to 0.34, 2 studies, 925 participants; high-quality evidence), and there may be no significant difference in toxicity (RR 1.27, 95% CI 0.48 to 3.33, 2 studies, 408 participants; low-quality evidence).Compared to chemotherapy, MEK inhibitors (which are active exclusively against BRAF-mutated melanoma) may not significantly improve overall survival (HR 0.85, 95% CI 0.58 to 1.25, 3 studies, 496 participants; low-quality evidence), but they probably lead to better progression-free survival (HR 0.58, 95% CI 0.42 to 0.80, 3 studies, 496 participants; moderate-quality evidence). However, MEK inhibitors probably have higher toxicity rates (RR 1.61, 95% CI 1.08 to 2.41, 1 study, 91 participants; moderate-quality evidence).Compared to BRAF inhibitors, the combination of BRAF plus MEK inhibitors was associated with better overall survival (HR 0.70, 95% CI 0.59 to 0.82, 4 studies, 1784 participants; high-quality evidence). BRAF plus MEK inhibitors was also probably better in terms of progression-free survival (HR 0.56, 95% CI 0.44 to 0.71, 4 studies, 1784 participants; moderate-quality evidence), and there appears likely to be no significant difference in toxicity (RR 1.01, 95% CI 0.85 to 1.20, 4 studies, 1774 participants; moderate-quality evidence).Compared to chemotherapy, the combination of chemotherapy plus anti-angiogenic drugs was probably associated with better overall survival (HR 0.60, 95% CI 0.45 to 0.81; moderate-quality evidence) and progression-free survival (HR 0.69, 95% CI 0.52 to 0.92; moderate-quality evidence). There may be no difference in terms of toxicity (RR 0.68, 95% CI 0.09 to 5.32; low-quality evidence). All results for this comparison were based on 324 participants from 2 studies.Network meta-analysis focused on chemotherapy as the common comparator and currently approved treatments for which high- to moderate-quality evidence of efficacy (as represented by treatment effect on progression-free survival) was available (based on the above results) for: biochemotherapy (with both interferon-alpha and interleukin-2); anti-CTLA4 monoclonal antibodies; anti-PD1 monoclonal antibodies; anti-CTLA4 plus anti-PD1 monoclonal antibodies; BRAF inhibitors; MEK inhibitors, and BRAF plus MEK inhibitors. Analysis (which included 19 RCTs and 7632 participants) generated 21 indirect comparisons.The best evidence (moderate-quality evidence) for progression-free survival was found for the following indirect comparisons:• both combinations of immune checkpoint inhibitors (HR 0.30, 95% CI 0.17 to 0.51) and small-molecule targeted drugs (HR 0.17, 95% CI 0.11 to 0.26) probably improved progression-free survival compared to chemotherapy;• both BRAF inhibitors (HR 0.40, 95% CI 0.23 to 0.68) and combinations of small-molecule targeted drugs (HR 0.22, 95% CI 0.12 to 0.39) were probably associated with better progression-free survival compared to anti-CTLA4 monoclonal antibodies;• biochemotherapy (HR 2.81, 95% CI 1.76 to 4.51) probably lead to worse progression-free survival compared to BRAF inhibitors;• the combination of small-molecule targeted drugs probably improved progression-free survival (HR 0.38, 95% CI 0.21 to 0.68) compared to anti-PD1 monoclonal antibodies;• both biochemotherapy (HR 5.05, 95% CI 3.01 to 8.45) and MEK inhibitors (HR 3.16, 95% CI 1.77 to 5.65) were probably associated with worse progression-free survival compared to the combination of small-molecule targeted drugs; and• biochemotherapy was probably associated with worse progression-free survival (HR 2.81, 95% CI 1.54 to 5.11) compared to the combination of immune checkpoint inhibitors.The best evidence (moderate-quality evidence) for toxicity was found for the following indirect comparisons:• combination of immune checkpoint inhibitors (RR 3.49, 95% CI 2.12 to 5.77) probably increased toxicity compared to chemotherapy;• combination of immune checkpoint inhibitors probably increased toxicity (RR 2.50, 95% CI 1.20 to 5.20) compared to BRAF inhibitors;• the combination of immune checkpoint inhibitors probably increased toxicity (RR 3.83, 95% CI 2.59 to 5.68) compared to anti-PD1 monoclonal antibodies; and• biochemotherapy was probably associated with lower toxicity (RR 0.41, 95% CI 0.24 to 0.71) compared to the combination of immune checkpoint inhibitors.Network meta-analysis-based ranking suggested that the combination of BRAF plus MEK inhibitors is the most effective strategy in terms of progression-free survival, whereas anti-PD1 monoclonal antibodies are associated with the lowest toxicity.Overall, the risk of bias of the included trials can be considered as limited. When considering the 122 trials included in this review and the seven types of bias we assessed, we performed 854 evaluations only seven of which (&lt; 1%) assigned high risk to six trials. We found high-quality evidence that many treatments offer better efficacy than chemotherapy, especially recently implemented treatments, such as small-molecule targeted drugs, which are used to treat melanoma with specific gene mutations. Compared with chemotherapy, biochemotherapy (in this case, chemotherapy combined with both interferon-alpha and interleukin-2) and BRAF inhibitors improved progression-free survival; BRAF inhibitors (for BRAF-mutated melanoma) and anti-PD1 monoclonal antibodies improved overall survival. However, there was no difference between polychemotherapy and monochemotherapy in terms of achieving progression-free survival and overall survival. Biochemotherapy did not significantly improve overall survival and has higher toxicity rates compared with chemotherapy.There was some evidence that combined treatments worked better than single treatments: anti-PD1 monoclonal antibodies, alone or with anti-CTLA4, improved progression-free survival compared with anti-CTLA4 monoclonal antibodies alone. Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival, and a combination of BRAF plus MEK inhibitors was associated with better overall survival for BRAF-mutated melanoma, compared to BRAF inhibitors alone.The combination of BRAF plus MEK inhibitors (which can only be administered to people with BRAF-mutated melanoma) appeared to be the most effective treatment (based on results for progression-free survival), whereas anti-PD1 monoclonal antibodies appeared to be the least toxic, and most acceptable, treatment.Evidence quality was reduced due to imprecision, between-study heterogeneity, and substandard reporting of trials. Future research should ensure that those diminishing influences are addressed. Clinical areas of future investigation should include the longer-term effect of new therapeutic agents (i.e. immune checkpoint inhibitors and targeted therapies) on overall survival, as well as the combination of drugs used in melanoma treatment; research should also investigate the potential influence of biomarkers.

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Ethylene thiourea is a white crystalline solid used extensively in the rubber industry as an accelerator in the vulcanization of elastomers. It is also a trace contaminant and metabolic degradation product of a widely used class of ethylene bisdithiocarbamate fungicides. Ethylene thiourea is known to produce thyroid neoplasms in rats and liver neoplasms in mice following long-term administration; thus, it was chosen by the National Toxicology Program in an investigation of the potential value of perinatal exposures in assessing chemical carcinogenicity. Chronic toxicity and carcinogenicity studies of ethylene thiourea, 99% pure, were conducted in F344/N rats and B6C3F1 mice of each sex. The studies were designed to determine 1) the effects of ethylene thiourea in rats and mice receiving adult exposure only (a typical carcinogenicity study), 2) the toxic and carcinogenic effects of ethylene thiourea on rats and mice receiving perinatal exposure only (dietary exposure of dams prior to breeding and throughout gestation and lactation), and 3) the effects of combined perinatal and adult exposure to ethylene thiourea. STUDIES IN F344/N RATS: In a preliminary study to determine the perinatal dietary concentrations for the 2-year studies, female F344/N rats were fed 0, 8, 25, 83, or 250 ppm ethylene thiourea in the feed beginning 2 weeks prior to breeding and continuing throughout gestation and lactation, and the pups were fed at these same concentrations up to 9 weeks postweaning. Based on decreased survival of rat pups between postnatal days 0 to 4 and reduction in body weight gains in male weanling rats receiving 250 ppm, dietary concentrations of 0, 9, 30, and 90 ppm were selected for the perinatal (F0) exposure levels in the 2-year studies. Groups of 10 male and 10 female rats, 8 to 9 weeks of age, were fed diets containing 0, 60, 125, 250, 500, or 750 ppm ethylene thiourea for 13 weeks to determine the adult dietary concentrations. Because of reduced weight gains and decreased feed consumption in rats receiving 500 or 750 ppm ethylene thiourea, dietary concentrations of 0, 25, 83, and 250 ppm were selected for the adult (F1) exposure during the 2-year studies. In the 2-year studies, perinatal and adult exposures to ethylene thiourea were applied separately and together to groups of male or female rats as shown in the following table. The principal toxic effects of ethylene thiourea involved the thyroid gland. Serum levels of thyroxine (T4) and/or triiodothyronine (T3) were significantly decreased in rats receiving adult concentrations of 83 or 250 ppm, and thyrotropin (thyroid-stimulating hormone, TSH) was significantly increased at these concentrations. In male and female rats receiving adult-only exposure of 83 or 250 ppm, the incidences of follicular cell hyperplasia or follicular cell adenoma of the thyroid gland were significantly increased relative to the controls. The incidences of follicular cell carcinoma were significantly increased in the 250 ppm groups, and carcinomas occurred more frequently in males than in females. Exposure Groups of Rats in the 2-Year Feed Studies of Ethylene Thiourea a F1 Concentration (ppm)b F0(ppm)c 0 25 83 250 0 60 -- 60 60 9 -- 60 -- -- 30 -- -- 60 -- 90 60 -- 60 60 a Ten rats from each group were sacrificed and evaluated at 9 months b Concentration of ethylene thiourea in feed given to rats beginning at 8 weeks of age for 24 months c Concentration of ethylene thiourea in feed through breeding, gestation, and lactation until pups were 8 weeks of age Perinatal-only exposure to 90 ppm had no effect on the incidence of thyroid neoplasms in these studies, although there was a marginal increase in follicular cell hyperplasia relative to the controls. However, for groups of rats receiving combined perinatal and adult exposure (F0:F1), males and females receiving concentrations of 90:250 ppm ethylene thiourea had significantly increased incidences of thyroid follicular cell neoplasms relative to those receiving adult-only exposure to 250 ppm. Further, groups of male rats receiving 90:83 ppm 83 ppm showed a significantly increased incidence of follicular cell hyperplasia. Final mean body weights of males and survival of males and females receiving combined perinatal (90 ppm) and adult (250 ppm) exposure were lower than those receiving adult-only exposure of 250 ppm. Thus, in rats, combined perinatal and adult exposure slightly enhanced the toxicity and proliferative effects on the thyroid gland observed with adult-only exposure to ethylene thiourea. Neoplasms of the Zymbal's gland were marginally increased in rats receiving 90:250 ppm (males - 0:0, 1/50; 90:250, 5/50; females - 0:0, 1/50; 90:250, 4/50). Mononuclear cell leukemia occurred with a significant trend in groups of male and female rats receiving perinatal exposure of 90 ppm and increasing adult concentrations (90:0, 90:83, and 90:250 ppm), and for female rats without perinatal exposure (0:0, 0:83, and 0:250 ppm). The incidences of mononuclear cell leukemia in males receiving 90:83 ppm and males and females receiving 90:250 ppm were statistically significant relative to the respective 0:0 ppm groups. Low incidences of renal tubule cell adenomas occurred in most dose groups of male rats, but not in the highest dose group or the controls. STUDIES IN B6C3F1 MICE: In a preliminary study to determine the perinatal dietary concentrations for the 2-year studies, adult female C57BL/6N mice were fed 0, 33, 100, 330, or 1,000 ppm ethylene thiourea in the feed beginning 2 weeks prior to breeding and continuing throughout gestation and lactation and up to 9 weeks postweaning. Because of reduced survival of mouse pups at postnatal day 28 and lower final mean body weights in weanlings receiving perinatal exposure of 1,000 ppm, dietary concentrations of 0, 33, 110, and 330 ppm were selected for the perinatal exposure levels in the 2-year studies. Groups of 10 male and 10 female mice, 8 to 9 weeks of age, were fed diets containing 0, 125, 250, 500, 1,000, or 2,000 ppm ethylene thiourea for 13 weeks to determine the adult dietary concentrations. Moderately severe diffuse follicular cell hyperplasia in the thyroid gland and centrilobular cytomegaly of the liver occurred in mice receiving 2,000 ppm. Because the severity of the thyroid lesion (and degree of hypothyroidism) at this concentration was considered potentially life threatening in 2-year studies, dietary concentrations of 0, 100, 330, and 1,000 ppm ethylene thiourea were selected for adult exposure during the 2-year studies. In the 2-year studies, perinatal and adult exposures to ethylene thiourea were applied separately and together to groups of male or female mice as shown in the following table. Exposure Groups of Mice in the 2-Year Feed Studies of Ethylene Thiourea a F1 Concentration (ppm)b F0(ppm)c 0 100 330 1,000 0 69 -- 60 60 33 -- 34/29d -- -- 110 -- -- 60 -- 330 60 -- 60 60 a Ten mice from each group except the 33:100 ppm group were sacrificed and evaluated at 9 months b Concentration of ethylene thiourea in feed given to mice beginning at 8 weeks of age for 24 months c Concentration of ethylene thiourea in feed through breeding, gestation, and lactation until pups were 8 weeks of age d 34 males and 29 females assigned to group The principal toxic effects of ethylene thiourea in mice occurred in the thyroid gland, liver, and pituitary gland. Serum levels of T3 were significantly decreased in groups of mice receiving adult concentrations of 1,000 ppm; TSH was significantly increased in mice receiving 330 and 1,000 ppm. The incidences of follicular cell hyperplasia and neoplasia increased principally in males receiving 1,000 ppm and in females receiving 330 or 1,000 ppm. Follicular cell carcinomas were significantly increased in mice receiving 1,000 ppm. Incidences of centrilobular hepatocellular cytomegaly (males and females), hepatocellular adenoma (females), hepatocellular carcinoma (males and females), and adenoma or carcinoma combined (males and females) also were significantly increased in mice receiving F1 concentrations of 330 or 1,000 ppm. In the pituitary gland, incidences of focal hyperplasia (males) or adenoma (males and females) of the pars distalis were significantly increased in groups of mice receiving 1,000 ppm ethylene thiourea. Perinatal exposure to concentrations of 330 ppm had no effect on the incidences of nonneoplastic lesions or neoplasms in mice. For groups of mice receiving combined perinatal and adult exposure, females receiving F0:F1 concentrations of 330:330 ppm had significantly increased incidences of follicular cell adenoma relative to those receiving adult-only exposure to 330 ppm. Similarly, male mice receiving F0:F1 concentrations of 330:330 ppm had significantly increased incidences of follicular cell hyperplasia. Thus, in mice, perinatal exposure slightly enhanced the proliferative effects on the thyroid gland of adult exposure. There were no effects of perinatal exposure in mice at sites other than in the thyroid gland. CONCLUSIONS: 2-Year Adult-Only Exposure:Under the conditions of these 2-year adult-only dietary exposures, there was clear evidence of carcinogenic activity of ethylene thiourea in male and female F344/N rats, as shown by increased incidences of thyroid follicular cell neoplasms. There was clear evidence of carcinogenic activity of ethylene thiourea in male and female B6C3F1 mice as shown by increased incidences of thyroid follicular cell neoplasms, hepatocellular neoplasms, and adenomas of the pars distalis of the pituitary gland. Nonneoplastic lesions associated with the administration of ethylene thiourea included follicular cell hyperplasia in rats and mice and follicular cell cytoplasmic vacuolation, centrilobular hepatocellular cytomegaly, and focal hyperplasia of the pars distalis of the pituitary gland in mice. Other effects associated with the administration of ethylene thiourea included decreased serum levels of T4 and/or T3 in rats and increased serum levels of TSH in rats and mice. Perinatal-Only Exposure:Perinatal exposure alone had no effect on the incidences of neoplasms in rats or mice after 2 years. Animals may have been able to tolerate higher perinatal exposure concentrations. Combined Perinatal and 2-Year Adult Exposures:Combined perinatal and 2-year adult dietary exposure to ethylene thiourea confirmed the findings of the 2-year adult-only exposures for the incidences of neoplasms in the thyroid gland of rats and mice and the liver and pituitary gland of mice. In male and female rats, combined perinatal and adult exposure to 90:250 ppm was associated with marginal increases, relative to the untreated (0:0 ppm) controls, in Zymbal's gland neoplasms and mononuclear cell leukemia, which may have been related to chemical administration. In rats receiving adult exposure to 250 ppm ethylene thiourea, perinatal exposure to 90 ppm was associated with a slightly enhanced incidence of thyroid neoplasms compared to adult-only exposure. However, increasing perinatal exposure from 0 to 90 ppm had no effect on incidences of thyroid neoplasms in rats receiving adult exposure to 83 ppm. Increasing perinatal exposure from 0 to 330 ppm was associated with a marginally increased incidence of thyroid neoplasms in female mice receiving adult exposure to 330 ppm, but there were no enhancing effects of perinatal exposure in mice receiving adult exposure to 1,000 ppm. Synonyms: 2-Imidazolidinethione; Imidazoline-2-thiol; 2-mercaptoimidazoline; N,N'-ethylenethiourea; 1,3-ethylenethiourea; 2-imadazoline-2-thiol

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Manganese is the 12th most abundant element in the earth's crust. The base metal does not occur naturally, but is a component of more than 100 minerals, including sulfides, oxides, carbonates, silicates, phosphates, and borates. In addition to occurring in foods and drinking water, manganese occurs in the atmosphere from dust, volcanic activity, forest fires, and industrial emissions. Manganese (II) sulfate monohydrate was chosen for study because of its stability, solubility, and availability. Toxicology and carcinogenesis studies were conducted by administering manganese (II) sulfate monohydrate (97% pure) in feed to groups of male and female F344/N rats and B6C3F1 mice for 14 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, germ cells of Drosophila melanogaster, and cultured Chinese hamster ovary cells. 14-DAY STUDY IN RATS: Groups of five male and five female rats received diets containing 0, 3,130, 6,250, 12,500, 25,000, or 50,000 ppm manganese (II) sulfate monohydrate. All rats survived to the end of the study. Male rats exposed to 50,000 ppm had a mean body weight gain 57% lower and a final mean body weight 13% lower than those of the controls. The mean body weight gain of 50,000 ppm females was 20% lower and the final mean body weight was 7% lower than those of the controls. During the second week, 50,000 ppm males and females exhibited diarrhea. 14-DAY STUDY IN MICE: Groups of five male and five female mice received diets containing 0, 3,130, 6,250, 12,500, 25,000, or 50,000 ppm manganese (II) sulfate monohydrate. One female mouse in the 25,000 ppm group died on day 1 of unknown causes; all other mice survived to the end of the study. Differences in body weights between exposed and control mice could not be attributed to chemical administration. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats received diets containing 0, 1,600, 3,130, 6,250, 12,500, or 25,000 ppm manganese (II) sulfate monohydrate. Mean daily ingestion of manganese (II) sulfate monohydrate ranged from 110 to 1,700 mg/kg body weight in males and 115 to 2,000 mg/kg in females. All rats survived to the end of the study. Mean body weight gains were marginally lower than that of controls in males exposed to 3,130 ppm or more; mean body weight gains were significantly lower than that of the controls in females exposed to 6,250,12,500, or 25,000 ppm. At the end of the study, absolute and relative liver weights of all exposed male rats and of 25,000 ppm female rats were significantly lower than those of controls. The total leukocyte count in males was similar between exposed and control rats; however, neutrophil counts of all exposed groups were greater than those of the controls, whereas lymphocyte counts of the 6,250, 12,500, and 25,000 ppm groups were significantly lower than those of the controls. Total leukocyte counts in 6,250,12,500, and 25,000 ppm females were significantly decreased because of a decrease in lymphocytes. Male rats also demonstrated marginal but significant increases in percent hematocrit and erythrocyte count in the 6,250,12,500, and 25,000 ppm groups. No clinical or histopathologic findings in rats were chemical related. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice received diets containing 0, 3,130, 6,250, 12,500, 25,000, or 50,000 ppm manganese (II) sulfate monohydrate. Mean daily ingestion of manganese (II) sulfate monohydrate ranged from 330 to 7,400 mg/kg body weight in males and 390 to 6,900 mg/kg body weight in females. No deaths were chemical related. The mean body weight gains of exposed male mice and of 50,000 ppm female mice were significantly lower than those of controls. The absolute and relative liver weights of 50,000 ppm males were significantly lower than those of controls. The percent hematocrit and hemoglobin concentration of males and females exposed to 50,000 ppm were lower than those of the controls, and the mean erythrocyte volumes were significantly lower than those of the controls. The total leukocyte counts of males in the 25,eukocyte counts of males in the 25,000 and 50,000 ppm groups were significantly lower than that of the controls. No clinical findings were attributed to manganese (II) sulfate monohydrate ingestion. Epithelial hyperplasia and hyperkeratosis of the forestomach occurred in three 50,000 ppm males. 2-YEAR STUDY IN RATS: Groups of 70 male and 70 female rats were fed diets containing 0, 1,500, 5,000, or 15,000 ppm manganese (II) sulfate monohydrate. Based on average daily feed consumption, these doses resulted in the daily ingestion of 60, 200, or 615 mg/kg body weight (males) or 70, 230, or 715 mg/kg (females). Eight to 10 rats from each group were evaluated at 9 and 15 months. Survival, Body Weights, Feed Consumption, and Clinical Findings: Survival of 15,000 ppm male rats in the 2-year study was significantly lower than that of the control group. The deaths of males in the control and exposure groups were attributed to a variety of spontaneous neoplastic and nonneoplastic lesions; however, the greater number of deaths in the 15,000 ppm group resulted from increased incidences of advanced renal disease related to ingestion of manganese (II) sulfate monohydrate. The decreased survival of the 15,000 ppm males did not occur until approximately week 93 of the study; before week 93, survival was similar in all groups. Survival of exposed females was similar to that of the controls. The mean body weight of 15,000 ppm male rats was within 5&amp;percnt; of the control group until week 89, by week 104, the mean body weight of 15,000 ppm males was 10&amp;percnt; lower than that of the control group. The mean body weights of 1,500 and 5,000 ppm male rats and all exposed female groups were similar to those of the controls throughout the study. Feed consumption by all exposure groups was similar to that by the control groups. No clinical findings were attributed to manganese (II) sulfate monohydrate ingestion. Hematology, Clinical Chemistry, and Tissue Metal Concentration Analyses No differences in hematology and clinical chemistry parameters attributable to the ingestion of manganese (II) sulfate monohydrate occurred between exposed and control groups. At both the 9- and 15-month interim evaluations, tissue concentrations of manganese were significantly elevated in the livers of 5,000 and 15,000 ppm male and female rats, with an accompanying depression of hepatic iron. Pathology Findings: The ingestion of diets containing 15,000 ppm manganese (II) sulfate monohydrate was associated with a marginal increase in the average severity of nephropathy in male rats (0 ppm, 2.9; 1,500 ppm, 3.0; 5,000 ppm, 3.0; 15,000 ppm, 3.2). The increased severity of nephropathy in the 15,000 ppm male rats was accompanied by significantly increased incidences of mineralization of the blood vessels (4/52, 10/51, 6/51,17/52) and glandular stomach (8/52,13/51, 9/51, 23/52), parathyroid gland hyperplasia (14/51, 14/46, 12/49, 23/50), and fibrous osteodystrophy of the femur (12/52,14/51,12/51, 24/52). These lesions are manifestations of renal failure, uremia, and secondary hyperparathyroidism. The increased incidence of advanced renal disease caused reduced survival of the high-dose male rats. No increase in the incidence of neoplasms in male or female rats was attributed to the ingestion of diets containing manganese (II) sulfate monohydrate. 2-YEAR STUDY IN MICE: Groups of 70 male and 70 female mice received diets containing 0, 1,500, 5,000, or 15,000 ppm manganese (II) sulfate monohydrate. These levels resulted in an average daily ingestion of 160, 540, or 1,800 mg/kg body weight (males) or 200, 700, or 2,250 mg/kg (females). Nine or 10 mice from each group were evaluated at the 9-month and 15-month interim evaluations. Survival, Body Weights, Feed Consumption, and Clinical Findings: Survival rates of exposed male and female mice in the 2-year study were similar to those of the control groups. The mean body weights of exposed male mice were similar to that of the control group. Compared to controls, female mice had exposure related lower mean body weights after week 37, and the final mean body weights for the 1,500, 5,000, and 15,000 ppm groups were 6&amp;percnt;, 9&amp;percnt;, and 13&amp;percnt; lower than that of the control group. Feed consumption by all exposure groups was similar to that by the control groups. No clinical findings were attributed to the administration of manganese (II) sulfate monohydrate. Hematology, Clinical Chemistry, and Tissue Metal Concentration Analyses No chemical-related differences between exposed and control groups occurred in hematology or clinical chemistry parameters. At the 9- and 15-month interim evaluations, tissue concentrations of manganese were significantly elevated in the livers of the 5,000 and 15,000 ppm groups. Hepatic iron levels were significantly lower in exposed females at the 9-month interim evaluation and in 5,000 and 15,000 males and all exposed females at the 15-month interim evaluation. Pathology Findings: Incidences of thyroid follicular dilatation and hyperplasia were significantly greater in 15,000 ppm male and female mice than in controls. Follicular cell adenomas occurred in one 15,000 ppm male at the 15-month interim evaluation and in three 15,000 ppm males at the end of the study but not in the lower exposure groups or the control group. Follicular cell adenomas also occurred in two control, one 1,500, and five 15,000 ppm female mice at the end of the study. It is uncertain if the slightly increased incidence of follicular cell adenoma is related to the ingestion of manganese (II) sulfate monohydrate. The incidences of focal hyperplasia of the forestomach epithelium were significantly greater in the 15,000 ppm male and exposed female groups. The hyperplasia was associated with ulcers and inflammation in some mice, particularly males. GENETIC TOXICOLOGY: Manganese (II) sulfate monohydrate was not mutagenic in Salmonella typhimurium strains TA97, TA98, TA100, TA1535, or TA1537, with or without exogenous metabolic activation (S9), and did not induce sex-linked recessive lethal mutations in germ cells of male Drosophila melanogaster. Tests for induction of sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells treated without S9 were positive; with S9, only the sister chromatid exchange test with manganese (11) sulfate monohydrate was positive. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of manganese (II) sulfate monohydrate in male or female F344/N rats receiving 1,500, 5,000, or 15,000 ppm. There was equivocal evidence of carcinogenic activity of manganese (II) sulfate monohydrate in male and female B6C3F1 mice, based on the marginally increased incidences of thyroid gland follicular cell adenoma and the significantly increased incidences of follicular cell hyperplasia. The ingestion of diets containing manganese (II) sulfate monohydrate was associated with an increased severity of nephropathy in male rats, focal squamous hyperplasia of the forestomach in male and female mice, and ulcers and inflammation of the forestomach in male mice. These studies were not designed to assess any neurotoxicity that might have been expected with chronic exposure to sufficiently high doses of manganese. Synonyms: Manganese sulfate; manganous sulfate; sulfuric acid. manganese2+ salt (1:1), monohydrate

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Furie R, Khamashta M, Merrill JT, Werth VP, Kalunian K, Brohawn P, et al. Anifrolumab, an anti-interferon-α receptor monoclonal antibody, in moderate-to-severe systemic lupus erythematosus. Arthritis Rheumatol 2017;69:376-86. Objective To assess the efficacy and safety of anifrolumab, a type I interferon (IFN) receptor antagonist, in a phase IIb, randomized, double-blind, placebo-controlled study of adults with moderate-to-severe systemic lupus erythematosus (SLE). Methods Patients (n = 305) were randomized to receive intravenous anifrolumab (300 mg or 1,000 mg) or placebo, in addition to standard therapy, every 4 weeks for 48 weeks. Randomization was stratified by SLE Disease Activity Index 2000 score (&lt;10 or ≥10), oral corticosteroid dosage (&lt;10 or ≥10 mg/day), and type I IFN gene signature test status (high or low) based on a 4-gene expression assay. The primary end point was the percentage of patients achieving an SLE Responder Index (SRI [4]) response at week 24 with sustained reduction of oral corticosteroids (&lt;10 mg/day and less than or equal to the dose at week 1 from week 12 through 24). Other end points (including SRI [4], British Isles Lupus Assessment Group [BILAG]-based Composite Lupus Assessment [BICLA], modified SRI [6], and major clinical response) were assessed at week 52. The primary end point was analyzed in the modified intent-to-treat (ITT) population and type I IFN-high subpopulation. The study result was considered positive if the primary end point was met in either of the 2 study populations. The Type I error rate was controlled at 0.10 (2-sided), within each of the 2 study populations for the primary end point analysis. Results The primary end point was met by more patients treated with anifrolumab (34.3% of 99 for 300 mg and 28.8% of 104 for 1,000 mg) than placebo (17.6% of 102) (P = 0.014 for 300 mg and P = 0.063 for 1,000 mg, versus placebo), with greater effect size in patients with a high IFN signature at baseline (13.2% in placebo-treated patients versus 36.0% [P = 0.004] and 28.2% [P = 0.029]) in patients treated with anifrolumab 300 mg and 1,000 mg, respectively. At week 52, patients treated with anifrolumab achieved greater responses in SRI(4) (40.2% versus 62.6% [P &lt; 0.001] and 53.8% [P = 0.043] with placebo, anifrolumab 300 mg, and anifrolumab 1,000 mg, respectively), BICLA (25.7% versus 53.5% [P &lt; 0.001] and 41.2% [P = 0.018], respectively), modified SRI(6) (28.4% versus 49.5% [P = 0.002] and 44.7% [P = 0.015], respectively), major clinical response (BILAG 2004 C or better in all organ domains from week 24 through week 52) (6.9% versus 19.2% [P = 0.012] and 17.3% [P = 0.025], respectively), and several other global and organ-specific end points. Herpes zoster was more frequent in the anifrolumab-treated patients (2.0% with placebo treatment versus 5.1% and 9.5% with anifrolumab 300 mg and 1,000 mg, respectively), as were cases reported as influenza (2.0% versus 6.1% and 7.6%, respectively), in the anifrolumab treatment groups. Incidence of serious adverse events was similar between groups (18.8% versus 16.2% and 17.1%, respectively). Conclusion Anifrolumab substantially reduced disease activity compared with placebo across multiple clinical end points in the patients with moderate-to-severe SLE. https://onlinelibrary.wiley.com/doi/10.1002/art.39962 Furie RA, Morand EF, Bruce IN, Manzi S, Kalunian KC, Vital EM, et al. Type I interferon inhibitor anifrolumab in active systemic lupus erythematosus (TULIP-1): a randomised, controlled, phase 3 trial. Lancet Rheumatol 2019;1:E208-19. Background Type I interferons are involved in systemic lupus erythematosus (SLE) pathogenesis. In a phase 2 trial, anifrolumab, a human monoclonal antibody to type I interferon receptor subunit 1, suppressed interferon gene signatures and substantially reduced SLE disease activity. Here, we sought to confirm the efficacy of anifrolumab versus placebo in a phase 3 trial of adult patients with SLE and moderate-to-severe disease activity despite standard-of-care treatment. Methods TULIP-1 was a double-blind, randomised, controlled, phase 3 trial done at 123 sites in 18 countries. Included patients were aged 18-70 years, with moderate-to-severe SLE, and ongoing stable treatment with either prednisone or equivalent, an antimalarial, azathioprine, mizoribine, mycophenolate mofetil or mycophenolic acid, or methotrexate. Patients were randomly assigned (2:1:2) to receive placebo, anifrolumab 150 mg, or anifrolumab 300 mg intravenously every 4 weeks for 48 weeks. Stable standard-of-care treatment continued except for mandatory attempts at oral corticosteroid tapering for patients receiving prednisone or equivalent of 10 mg/day or more at baseline. The primary outcome was the difference between the proportion of patients who achieved an SLE responder index-4 (SRI-4) response at week 52 with anifrolumab 300 mg versus with placebo. Key secondary outcomes were the difference between the anifrolumab 300 mg group and the placebo group in: proportion of patients in the interferon gene signature test-high subgroup who achieved SRI-4 at week 52; proportion of patients on 10 mg/day or more corticosteroids at baseline who achieved a sustained dose reduction to 7·5 mg/day or less from week 40 to 52; proportion of patients with a cutaneous lupus erythematosus disease area and severity index (CLASI) activity score of 10 or higher at baseline who achieved a 50% or more reduction in CLASI score by week 12; proportion of patients who achieved SRI-4 at week 24; and annualised flare rate through week 52. Other measures of disease activity were also assessed at week 52, including the British Isles Lupus Assessment Group-based composite lupus assessment (BICLA). Safety was also assessed. Efficacy and safety analyses were done in the population of patients who received at least one dose of study drug. This trial was registered at ClinicalTrials.gov (NCT02446912). Findings Between June 9, 2015, and June 16, 2017, 457 patients were randomly assigned to the anifrolumab 300 mg group (n = 180), the anifrolumab 150 mg group (n = 93), or the placebo group (n = 184). The proportion of patients at week 52 with an SRI-4 response was similar between anifrolumab 300 mg (65 [36%] of 180) and placebo (74 [40%] of 184; difference - 4·2 [95% CI -14·2 to 5·8], p = 0·41). Similarly, proportions of patients with an SRI-4 response at week 24, and at week 52 in patients in the interferon gene signature test-high subgroup, did not differ between the anifrolumab and placebo groups. In patients with baseline oral corticosteroids of at least 10 mg/day, sustained dose reduction to 7·5 mg/day or less was achieved by 42 (41%) of 103 patients in the anifrolumab 300 mg group and 33 (32%) of 102 patients in the placebo group (difference 8·9 [95% CI -4·1 to 21·9]). In patients with CLASI activity score of at least 10 at baseline, at least 50% reduction by week 12 was achieved by 24 (42%) of 58 patients in the anifrolumab 300 mg group and 14 (25%) of 54 in the placebo group (difference 17·0 [95% CI -0·3 to 34·3]). Annualised flare rates were 0·60 for anifrolumab and 0·72 for placebo (rate ratio 0·83 [95% CI 0·60 to 1·14]). BICLA response was achieved by 67 (37%) of 180 patients receiving anifrolumab 300 mg versus 49 (27%) of 184 receiving placebo (difference 10·1 [95% CI 0·6 to 19·7]). Anifrolumab's safety profile was similar to that observed in phase 2, with similar proportions of patients having a serious adverse event between groups (25 [14%] of 180 for anifrolumab 300 mg, ten [11%] of 93 for anifrolumab 150 mg, and 30 [16%] of 184 for placebo). Interpretation The primary endpoint was not reached. However, several secondary endpoints, including reduction in oral corticosteroid dose, CLASI responses, and BICLA responses, suggest clinical benefit of anifrolumab compared with placebo. Conclusive evidence for the efficacy of anifrolumab awaits further phase 3 trial data. Despite the inherent limitations of a 1-year phase 3 study, such as incomplete knowledge of applicability to the general population and scarce detection of rare safety signals, in addition to complications from prespecified restricted medication rules, our results suggest that anifrolumab might have the potential to provide a treatment option for patients who have active SLE while receiving standard therapy. Funding AstraZeneca. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(19)30076-1/fulltext Morand EF, Furie R, Tanaka Y, Bruce IN, Askanase AD, Richez C, et al. Trial of anifrolumab in active systemic lupus erythematosus. N Engl J Med 2020;382:211-21. Background Anifrolumab, a human monoclonal antibody to type I interferon receptor subunit 1 investigated for the treatment of systemic lupus erythematosus (SLE), did not have a significant effect on the primary end point in a previous phase 3 trial. The current phase 3 trial used a secondary end point from that trial as the primary end point. Methods We randomly assigned patients in a 1:1 ratio to receive intravenous anifrolumab (300 mg) or placebo every 4 weeks for 48 weeks. The primary end point of this trial was a response at week 52 defined with the use of the British Isles Lupus Assessment Group (BILAG)-based Composite Lupus Assessment (BICLA). A BICLA response requires reduction in any moderate-to-severe baseline disease activity and no worsening in any of nine organ systems in the BILAG index, no worsening on the Systemic Lupus Erythematosus Disease Activity Index, no increase of 0.3 points or more in the score on the Physician Global Assessment of disease activity (on a scale from 0 [no disease activity] to 3 [severe disease]), no discontinuation of the trial intervention, and no use of medications restricted by the protocol. Secondary end points included a BICLA response in patients with a high interferon gene signature at baseline; reductions in the glucocorticoid dose, in the severity of skin disease, and in counts of swollen and tender joints; and the annualized flare rate. Results A total of 362 patients received the randomized intervention: 180 received anifrolumab and 182 received placebo. The percentage of patients who had a BICLA response was 47.8% in the anifrolumab group and 31.5% in the placebo group (difference, 16.3 percentage points; 95% confidence interval, 6.3 to 26.3; P = 0.001). Among patients with a high interferon gene signature, the percentage with a response was 48.0% in the anifrolumab group and 30.7% in the placebo group; among patients with a low interferon gene signature, the percentage was 46.7% and 35.5%, respectively. Secondary end points with respect to the glucocorticoid dose and the severity of skin disease, but not counts of swollen and tender joints and the annualized flare rate, also showed a significant benefit with anifrolumab. Herpes zoster and bronchitis occurred in 7.2% and 12.2% of the patients, respectively, who received anifrolumab. There was one death from pneumonia in the anifrolumab group. Conclusions Monthly administration of anifrolumab resulted in a higher percentage of patients with a response (as defined by a composite end point) at week 52 than did placebo, in contrast to the findings of a similar phase 3 trial involving patients with SLE that had a different primary end point. The frequency of herpes zoster was higher with anifrolumab than with placebo. (Funded by AstraZeneca; ClinicalTrials.gov number, NCT02446899.) https://www.nejm.org/doi/full/10.1056/nejmoa1912196.

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Integrated Care Pathways (ICPs) are management technologies which formalise multi-disciplinary team-working and enable professionals to examine and address how they articulate their respective roles, responsibilities and activities. They map out a patient's journey and aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. Initially introduced into the health care context in the 1980s in the US, enthusiasm for ICPs now extends across the world. They have been promoted as a means to realise: evidence based practice, clinical governance, continuity of care, patient empowerment, efficiency gains, service re-engineering, role realignment and staff education.While ICPs are now being developed and implemented across international health care arena, evidence to support their use is equivocal and understanding of their 'active ingredients' is poor. Reviews of evidence of ICP effectiveness have focused on their use in specific patient populations. However, ICPs are 'complex interventions' and are increasingly being implemented for a variety of purposes in a range of organisational contexts. Identification of the circumstances in which ICPs are effective is the first step towards developing hypotheses about their active ingredients and the generative mechanisms by which they have their effects.This review was designed to address a slightly different set of questions to those that typify systematic reviews of ICP effectiveness. Rather than simply asking: 'Are ICPs effective?', our concern was to identify the circumstances in which ICPs are effective, for whom and in what contexts. In addition to identifying evidence of ICP effectiveness, the review therefore required attention to the contexts in which ICPs are utilised, the purposes to which they are put and the factors critical to their success. In framing the review in this way we are drawing on the insights afforded by Pawson and Tilley's realistic evaluation methodology. The underlying rationale for this approach is that if we know and understand how different interventions produce varying effects in different circumstances, we are better able to decide what policies/services to implement in what conditions. To identify the purposes for which ICPs are effective, for whom and in what contexts;To identify the purposes for which ICPs are not effective, for whom and in what contexts;To produce recommendations on how ICPs should be used in the full range of health care settings. Types of participants - The review focused on adults and children that accessed health care settings in which ICPs are used.Types of intervention(s)/phenomena of interest - For the purposes of the review, the ICP had to meet the defining characteristics set by the European Pathway Association (EPA):An explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations;Facilitation of communication, coordination of roles, and sequencing of activities of the multidisciplinary care team, patients and their relatives;The documentation, monitoring, and evaluation of variances and outcomes;The identification of the appropriate resources.Here multidisciplinary is taken to refer to the involvement of two or more disciplines.Types of outcomes - Outcome measures were determined by the purposes of the studies selected for review and the type of study participant. Specific clinical outcomes were determined by the group of patients for which the ICP was developed.Types of studies - To address the aims of the review it was necessary to examine evidence of ICP effectiveness across the full spectrum of contexts in which they are in use. In order to keep the study to a manageable scale we limited its scope to randomised controlled trials (RCTs). All RCTs reported between 1980 and 2008 (March) were included in the review. The search was restricted to publications after 1980 coinciding with the emergence of ICPs in the health care context. Non-English language studies were considered for inclusion based on the English language abstract where this was available. Papers were included if an English, German or French translation was available. The review excluded studies that: SEARCH STRATEGY: The strategy consisted of high precision MeSH and non-MeSH index terms and keywords to ensure that all relevant material was captured (). To avoid any potential replication, initial searches of the Joanna Briggs Institute for Evidence Based Nursing and Midwifery and Cochrane Library databases were conducted to establish that no other systematic reviews existed or were currently in progress. Following these initial enquiries a three step search strategy was designed to identify both published and unpublished studies. Stage one involved searching online databases using preliminary keywords, stage two involved using additional search words identified in the title or abstracts found in stage one and stage three involved hand searches of reference lists, bibliographies and key journals including the Journal of Integrated Care Pathways and International Journal of Integrated Care. Our search strategy located 4055 papers, of which 31 were retrieved for further evaluation. We critically appraised 9 papers, representing 7 studies. These studies were appraised for methodological quality using the JBI Critical Appraisal Checklist for Experimental Studies (See ). This appraisal focused specifically upon the reliability and validity of the study method and findings. Two reviewers independently assessed all of the included studies. In cases where reviewers could not reach an agreement a third reviewer was consulted. If disagreement was due to a lack of information then the study authors were contacted for clarification. Following the process of critical appraisal, 9 papers which represents 7 studies, were considered to be of a high enough quality to proceed to data extraction. As the aim of the review was to capture information on context as well as effectiveness, a bespoke data extraction tool was developed. The tool drew on the information included in the JBI extraction sheet for experimental studies and also incorporated specific information and issues relevant to the purpose of the review including aspects of ICP purpose, information on context and critical success factors (). Given the heterogeneity of the included studies meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is therefore presented. Based on the evidence considered in this review, we conclude that:Based on the evidence considered in this review we conclude that:Active Ingredients - We have argued that ICPs are a classic example of a complex intervention. That is they comprise 'a number of separate elements which seem essential to the proper functioning of the intervention although the "active ingredient" of the intervention that is effective is difficult to specify'. None of the studies included in the review were underpinned by explicit theories of ICPs' active ingredients or their generative effects. Moreover, the information provided on ICP development and implementation processes was varied and in no case was any evidence provided to enable the role of these components of the intervention to be assessed. The interventions described by the studies in the review varied in terms of their key components ().Generative Mechanisms - Although none of the studies explicitly address the question of generative mechanisms, in several cases it was possible to make inferences about authors' implicit assumptions, based on the discussion sections of the papers (). On the basis of the evidence considered in the review we suggest that ICPs can be considered as having a multiple role as directing, coordinating, organising, decision-making, and accumulating devices. In addition, because ICPs accumulate information, it seems reasonable to infer that they also function as 'distributing devices' by circulating information to users of the pathway, although no definitive evidence is provided in the studies reviewed to support this assertion. Our review indicates that ICPs can have positive effects on service quality and efficiency as a result of their functions. They are effective in supporting the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. They also have value in supporting implementation of best practice guidelines and protocols by translating these into a format which is suitable for daily use by busy health professionals, thereby improving inter and intra-professional consensus and reducing unacceptable variations in clinical practice. Because they function as accumulating and distributing devices ICPs may also bring about improvements in documentation, which in turn augments their coordinating effects. They provide a focal point of reference - a common resource - to which various members can refer in order to understand where their role fits into the larger whole and determine what actions are necessary and when. Recommendation 1: Given the costs of their development, service providers should restrict ICP use to those areas of service provision where there are clearly identified deficiencies in existing care provision and/or where change is required.Recommendation 2: Prior to ICP development, developers should seek to specify how they wish to change practice, and which of the potential active ingredients of ICPs are necessary for this purpose.Recommendation 3: The evidence suggests that the ICP will change practice. It is imperative therefore, that the directions for action embedded in the tool are based on best practice or evidence.Recommendation 4: ICPs can be usefully deployed to make best practice guidelines available to staff in a form that is useable in daily practice.Recommendation 5: In cases where trajectories of care are more variable ICPs need to have greater degrees of in-built flexibility. Moreover, it is important that staff are supported in exercising professional judgement in those cases when adherence to the pathway is not in the individual patient's interest.Recommendation 6: ICP developers should consider carefully the patient population to whom the ICP applies and identify any sub-groups for whom its use may not be appropriate. Recommendation 1: Primary research is necessary in order to provide stronger evidence of the active ingredients of ICPs, their generative mechanisms and inter-relationships.Recommendation 2: Evaluations of ICPs should specify the ingredients of the intervention, including processes to support development, implementation and sustainability as well as the detail of the ICP artefact itself.Recommendation 3: Evaluations of ICPs need to be underpinned by clarity as to the purposes of the intervention.Recommendation 4: Evaluations of ICPs must include theoretically informed outcome and process measures which take into account the perspective of all relevant stakeholders and the wider system effects of the intervention.Recommendation 5: Evaluations of ICPs should include theoretically informed process outcomes in order to develop understanding of ICP use in practice so that the reasons for behavioural change or its absence are understood.Recommendation 6: Evaluations of ICPs should provide adequate information on the 'control'.Recommendation 7: Evaluations of ICPs should provide adequate information on the local context, taking care to identify critical success factors.Recommendation 8: It is unlikely that ICPs will work for all purposes and in all contexts. Researchers should aim to produce realistic evaluations of ICPs which seek to develop an explanation (and therefore a theory) about how the intervention in question works in particular situations/contexts, by exploring the relationship between context, mechanism and outcome.

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Mercuric chloride is an inorganic compound that has been used in agriculture as a fungicide, in medicine as a topical antiseptic and disinfectant, and in chemistry as an intermediate in the production of other mercury compounds. The widespread use of mercury has resulted in increased levels of mercury in rivers and lakes. Mercuric chloride was evaluated in toxicity and carcinogenicity studies because of its extensive use and its occurrence as an environmental pollutant, and because of the lack of adequate long-term rodent studies. Toxicology and carcinogenesis studies were conducted by administering mercuric chloride (greater than 99% pure) in deionized water by gavage to groups of F344 rats or B6C3F1 mice for 16 days, 6 months, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium (strains TA98, TA100, TA1535, and TA1537), in mouse lymphoma L5178Y cells, in Chinese hamster ovary cells, and in Drosophila melanogaster. 16-DAY STUDIES: Groups of five rats of each sex received 0, 1.25, 2.5, 5, 10, or 20 mg mercuric chloride/kg body weight and groups of five mice of each sex received 0, 5, 10, 20, 40, or 80 mg/kg in deionized water by gavage for 12 dose days. Two male rats in the 20 mg/kg group died in the first week, as did all male and four female mice from the 80 mg/kg group and one male mouse from the 40 mg/kg group. The final mean body weight of male rats receiving 20 mg/kg was 10% lower than that of the controls; the final mean body weight of 20 mg/kg females was 9% lower than that of the controls. Final mean body weights and body weight gains of dosed mice were similar to those of the controls. Absolute and relative kidney weights of male rats receiving 2.5 mg/kg or greater doses and of female rats administered 5 mg/kg or more were significantly greater than those of the controls. Absolute kidney weights of mice were significantly increased in all male dose groups and in the 40 mg/kg female dose group; relative kidney weights of dosed male and female mice were significantly greater than the controls. Analysis of kidney, liver, and brain tissues for mercury residues revealed that the highest mercury concentration was in the kidneys of rats and mice. Acute renal tubule nephropathy occurred in dosed rats and was slightly more severe in males than in females. Chemical-related lesions in mice included renal tubule necrosis, inflammation and necrosis of the forestomach, and necrosis of the glandular stomach. 6-MONTH STUDIES: Groups of 10 rats of each sex received 0, 0.312, 0.625, 1.25, 2.5, or 5 mg mercuric chloride/kg body weight in deionized water by gavage for 26 weeks. Groups of 10 mice of each sex received 0, 1.25, 2.5, 5, 10, or 20 mg/kg in deionized water by gavage for 26 weeks (males) or 27 weeks (females). No deaths related to mercuric chloride administration occurred in rats or mice. Mean body weight gains of male rats that received 5 mg/kg and all female rat dose groups that received 0.625 mg/kg or greater were significantly lower than the controls. The final mean body weight and body weight gain of male mice in the 20 mg/kg group were significantly lower than those of the controls; final mean body weights and body weight gains of other dosed male mice and all dosed female mice were similar to those of the controls. Absolute and relative kidney weights of all dosed male rats and of female rats that received 0.625 mg/kg or greater were significantly greater than those of the controls. In male mice, absolute kidney weights in the three highest dose groups were significantly increased; no biologically significant differences in organ weights occurred in female mice. Analysis of kidney, liver, and brain tissues for mercury residues revealed the highest mercury concentration in the kidneys of rats and mice. The severity of chronic nephropathy increased with dose in male rats. Cytoplasmic vacuolation of renal tubule epithelial cells was observed in male mice in the 5, 10, and 20 mg/kg groups. No histopathologic changes in female mice were related to chemical exposure. 2-YEAR STUDIES: Groups YEAR STUDIES: Groups of 60 rats of each sex received 0, 2.5, or 5 mg mercuric chloride/kg body weight and groups of 60 mice of each sex received 0, 5, or 10 mg/kg in deionized water by gavage 5 days per week for 2 years. The doses were based on decreased weight gains in rats receiving 10 and 20 mg/kg and the decreased weight in male mice receiving 40 mg/kg during the 16-day studies, and on the decreased weight gains and toxicity results seen in the 6-month studies. Increased absolute and relative kidney weights in rats and male mice in the 6-month studies and degenerative renal changes suggested that higher dose levels would result in inadequate survival rates for a 2-year study. 15-Month Interim Evaluations: Relative kidney weights were significantly increased in dosed rats and female mice. The severity of nephropathy was increased in male rats, but not in females. High-dose male and female rats had minimal to mild hyperplasia of the basal cell layer in the forestomach epithelium (diagnosed as acanthosis); this lesion was not found in control or low-dose rats. Male mice had an increased severity of vacuolation of the renal tubule epithelium; no chemical-related lesions occurred in the kidneys of females. The incidence of inflammation of the olfactory epithelium lining the nasal cavity increased in male and female high-dose mice. Survival, Body Weights, and Clinical Signs: Survival of dosed male rats was lower than that of the controls (26/50, 10/50, 5/50); survival of dosed female rats was similar to that of the controls (35/50, 28/49, 30/50). Although more than 60&amp;percnt; of the mice in each dose group survived to study end, survival rates of high-dose male mice and dosed female mice were lower than those of the controls (males: 36/50, 36/50, 31/50; females: 41/50, 35/50, 31/50). The final mean body weights of high-dose male and female rats were 15&amp;percnt; and 14&amp;percnt; lower than controls, respectively. The mean body weight of low-dose female rats was generally similar to controls throughout the 2-year study; the mean body weight of low-dose male rats was similar to that of the control through week 89. In mice, mean body weights of all male and female dose groups were similar to those of the controls throughout the studies. Pathology Findings: Chronic nephropathy appeared to develop at an accelerated rate and led to decreased survival in both dosed male rat groups. Secondary effects of renal dysfunction in dosed male rats resulted in increased incidences of fibrous osteodystrophy of the bone, mineralization of various tissues, and parathyroid gland hyperplasia. Based on evaluations of single and step sections, the incidence of renal tubule hyperplasia was increased in high-dose male rats (control, 3/50; high-dose, 10/50), but the incidences of renal tubule adenoma in high-dose and control males were similar (4/50, 5/50). Renal tubule hyperplasia was also slightly increased in high-dose female rats (2/50, 5/50) and adenomas were seen in high-dose females, but not in controls (0/50, 2/50). Incidences of forestomach hyperplasia in rats were markedly increased in dosed males (3/49, 16/50, 35/50) and high-dose females (5/50, 5/49, 20/50). Squamous cell papillomas of the forestomach were found in 3 low-dose and 12 high-dose males and in 2 high-dose females. No squamous cell carcinomas were found. The incidence of thyroid follicular cell carcinoma was marginally increased in high-dose male rats (1/50, 2/50, 6/50). However, a corresponding increased incidence in follicular cell adenomas (1/50, 4/50, 0/50) or hyperplasia (2/50, 4/50, 2/50) in males did not occur, and the overall incidence of follicular cell neoplasms was not significantly increased (2/50, 6/50, 6/50). The incidence of nasal mucosa inflammation in male and female rats was increased in the high-dose groups (male: 9/50, 8/47, 18/50; female: 0/49, 5/49, 15/50) and may have been related to chemical administration. The incidences of mammary gland fibroadenomas were significantly decreased in dosed female rats (15/50, 5/48, 2/50). The incidence and severity of nephropathy were increased in dosed mice; secondary effects of renal dysfunction did not occur. Renal tubule hyperplasia was found in one control and two high-dose male mice. Two renal tubule adenomas and one renal tubule adenocarcinoma were seen in high-dose male mice. Additional step sections revealed focal hyperplasia in another control male; no additional renal tubule neoplasms were found in high-dose or control males. Proliferative lesions of the renal tubule epithelium were not found in female mice. The incidence of metaplasia of the olfactory epithelium increased with dose in male and female mice. No other biologically significant lesions were found. GENETIC TOXICOLOGY: Mercuric chloride was not mutagenic in Salmonella typhimurium strains TA100, TA1535, TA1537, or TA98 with or without exogenous metabolic activation (S9). Induction of sex-linked recessive lethal mutations in germ cells of male Drosophila melanogaster did not occur when mercuric chloride was administered in feed or by injection. However, positive results were obtained in mutagenicity tests with mammalian cells. In the absence of S9, mercuric chloride induced trifluorothymidine resistance in mouse L5178Y cells and chromosomal aberrations in Chinese hamster ovary cells. In the Chinese hamster ovary cell test for induction of sister chromatid exchanges, mercuric chloride produced a negative response without S9 and a weakly positive response in the presence of S9. CONCLUSIONS: Under the conditions of these 2-year gavage studies, there was some evidence of carcinogenic activity of mercuric chloride in male F344 rats based on the increased incidence of squamous cell papillomas of the forestomach. Marginally increased incidences of thyroid follicular cell adenomas and carcinomas may have been related to mercuric chloride exposure. There was equivocal evidence of carcinogenic activity of mercuric chloride in female F344 rats based on two squamous cell papillomas of the forestomach. There was equivocal evidence of carcinogenic activity of mercuric chloride in male B6C3F1 mice based on the occurrences of two renal tubule adenomas and one renal tubule adenocarcinoma. There was no evidence of carcinogenic activity of mercuric chloride in female B6C3F1 mice receiving 5 or 10 mg/kg. Nonneoplastic lesions associated with exposure to mercuric chloride included increased severity of nephropathy in male rats and male and female mice. There was an increased incidence of renal tubule hyperplasia in male rats. The incidence of forestomach hyperplasia was increased in dosed male and female rats. Increased incidences of nasal mucosa inflammation were associated with mercuric chloride administration in rats. Increased incidences of olfactory epithelial metaplasia in mice were also associated with mercuric chloride administration. Synonyms: Abavit B, calochlor, corrosive sublimate, dichloromercury, mercuric bichloride, mercury chloride, mercury (II) chloride, mercury bichloride, mercury perchloride, sublimate, sulem, bichloride of mercury, corrosive mercury chloride, perchloride of mercury, mercury dichloride Trade name: Fungchex

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Pyridine is used as a denaturant in alcohol and anti freeze mixtures, as a solvent for paint, rubber, and polycarbonate resins, and as an intermediate in the manufacture of insecticides, herbicides, and fungicides. It is used in the production of piperidine, an intermediate in the manufacture of rubber and mepiquat chloride, and as an intermediate and solvent in the preparation of vitamins and drugs, dyes, textile water repellants, and flavoring agents in food. Pyridine was nominated for study because of its large production volume and its use in a variety of food, medical, and industrial products. Male and female F344/N rats, male Wistar rats, and male and female B6C3F1 mice were exposed to pyridine (approximately 99% pure) in drinking water for 13 weeks or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, L5178Y mouse lymphoma cells, cultured Chinese hamster ovary cells, Drosophila melanogaster, and mouse bone marrow cells. 13-WEEK STUDY IN F344/N RATS: Groups of 10 male and 10 female F344/N rats were exposed to pyridine in drinking water at concentrations of 0, 50, 100, 250, 500, or 1,000 ppm (equivalent to average daily doses of 5, 10, 25, 55, or 90 mg pyridine/kg body weight). Two females exposed to 1,000 ppm died during week 1. Final mean body weights of 1,000 ppm males and females and 500 ppm females were significantly less than controls. Water consumption by female rats exposed to 1,000 ppm was less than that by controls. At study termination, evidence of anemia persisted in the 500 and 1,000 ppm males and all exposed groups of females. There was evidence of hepatocellular injury and/or altered hepatic function demonstrated by increased serum alanine aminotransferase and sorbitol dehydrogenase activities and bile acid concentrations in 500 and 1,000 ppm rats. The estrous cycle length of 1,000 ppm females was significantly longer than that of the controls. Liver weights of males and females exposed to 250 ppm or greater were significantly greater than controls. In the liver, the incidences of centrilobular degeneration, hypertrophy, chronic inflammation, and pigmentation were generally increased in 500 and 1,000 ppm males and females relative to controls. In the kidney, the incidences of granular casts and hyaline degeneration (hyaline droplets) were significantly increased in 1,000 ppm males and slightly increased in 500 ppm males; these lesions are consistent with 2u-globulin nephropathy. Additionally, there were increased incidences and/or severities of protein casts, chronic inflammation, mineralization, and regeneration primarily in 500 and 1,000 ppm males. 13-WEEK STUDY IN MALE WISTAR RATS: Groups of 10 male Wistar rats were exposed to pyridine in drinking water at concentrations of 0, 50, 100, 250, 500, or 1,000 ppm (equivalent to average daily doses of 5, 10, 30, 60, or 100 mg/kg). One male rat exposed to 500 ppm died during week 1. Final mean body weights of rats exposed to 250, 500, or 1,000 ppm were significantly less than those of the controls. Water consumption by rats exposed to 1,000 ppm was lower than that by controls. There was evidence of hepatocellular injury and/or altered hepatic function in the 500 and 1,000 ppm groups, similar to that observed in the 13-week study in F344/N rats. Incidences of centrilobular degeneration, hypertrophy, chronic inflammation, and pigmentation in the liver of rats exposed to 500 or 1,000 ppm were significantly increased relative to controls. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were exposed to pyridine in drinking water at concentrations of 0, 50, 100, 250, 500, or 1,000 ppm (equivalent to average daily doses of 10, 20, 50, 85, or 160 mg/kg for males and 10, 20, 60, 100, or 190 mg/kg for females). One female mouse exposed to 250 ppm died during week 2. Final mean body weights of female mice exposed to 1,000 ppm were significantly less than those of controls. Water consumption by exposed female mice was lower than that by controls at week 1 but generally slightly higher than controls at week 13. Sperm motirm motility in exposed male mice was significantly decreased relative to controls. Liver weights were significantly increased relative to controls in males exposed to 100 ppm or greater and in 250 and 500 ppm females. No chemical-related lesions were observed in male or female mice. 2-YEAR STUDY IN F344/N RATS: Groups of 50 male and 50 female F344/N rats were exposed to pyridine in drinking water at concentrations of 0, 100, 200, or 400 ppm (equivalent to average daily doses of 7, 14, or 33 mg/kg) for 104 (males) or 105 (females) weeks. Survival, Body Weights, and Water Consumption Survival of exposed males and females was similar to that of controls. Mean body weights of 400 ppm males and females were generally less than those of the controls throughout the study, and those of 200 ppm males and females were less during the second year of the study. Water consumption by males and females exposed to 200 or 400 ppm was generally greater than that by controls. Pathology Findings Incidences of renal tubule adenoma and renal tubule adenoma or carcinoma (combined) in male rats exposed to 400 ppm were significantly increased compared to controls and exceeded the historical control ranges. The findings from an extended evaluation (step section) of the kidneys did not reveal additional carcinomas, but additional adenomas were observed in each group of males. In the standard evaluation, an increased incidence of renal tubule hyperplasia was observed in 400 ppm males compared to controls. Incidences of mononuclear cell leukemia in female rats were significantly increased in the 200 and 400 ppm groups, and the incidence in the 400 ppm group exceeded the historical control range. Exposure concentration-related nonneoplastic liver lesions were observed in males and females, and the incidences were generally increased in groups exposed to 400 ppm. These included centrilobular cytomegaly, cytoplasmic vacuolization, periportal fibrosis, fibrosis, centrilobular degeneration and necrosis, and pigmentation. Bile duct hyperplasia occurred more often in exposed females than in controls. 2-YEAR STUDY IN MALE WISTAR RATS: Groups of 50 male Wistar rats were exposed to pyridine in drinking water at concentrations of 0, 100, 200, or 400 ppm (equivalent to average daily doses of 8, 17, or 36 mg/kg) for 104 weeks. Survival, Body Weights, and Water Consumption Survival of rats exposed to 200 or 400 ppm was significantly less than that of the controls. Mean body weights of rats exposed to 100, 200, or 400 ppm were significantly less than controls. Water consumption was similar by control and exposed rats. Pathology Findings The incidence of testicular interstitial cell adenoma in rats exposed to 400 ppm was significantly increased compared to controls. Incidences of interstitial cell hyperplasia were observed in control and exposed groups and were slightly, but not significantly, increased in rats exposed to 200 or 400 ppm. Severity of nephropathy was marked in all groups, and additional evidence of kidney disease, including mineralization in the glandular stomach, parathyroid gland hyperplasia, and fibrous osteodystrophy, was observed in 100 and 200 ppm rats. The incidences of hepatic centrilobular degeneration and necrosis, fibrosis, periportal fibrosis, and/or pigmentation were increased in one or more exposed groups. 2-YEAR STUDY IN MICE: Groups of 50 male B6C3F1 mice were exposed to pyridine in drinking water at concentrations of 0, 250, 500, or 1,000 ppm (equivalent to average daily doses of 35, 65, or 110 mg/kg) for 104 weeks, and groups of 50 female B6C3F1 mice were exposed to pyridine in drinking water at concentrations of 0, 125, 250, or 500 ppm (equivalent to average daily doses of 15, 35, or 70 mg/kg) for 105 weeks. Survival, Body Weights, and Water Consumption Survival of exposed males and females was similar to that of the controls. Mean body weights of 250 and 500 ppm females were less than controls. Water consumption by males exposed to 250 or 500 ppm was generally greater than that by controls during the last year of the study; male mice exposed to 1,000 ppm consumed less water than controls throughout the study. Water consumption by exposed females was generally lower than that by controls during the first year of the study, but greater than controls during the second year. Pathology Findings Hepatocellular neoplasms, including hepatoblastomas, in exposed male and female mice were clearly related to pyridine exposure. Additionally, many mice had multiple hepatocellular neoplasms. The incidences of hepatocellular neoplasms in exposed males and females generally exceeded the historical control ranges for drinking water studies. Neoplasms from control mice, 1,000 ppm males, and 500 ppm females were negative when stained for p53 protein. GENETIC TOXICOLOGY: Pyridine was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 or in L5178Y mouse lymphoma cells, with or without S9 metabolic activation, and it did not induce sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells, with or without S9. Pyridine was tested for induction of sex-linked recessive lethal mutations in adult male Drosophila melanogaster, and mixed results were obtained. In one experiment, administration by injection gave negative results, but feeding produced an equivocal response. A second experiment generated negative results by injection and feeding. A third experiment showed significant increases in sex-linked recessive lethal mutations in flies treated with pyridine by injection but not by feeding. Overall, results of the sex-linked recessive lethal mutations test in Drosophila melanogaster were considered negative by feeding and equivocal by injection. Results of a single reciprocal translocation test in male Drosophila melanogaster were negative. No induction of chromosomal aberrations or micronuclei was noted in bone marrow cells of male mice administered pyridine via intraperitoneal injection. CONCLUSIONS: Under the conditions of these 2-year drinking water studies, there was some evidence of carcinogenic activity of pyridine in male F344/N rats based on increased incidences of renal tubule neoplasms. There was equivocal evidence of carcinogenic activity of pyridine in female F344/N rats based on increased incidences of mononuclear cell leukemia. There was equivocal evidence of carcinogenic activity in male Wistar rats based on an increased incidence of interstitial cell adenoma of the testis. There was clear evidence of carcinogenic activity of pyridine in male and female B6C3F1 mice based on increased incidences of malignant hepatocellular neoplasms. In F344/N rats, exposure to pyridine resulted in increased incidences of centrilobular cytomegaly and degeneration, cytoplasmic vacuolization, and pigmentation in the liver of males and females; periportal fibrosis, fibrosis, and centrilobular necrosis in the liver of males; and bile duct hyperplasia in females. In male Wistar rats, pyridine exposure resulted in increased incidences of centrilobular degeneration and necrosis, fibrosis, periportal fibrosis, and pigmentation in the liver, and, secondary to kidney disease, mineralization in the glandular stomach and parathyroid gland hyperplasia. Synonyms: Azabenzene, azine

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Codeine is used in a variety of pharmaceuticals including analgesics, sedatives, hypnotics, antiperistaltics, and antitussive agents. The National Cancer Institute and the Food and Drug Administration nominated codeine for study because it is a widely used drug and it is representative of the morphine class of compounds, for which chronic carcinogenicity studies had not been conducted. The oral route of administration was selected because it is the primary route of human exposure. Male and female F344/N rats and B6C3F1 mice were given codeine (99% pure) in feed for 14 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells. 14-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were given 0, 1,562, 3,125, 6,250, 12,500, or 25,000 ppm codeine in feed for 14 days, which resulted in daily doses of approximately 125, 250, 450, 650, or 750 mg codeine/kg body weight to males and 125, 250, 500, 700, or 300 mg/kg to females. One female exposed to 6,250 ppm, one male and three females exposed to 12,500 ppm, and all males and females exposed to 25,000 ppm died during the study. Final mean body weights and mean body weight gains of all exposed groups except 1,562 ppm females were significantly lower than those of the controls. No chemical-related gross lesions were observed in rats at necropsy. Thickening of the forestomach mucosa (hyperplasia and hyperkeratosis) and lymphoid depletion of the thymus in exposed males and females and testicular degeneration in exposed males, observed primarily in the 12,500 and 25,000 ppm groups, were associated with decreased survival and increased morbidity in these groups. 14-DAY STUDY IN MICE: Groups of five male and five female B6C3F1 mice were given 0, 781, 1,562, 3,125, 6,250, or 12,500 ppm codeine in feed for 14 days, which resulted in daily doses of approximately 150, 300, 600, 1,300, or 3,000 mg codeine/kg body weight to males and 200, 400, 750, 1,500, or 3,000 mg/kg to females. All mice survived to the end of the study. The final mean body weight of 3,125 ppm females was significantly greater than that of the controls; the final mean body weight of 12,500 ppm females and the mean body weight gains of 12,500 ppm males and females were significantly lower than those of the controls. Absolute and relative liver weights of 3,125, 6,250, and 12,500 ppm males and of 12,500 ppm females and the absolute and relative right kidney weights of 12,500 ppm males were significantly lower than those of the controls. No gross or histopathologic lesions were attributed to codeine exposure. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were given 0, 390, 781, 1,562, 3,125, or 6,250 ppm codeine in feed for 13 weeks, which resulted in daily doses of approximately 25, 50, 100, 200, or 450 mg codeine/kg body weight to males and 25, 50, 100, 250, or 500 mg/kg to females. There were no chemical-related deaths during the study. Final mean body weights and mean body weight gains of all groups of exposed males and of females exposed to 1,562, 3,125, and 6,250 ppm were significantly lower than those of the controls. Feed consumption decreased with increasing exposure concentration during the first week of the study; however, by the end of the study, feed consumption by most exposed groups was similar to that by the controls. There were alterations of various hematology and clinical chemistry parameters at the end of the study. There was a mild dose-dependent lymphopenia in females receiving 1,562 ppm and above and in 6,250 ppm males. There also was a minimal to mild macrocytosis that occurred in all exposed groups of males and in females exposed to 781, 3,125, or 6,250 ppm. No significant differences between control and exposed rats were observed in sperm morphology or vaginal cytology parameters. Absolute and relative adrenal gland weights of exposed males and of 3,125 and 6,250 ppm females were significantly greater than those of the controls. Absolute and relative liver weights of exposed males werees were significantly lower than those of the controls. Relative thymus weights of 3,125 and 6,250 ppm males were significantly lower than that of the controls. No chemical-related gross or histopathologic lesions were observed in male or female rats. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were given 0, 390, 781, 1,562, 3,125, or 6,250 ppm codeine in feed for 13 weeks, which resulted in daily doses of approximately 60, 120, 260, 460, or 1,000 mg codeine/kg body weight to males and 60, 130, 280, 530, or 1,200 mg/kg to females. Two male mice in the 3,125 ppm group died during week 7. All other mice survived to the end of the study. Final mean body weights of exposed males and females were similar to those of the controls. Feed consumption by exposed males and females was similar to that by the controls. Abnormal posture was observed in all exposed groups of males. There were no significant differences in hematology or urinalysis parameters in male or female mice. Minor, sporadic changes occurred in a few of the clinical chemistry parameters; they were not considered biologically significant. No significant differences in sperm morphology or vaginal cytology were attributed to codeine exposure. Absolute and relative kidney weights of 3,125 and 6,250 ppm males were lower than those of the controls. No chemical-related differences in organ weights were observed in females. No chemical-related gross or histopathologic lesions were observed in male or female mice. 2-YEAR STUDY IN RATS: Groups of 60 male and 60 female F344/N rats were fed diets containing 0, 400, 800, or 1,600 ppm codeine for up to 106 weeks, with 9 or 10 rats per group evaluated at 15 months. These exposure concentrations resulted in average daily doses of approximately 15, 30, and 70 mg codeine/kg body weight to males and 15, 40, and 80 mg/kg to females. Survival, Body Weights, Feed Consumption, and Clinical Findings Survival of 400 ppm females was significantly greater than that of the controls; survival of all groups of exposed males and of 800 and 1,600 ppm females was similar to that of the controls. There was an exposure-related decrease in mean body weights of males and females. The final mean body weight of 1,600 ppm males was 88&amp;percnt; that of the controls, and the final mean body weight of 1,600 ppm females was 89&amp;percnt; that of the controls. Feed consumption by exposed groups was similar to that by the controls. Chemical-related clinical findings were limited to ocular discharge in exposed males and females. Pathology Findings: Absolute and relative adrenal gland weights of 800 and 1,600 ppm males were significantly greater than those of the controls at 15 months. There were no increased incidences of neoplasms attributable to codeine exposure at any site. At 2 years, there were exposure-related decreases in the incidences of adrenal medulla hyperplasia in males and females. There was an exposure-related decrease in the incidence of benign pheochromocytomas in males, and the incidences in exposed males were significantly lower than that in the controls. In 1,600 ppm females the incidences of mammary gland fibroadenomas and of fibroadenomas or adenocarcinomas (combined) were significantly lower than those in the controls. The decreased incidences of benign pheochromocytomas in males and mammary gland neoplasms in females were considered to be related to codeine exposure. 2-YEAR STUDY IN MICE: Groups of 60 male and 60 female B6C3F1 mice were fed diets containing 0, 750, 1,500, or 3,000 ppm codeine for up to 106 weeks, with 9 or 10 mice per group evaluated at 15 months. These exposure concentrations resulted in average daily doses of approximately 100, 200, or 400 mg codeine/kg body weight to males and females. Survival, Body Weights, Feed Consumption, and Clinical Findings: Survival of exposed males and females was similar to that of the controls. Mean body weights of 750 and 1,500 ppm males and females were similar to those of the controls throughout most of the study. Mean body weights of 3,000 ppm males and females were less than those of the controls from about week 13, and the final mean body weights of these groups were 86% and 82% those of the respective controls. Feed consumption by exposed groups was similar to that by the controls. Pathology Findings: There were no increased incidences of neoplasms attributable to codeine exposure at any site. At 15 months, the incidence of thyroid gland follicular cell hyperplasia in 3,000 ppm males was significantly greater than that of the controls, and this lesion was observed in 1,500 and 3,000 ppm females. At 2 years, the incidences of follicular cell hyperplasia in all exposed groups of mice were significantly greater than those in the controls, but there were no increases in thyroid gland follicular cell neoplasms. The incidence of centrilobular fatty change in the liver of 3,000 ppm males was significantly lower than that in the controls at 15 months, and the decreased incidence appeared to be related to exposure level. At 2 years, the incidences of eosinophilic foci, foci of fatty change, centrilobular cytomegaly, and centrilobular fatty change in 3,000 ppm males were lower than those in the controls. The incidence of hepatocellular adenomas and the incidence of hepatocellular adenomas or carcinomas (combined) in 3,000 ppm males and females were significantly lower than those in the controls; this was considered to be related to lower body weights in these groups. GENETIC TOXICOLOGY: Codeine phosphate was not mutagenic in any of four strains of Salmonella typhimurium, with or without S9 metabolic activation enzymes. In cytogenetic tests with cultured Chinese hamster ovary cells, codeine phosphate induced dose-related increases in sister chromatid exchanges, with and without S9, only at concentration levels that caused cell cycle delay. No induction of chromosomal aberrations was noted in cultured Chinese hamster ovary cells treated with codeine phosphate, with or without S9. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of codeine in male or female F344/N rats exposed to 400, 800, or 1,600 ppm. There was no evidence of carcinogenic activity of codeine in male or female B6C3F1 mice exposed to 750, 1,500, or 3,000 ppm. Thyroid gland follicular cell hyperplasia was increased in exposed male and female mice. Decreased incidences of benign pheochromocytomas of the adrenal medulla in male rats and mammary gland fibroadenomas and fibroadenomas or adenocarcinomas (combined) in female rats were related to codeine exposure. Synonyms: 7,8-didehydro-4,5-epoxy-3-methoxy-17-methylmorphinan-6-ol; methylmorphine; 3-0-methylmorphine monohydrate; N-methylnorcodeine; morphine-3-methyl ether; morphine monomethyl ether Trade names: Codeinum, Codicept, Coducept, Metilmorfina

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Turmeric oleoresin is the organic extract of turmeric, a ground powder from the root of the Curcuma plant, and is added to food items as a spice and coloring agent. Turmeric oleoresin, turmeric, and curcumin (the major component found in turmeric) were nominated by the National Cancer Institute and the Food and Drug Administration for study because these chemicals are used in food items and curry powders, and there was little information on their toxic or carcinogenic properties. Pure curcumin was not available in sufficient quantities for study, and a turmeric oleoresin with a high curcumin content (79% to 85%) was selected for evaluation. Toxicity and carcinogenicity studies were conducted by administering turmeric oleoresin in feed to groups of male and female F344/N rats and B6C3F1 mice for 13 weeks and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were fed diets containing 0, 1,000, 5,000, 10,000, 25,000, or 50,000 ppm turmeric oleoresin. All rats survived until the end of the study. The final mean body weight of males receiving 50,000 ppm was 5% lower than that of the controls. Feed consumption by exposed male and female rats was similar to that by the controls. Dietary levels of 1,000, 5,000,10,000, 25,000, or 50,000 ppm turmeric oleoresin were estimated to deliver average daily doses of 50, 250, 480, 1,300, or 2,600 mg/kg body weight to males and 60, 300, 550, 1,450, or 2,800 mg/kg to females. The absolute and relative liver weights of female rats and the relative liver weights of male rats receiving 5,000, 10,000, 25,000, and 50,000 ppm were significantly greater than those of the controls. There were no biologically significant differences in hematologic, clinical chemistry, or urinalysis parameters. Clinical findings included stained fur, and discolored feces and urine of exposed animals, presumably due to the parent compound or its metabolites. Hyperplasia of the mucosal epithelium was observed in the cecum and colon of male and female rats that received 50,000 ppm. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were fed diets containing 0,1,000, 5,000,10,000, 25,000, or 50,000 ppm turmeric oleoresin. There were no deaths attributed to turmeric oleoresin and the final mean body weight gains and final mean body weights of all exposed groups of male and female mice were similar to those of the controls. Feed consumption by exposed male and female mice was similar to that by the controls. Dietary levels of 1,000, 5,000,10,000, 25,000, or 50,000 ppm turmeric oleoresin were estimated to deliver average daily doses of 150, 750, 1,700, 3,850, or 7,700 mg/kg body weight to males and 200, 1,000, 1,800, 4,700 or 9,300 mg/kg to females. Absolute and relative liver weights of male mice that received 5,000 ppm and male and female mice that received 10,000, 25,000 and 50,000 ppm were significantly greater than those of the controls. Clinical findings in mice included stained fur, and discolored feces and urine. There were no biologically significant differences in hematologic, clinical chemistry, or urinalysis parameters, and there were no chemical related histopathologic lesions. 2-YEAR STUDY IN RATS: The exposure level selection for the 2-year study was based on the 13-week study, which showed that rats could tolerate diets containing up to 50,000 ppm. Groups of 60 male and 60 female F344/N rats were fed diets containing 2,000, 10,000, or 50,000 ppm turmeric oleoresin for 104 (males) or 103 (females) weeks, which were estimated to deliver average daily doses of 80, 460, or 2,000 mg/kg to males and 90, 440, or 2,400 mg/kg to females. Nine or 10 rats from each exposure group were evaluated after 15 months. Survival, Mean Body Weights, Feed Consumption, and Clinical Findings: Survival of exposed male and female rats was similar to that of the controls (male: O ppm, 18/50; 2,000 ppm, 17/50; 10,000 ppm, 15/50; 50,000 ppm, 17/50; female: 33/50, 27/50, 28/50, 34/50). Th50, 28/50, 34/50). The final mean body weights of all exposed male rats and female rats receiving 2,000 and 10,000 ppm were similar to those of the controls. The final mean body weights of male and female rats that received 50,000 ppm were slightly lower (up to 10&amp;percnt;) than those of the controls throughout much of the study. Feed consumption by exposed male and female rats was similar to that by controls throughout the study. The absolute and relative liver weights of female rats receiving 10,000 or 50,000 ppm were significantly greater than those of controls at the 15-month interim evaluation. There were no clinical findings related to toxicity. Hematology and Clinical Chemistry: In male and female rats receiving 50,000 ppm the hematocrit values, hemoglobin concentrations, and erythrocyte counts at the 15-month interim evaluation were significantly lower than those in the controls. In addition, platelet counts in male and female rats that received 50,000 ppm and reticulocyte counts in male rats that received 50,000 ppm were significantly higher than those in the controls. No biologically significant differences were observed in clinical chemistry parameters. Pathology Findings: Chemical-related nonneoplastic lesions occurred in the gastrointestinal tract of rats that received 50,000 ppm. Males receiving 50,000 ppm had increased incidences of ulcers, hyperplasia, and hyperkeratosis of the forestomach. Male and female rats that received 50,000 ppm had ulcers, chronic active inflammation, and hyperplasia of the cecum. Similar lesions also occurred in the colon of males receiving 50,000 ppm. Male and female rats that received 50,000 ppm and male rats that received 10,000 ppm had significantly increased incidences of sinus ectasia of the mesenteric Iymph node. The incidences of clitoral gland adenoma in all exposed groups of female rats were significantly increased. Clitoral gland carcinomas occurred in one control female and in four 2,000 ppm females, but not in females that received 10,000 or 50,000 ppm. The incidences of clitoral gland adenoma or carcinoma (combined) in all exposed groups of female rats were similar (6/50, 16/48, 15/47, 16/49) and did not increase with exposure level. The incidence of clitoral gland hyperplasia was similar among exposed and control groups of female rats (7/50, 5/48, 4/47, 7149). 2-YEAR STUDY IN MICE: The exposure level selection for the 2-year study was based on the 13-week study, which showed that mice could tolerate diets containing up to 50,000 ppm. Groups of 60 male and 60 female B6C3F1 mice were fed diets containing 2,000, 10,000, or 50,000 ppm turmeric oleoresin for 103 weeks, which were estimated to deliver average daily doses of 220, 520, or 6,000 mg/kg to males and 320,1,620, or 8,400 mg/kg to females. Nine or 10 mice from each exposure group were evaluated after 15 months. Survival, Mean Body Weights, Feed Consumption, and Clinical Findings: Survival of exposed male and female mice was similar to that of the controls (male: O ppm, 43/50; 2,000 ppm, 43/50; 10,000 ppm, 37/50; 50,000 ppm 42/50; female: 39/50, 41/50, 34/50, 42/50). The mean body weight of female mice receiving 50,000 ppm was slightly lower (up to 12&amp;percnt;) than that of the controls from about week 25. The final mean body weights of males that received 50,000 ppm and females that received 10,000 and 50,000 ppm were significantly lower than those of controls. The final mean body weights of other exposed groups of male and female mice were similar to those of the controls. Feed consumption by exposed male and female mice was similar to that by the controls throughout the study. The absolute and relative liver weights of male and female mice receiving 10,000 and 50,000 ppm were significantly greater than those of the controls at the l5-month interim evaluation. There were no clinical findings related to toxicity. Hematology and Clinical Chemistry: No biologically significant differences were observed in hematologic parameters. The alkaline phosphatase values of male and female mice that received 10,000 and 50,000 ppm were significantly higher than those of controls at the 15-month interim evaluation. Pathology Findings: The incidences of hepatocellular adenoma in male and female mice receiving 10,000 ppm, but not those in mice receiving 2,000 or 50,000 ppm, were significantly increased (male: 25/50, 28/50, 35/50, 30/50; female: 7/50, 8/50, 19/51, 14/50). The number of male and female mice in the 10,000 and 50,000 ppm groups with multiple hepatocellular neoplasms was significantly greater than that in the controls. The incidences of hepatocellular carcinoma were similar among exposed and control groups. In contrast to rats, there were no chemical-related nonneoplastic lesions of the gastrointestinal tract in mice. Three males that received 2,000 ppm and three males that received 10,000 ppm had carcinomas of the small intestine; neoplasms of the small intestine were not observed in control males or in males that received 50,000 ppm. Female mice receiving 50,000 ppm had a significantly increased incidence of thyroid gland follicular cell hyperplasia. GENETIC TOXICOLOGY: Turmeric oleoresin was not mutagenic in Salmonella typhimurium strains TA100, TA1535, TA1537, or TA98 with or without exogenous metabolic activation (S9). It induced small but significant increases in sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells. The positive response in the sister chromatid exchange test occurred in the presence of S9, whereas the aberrations response occurred without S9. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of turmeric oleoresin in male F344/N rats administered 2,000, 10,000, or 50,000 ppm. There was equivocal evidence of carcinogenic activity of turmeric oleoresin in female F344/N rats based on increased incidences of clitoral gland adenomas in the exposed groups. There was equivocal evidence of carcinogenic activity of turmeric oleoresin in male B6C3F1 mice based on a marginally increased incidence of hepatocellular adenoma at the 10,000 ppm level, and the occurrence of carcinomas of the small intestine in the 2,000 and 10,000 ppm groups. There was equivocal evidence of carcinogenic activity of turmeric oleoresin in female B6C3F1 mice based on an increased incidence of hepatocellular adenomas in the 10,000 ppm group. Turmeric oleoresin ingestion was also associated with increased incidences of ulcers, hyperplasia, and inflammation of the forestomach, cecum, and colon in male rats and of the cecum in female rats. In female mice, ingestion of diets containing turmeric oleoresin was also associated with an increased incidence of thyroid gland follicular cell hyperplasia. Synonyms for Turmeric Oleoresin: curcuma oil; oil of turmeric; turmeric oil; curcuma longa oils; curcuma long oil; Curcumin Synonyms for Curcumin: 1,7-Bis(4-hydroxy-3-methoxyphenyl)-1,6-heptadiene-3,5-dione; C.I. Natural Yellow 3; C.I. 75300; Curcuma; diferuloylmethane; E 100; Haidr; Halad; Haldar; Halud; HSDB 4334; Indian Saffron; kacha haldi; Kurkumin; merita earth; Souchet; Turmeric Yellow; yellow ginger; yellow root; Yo-kin; Zlut Prirodni 3; NCI-C613253

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It is currently thought that most-but not all-individuals infected with SARS-CoV-2 develop symptoms, but the infectious period starts on average 2 days before the first overt symptoms appear. It is estimated that pre- and asymptomatic individuals are responsible for more than half of all transmissions. By detecting infected individuals before they have overt symptoms, wearable devices could potentially and significantly reduce the proportion of transmissions by pre-symptomatic individuals. Using laboratory-confirmed SARS-CoV-2 infections (detected via serology tests [to determine if there are antibodies against the SARS-CoV-2 in the blood] or SARS-CoV-2 infection tests such as polymerase chain reaction [PCR] or antigen tests) as the gold standard, we will determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the following two algorithms to detect first time SARS-CoV-2 infection including early or asymptomatic infection: • The algorithm using Ava bracelet data when coupled with self-reported Daily Symptom Diary data (Wearable + Symptom Data Algo; experimental condition) • The algorithm using self-reported Daily Symptom Diary data alone (Symptom Only Algo; control condition) In addition, we will determine which of the two algorithms has superior performance characteristics for detecting SARS-CoV-2 infection including early or asymptomatic infection as confirmed by SARS-CoV-2 virus testing. The trial is a randomized, single-blinded, two-period, two-sequence crossover trial. The study will start with an initial learning phase (maximum of 3 months), followed by period 1 (3 months) and period 2 (3 months). Subjects entering the study at the end of the recruitment period may directly start with period 1 and will not be part of the learning phase. Each subject will undergo the experimental condition (the Wearable + Symptom Data Algo) in either period 1 or period 2 and the control condition (Symptom Only Algo) in the other period. The order will be randomly assigned, resulting in subjects being allocated 1:1 to either sequence 1 (experimental condition first) or sequence 2 (control condition first). Based on demographics, medical history and/or profession, each subject will be stratified at baseline into a high-risk and normal-risk group within each sequence. The trial will be conducted in the Netherlands. A target of 20,000 subjects will be enrolled. Based on demographics, medical history and/or profession, each subject will be stratified at baseline into a high-risk and normal-risk group within each sequence. This results in approximately 6500 normal-risk individuals and 3500 high-risk individuals per sequence. Subjects will be recruited from previously studied cohorts as well as via public campaigns and social media. All data for this study will be collected remotely through the Ava COVID-RED app, the Ava bracelet, surveys in the COVID-RED web portal and self-sampling serology and PCR kits. More information on the study can be found in www.covid-red.eu . During recruitment, subjects will be invited to visit the COVID-RED web portal. After successfully completing the enrolment questionnaire, meeting eligibility criteria and indicating interest in joining the study, subjects will receive the subject information sheet and informed consent form. Subjects can enrol in COVID-RED if they comply with the following inclusion and exclusion criteria: Inclusion criteria: • Resident of the Netherlands • At least 18 years old • Informed consent provided (electronic) • Willing to adhere to the study procedures described in the protocol • Must have a smartphone that runs at least Android 8.0 or iOS 13.0 operating systems and is active for the duration of the study (in the case of a change of mobile number, the study team should be notified) • Be able to read, understand and write Dutch Exclusion criteria: • Previous positive SARS-CoV-2 test result (confirmed either through PCR/antigen or antibody tests; self-reported) • Current suspected (e.g. waiting for test result) COVID-19 infection or symptoms of a COVID-19 infection (self-reported) • Participating in any other COVID-19 clinical drug, vaccine or medical device trial (self-reported) • Electronic implanted device (such as a pacemaker; self-reported) • Pregnant at the time of informed consent (self-reported) • Suffering from cholinergic urticaria (per the Ava bracelet's user manual; self-reported) • Staff involved in the management or conduct of this study INTERVENTION AND COMPARATOR: All subjects will be instructed to complete the Daily Symptom Diary in the Ava COVID-RED app daily, wear their Ava bracelet each night and synchronize it with the app each day for the entire period of study participation. Provided with wearable sensor and/or self-reported symptom data within the last 24 h, the Ava COVID-RED app's underlying algorithms will provide subjects with a real-time indicator of their overall health and well-being. Subjects will see one of three messages, notifying them that no seeming deviations in symptoms and/or physiological parameters have been detected; some changes in symptoms and/or physiological parameters have been detected and they should self-isolate; or alerting them that deviations in their symptoms and/or physiological parameters could be suggestive of a potential COVID-19 infection and to seek additional testing. We will assess the intraperson performance of the algorithms in the experimental condition (Wearable + Symptom Data Algo) and control conditions (Symptom Only Algo). Note that both algorithms will also instruct to seek testing when any SARS-CoV-2 symptoms are reported in line with those defined by the Dutch national institute for public health and the environment 'Rijksinstituut voor Volksgezondheid en Milieu' (RIVM) guidelines. The trial will evaluate the use and performance of the Ava COVID-RED app and Ava bracelet, which uses sensors to measure breathing rate, pulse rate, skin temperature and heart rate variability for the purpose of early and asymptomatic detection and monitoring of SARS-CoV-2 in general and high-risk populations. Using laboratory-confirmed SARS-CoV-2 infections (detected via serology tests, PCR tests and/or antigen tests) as the gold standard, we will determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each of the following two algorithms to detect first-time SARS-CoV-2 infection including early or asymptomatic infection: the algorithm using Ava bracelet data when coupled with the self-reported Daily Symptom Diary data and the algorithm using self-reported Daily Symptom Diary data alone. In addition, we will determine which of the two algorithms has superior performance characteristics for detecting SARS-CoV-2 infection including early or asymptomatic infection as confirmed by SARS-CoV-2 virus testing. The protocol contains an additional twenty secondary and exploratory objectives which address, among others, infection incidence rates, health resource utilization, symptoms reported by SARS-CoV-2-infected participants and the rate of breakthrough and asymptomatic SARS-CoV-2 infections among individuals vaccinated against COVID-19. PCR or antigen testing will occur when the subject receives a notification from the algorithm to seek additional testing. Subjects will be advised to get tested via the national testing programme and report the testing result in the Ava COVID-RED app and a survey. If they cannot obtain a test via the national testing programme, they will receive a nasal swab self-sampling kit at home, and the sample will be tested by PCR in a trial-affiliated laboratory. In addition, all subjects will be asked to take a capillary blood sample at home at baseline (between month 0 and 3.5 months after the start of subject recruitment), at the end of the learning phase (month 3; note that this sampling moment is skipped if a subject entered the study at the end of the recruitment period), period 1 (month 6) and period 2 (month 9). These samples will be used for SARS-CoV-2-specific antibody testing in a trial-affiliated laboratory, differentiating between antibodies resulting from a natural infection and antibodies resulting from COVID-19 vaccination (as vaccination will gradually be rolled out during the trial period). Baseline samples will only be analysed if the sample collected at the end of the learning phase is positive, or if the subject entered the study at the end of the recruitment period, and samples collected at the end of period 1 will only be analysed if the sample collected at the end of period 2 is positive. When subjects obtain a positive PCR/antigen or serology test result during the study, they will continue to be in the study but will be moved into a so-called COVID-positive mode in the Ava COVID-RED app. This means that they will no longer receive recommendations from the algorithms but can still contribute and track symptom and bracelet data. The primary analysis of the main objective will be executed using the data collected in period 2 (months 6 through 9). Within this period, serology tests (before and after period 2) and PCR/antigen tests (taken based on recommendations by the algorithms) will be used to determine if a subject was infected with SARS-CoV-2 or not. Within this same time period, it will be determined if the algorithms gave any recommendations for testing. The agreement between these quantities will be used to evaluate the performance of the algorithms and how these compare between the study conditions. All eligible subjects will be randomized using a stratified block randomization approach with an allocation ratio of 1:1 to one of two sequences (experimental condition followed by control condition or control condition followed by experimental condition). Based on demographics, medical history and/or profession, each subject will be stratified at baseline into a high-risk and normal-risk group within each sequence, resulting in approximately equal numbers of high-risk and normal-risk individuals between the sequences. In this study, subjects will be blinded to the study condition and randomization sequence. Relevant study staff and the device manufacturer will be aware of the assigned sequence. The subject will wear the Ava bracelet and complete the Daily Symptom Diary in the Ava COVID-RED app for the full duration of the study, and they will not know if the feedback they receive about their potential infection status will only be based on the data they entered in the Daily Symptom Diary within the Ava COVID-RED app or based on both the data from the Daily Symptom Diary and the Ava bracelet. A total of 20,000 subjects will be recruited and randomized 1:1 to either sequence 1 (experimental condition followed by control condition) or sequence 2 (control condition followed by experimental condition), taking into account their risk level. This results in approximately 6500 normal-risk and 3500 high-risk individuals per sequence. Protocol version: 3.0, dated May 3, 2021. Start of recruitment: February 19, 2021. End of recruitment: June 3, 2021. End of follow-up (estimated): November 2021 TRIAL REGISTRATION: The Netherlands Trial Register on the 18<supth</sup of February, 2021 with number NL9320 ( https://www.trialregister.nl/trial/9320 ) FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

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C.I. Pigment Red 3, a yellowish red solid, is widely used for coloring paints, inks, plastics, and rubber, and in textile printing. It is used in a wide range of consumer items such as wallpaper, typewriter ribbons, carbon paper, and art materials. Toxicology and carcinogenicity studies were conducted by feeding groups of F344/N rats and B6C3F1 mice of each sex diets containing C.I. Pigment Red 3 (97% pure) for 2 weeks, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells. 2-Week Studies: Groups of five rats and five mice of each sex were given feed containing 0, 6,000, 12,500, 25,000, 50,000, or 100,000 ppm C.I. Pigment Red 3 for 2 weeks. No chemical-related deaths occurred in rats or mice. Final mean body weights of exposed rats and male mice were lower than controls; female mice that received 6,000 and 50,000 ppm had significantly increased final mean body weights compared to that of the controls. The feed consumption of treated rats and mice was slightly greater than that of the controls, suggesting that C.I. Pigment Red 3 had no adverse effects on the feed palatability. Dose-related decreases in erythrocyte counts and hematocrit values and an increase in reticulocyte counts were observed in rats. Changes in these parameters were observed in mice, but there were no clear, dose-related trends. 13-Week Studies: Groups of ten rats and ten mice of each sex were given feed containing 0, 3,000, 6,000, 12,500, 25,000, or 50,000 ppm C.I. Pigment Red 3 for 13 weeks. No chemical-related deaths were observed in rats or mice. The final mean body weights of exposed female rats were significantly lower than that of the controls; the final mean body weights of exposed male rats and exposed mice were similar to controls. There were significant increases in relative liver and kidney weights of exposed male rats. Increases in the relative liver weights in mice did not occur with a dose-related trend and thus they were not considered related to chemical administration. Sites for the toxicity of C.I. Pigment Red 3 were the bone marrow, kidney, liver, and spleen in rats. Lesions observed in rats included bone marrow hyperplasia, congestion and hematopoietic cell proliferation of the spleen, and iron-positive pigmentation of the spleen, kidney, and liver. Sites for the toxicity of C.I. Pigment Red 3 in mice were the liver, kidney, and spleen in males and the liver and spleen in females. Lesions noted among mice in the spleen were hematopoietic cell proliferation and iron-positive pigmentation. In the liver, there was hematopoietic cell proliferation in male and female mice. Cytomegaly occurred in the renal tubule epithelium of the male mouse kidney. 2-Year Studies: Doses selected for the 2-year feed studies were 0, 6,000, 12,500, and 25,000 ppm for rats and 0, 12,500, 25,000, and 50,000 ppm for mice. The dose selection for rats was based on body weight changes observed for females that received 50,000 ppm; the dose selection for mice was based on the lack of body weight depression or death at the doses tested during the 13-week studies. Concentrations higher than 50,000 ppm in the feed were not used because higher levels might have adversely affected the nutritional value of the diet during the 2-year studies. Body Weight, Feed Consumption, Clinical Findings, and Survival in the 2-Year Studies: Final mean body weights for male rats that received 25,000 ppm, female rats that received 12,500 and 25,000 ppm, and male and female mice that received 50,000 ppm were more than 10% lower than those of the controls. Feed consumption of exposed rats and mice was similar to that of the controls. No clinical findings indicative of toxicity were observed in rats or mice. The survival of low-dose male rats was greater than that of the controls (0 ppm, 28/50; 6,000 ppm, 40/50; 12,500 ppm, 28/50; 25,000 ppm, 20/50). Survival of exposed female rats and exposed male mice was similar to the controls; the survival of high-dose female mice was significantly decreased compared to thcompared to that of the controls (39/50, 37/50, 31/50, 25/50). The reduced survival in this dose group may have been due to the increased incidence of ovarian abscesses. Neoplasms and Nonneoplastic Lesions in the 2-Year Studies: Benign adrenal pheochromocytomas were significantly increased in the 12,500 and 25,000 ppm groups of male rats compared to the controls (22/50, 29/50, 35/50, 34/50). However, malignant neoplasms were not increased in incidence (6/50, 7/50, 10/50, 4/50). The incidence of adrenal pheochromocytomas in dosed groups exceeded the range for NTP historical controls for feed studies (22&amp;percnt;-48&amp;percnt;), and the increased incidence of this neoplasm was attributed to C.I. Pigment Red 3 administration. Squamous cell papillomas of the skin occurred with a positive trend in male rats (0/50, 4/50, 2/50, 6/50), and the incidence in the high-dose group was significantly greater than that of the controls. A poorly differentiated squamous cell carcinoma (diagnosed as carcinoma) was observed in a control male. The historical control rate for squamous cell papillomas in NTP feed studies is low (16/800 or 2&amp;percnt;, range 0&amp;percnt;-4&amp;percnt;), and the higher incidence of this tumor in male rats may have been caused by the administration of C.I. Pigment Red 3. Hepatocellular adenomas occurred with a positive trend in female rats, with a significantly greater incidence in the high-dose group than in the control group (0/50, 0/50, 1/50, 10/50). This neoplasm has occurred in only one historical control group in NTP feed studies (3/800, range 0&amp;percnt;-6&amp;percnt;), and the increase in hepatocellular adenomas in female rats was attributed to chemical administration. Chemical-related nonneoplastic lesions observed in the livers of male and female rats included eosinophilic or mixed type foci of cellular alteration. Foci were often accompanied by angiectasis and cystic degeneration in males and by granulomas and cholesterol pigmentation in females. Chronic nephropathy occurred with increased severity in exposed male and female rats. The lesions were more severe in males than in females. Other lesions considered secondary to renal disease included parathyroid gland hyperplasia, fibrous osteodystrophy of the bone, and mineralization of various organs (stomach, intestine, heart, and blood vessels). The increased incidence of hyperplasia of the transitional epithelium of the renal papilla observed in treated rats was considered to be part of the chronic nephropathy. Zymbal's gland carcinoma incidences were marginally increased in the mid- and high-dose male rats (0/50, 0/50, 2/50, 3/50). The incidence in the high-dose group was outside the NTP historical control range (0&amp;percnt;-4&amp;percnt;), and the Zymbal's gland carcinomas may have been related to C.I. Pigment Red 3 administration. Mononuclear cell leukemias, mammary gland fibroadenomas, and preputial gland/clitoral gland adenomas occurred at lower incidences in exposed male and female rats. The decrease in mononuclear cell leukemia was attributed to the direct effect of C.I. Pigment Red 3 or its metabolites on the mechanism responsible for inducing leukemias in aging rats, while the decreased incidence of mammary gland fibroadenomas might be attributed to decreased body weights in female rats. The cause of the decreased incidences of preputial and clitoral gland tumors is unknown. Tubule adenomas of the renal cortex occurred at a significantly higher incidence in high-dose male mice than in controls (0 ppm, 0/50; 12,500 ppm, 0/50; 25,000 ppm, 0/50; 50,000 ppm, 6/50). Because this tumor occurred only in exposed males and was outside the range for NTP historical controls in feed studies (0&amp;percnt;-2&amp;percnt;), renal cortical tubule adenomas in male mice were considered to be related to the administration of C.I. Pigment Red 3. Follicular cell adenoma of the thyroid gland occurred with a positive trend in male mice (0/50, 0/49, 1/50, 5/50). Theincidence in the high-dose group was significantly greater than that in the controls. This chemical-related effect is supported by the increased incidence of follicular cell hyperplasia. Because the incidence of this tumor exceeded the range of the historical controls from NTP feed studies (0&amp;percnt;-4&amp;percnt;), the increase of follicular cell adenoma was attributed to chemical administration. Female mice receiving C.I. Pigment Red 3 had a significant increase in follicular cell hyperplasia but showed no increase in tumor incidence at this site. Focal renal tubule hyperplasia and cystic hyperplasia occurred in exposed male mice but not in the controls. Cytomegaly (karyomegaly) of the renal tubule epithelium was seen in all treated male mice. The severity of the accompanying chronic nephropathy was increased in both male and female mice. Genetic Toxicology: C.I. Pigment Red 3 was mutagenic in Salmonella typhimurium strains TA100 and TA98 in the presence of exogenous metabolic activation (S9); no increases in gene mutation were observed in strains TA1535 and TA1537, with or without S9. C.I. Pigment Red 3 did not induce sister chromatid exchanges or chromosomal aberrations in Chinese hamster ovary cells in either the presence or the absence of S9. Conclusions: Under the conditions of these 2-year feed studies, there was some evidence of carcinogenic activity of C.I. Pigment Red 3 in male F344/N rats as exhibited by increased incidences of benign pheochromocytomas of the adrenal gland. The marginal increase in the incidences of squamous cell papillomas of the skin and Zymbal's gland carcinomas may have been related to C.I. Pigment Red 3 administration. There was some evidence of carcinogenic activity of C.I. Pigment Red 3 in female F344/N rats as indicated by the increased incidence of hepatocellular adenomas. There was some evidence of carcinogenic activity of C.I. Pigment Red 3 in male B6C3F1 mice as exhibited by the increased incidences of tubule adenomas of the renal cortex and follicular cell adenomas of the thyroid gland. There was no evidence of carcinogenic activity of C.I. Pigment Red 3 in female B6C3F1 mice that received 12,500, 25,000, or 50,000 ppm. The incidences of mononuclear cell leukemia and preputial gland tumors in male rats and mononuclear cell leukemia, mammary gland fibroadenoma, and clitoral gland tumors in female rats were lower in the exposed groups. The incidences of liver foci were markedly increased in exposed male and female rats. The severity of chronic nephropathy was increased in male rats and to a lesser extent in female rats given C.I. Pigment Red 3. An increase in the severity of nephropathy was observed in male and female mice; cytomegaly (karyomegaly) of renal tubule epithelium was observed in male mice. Thyroid follicular cell hyperplasia occurred with an increased incidence in male and female mice receiving C.I. Pigment Red 3. Synonyms: 2-Naphthalenol, 1-((4-methyl-2-nitrophenyl)azo)-; Calcotone Toluidine Red YP; Fast Red A; Pigment Scarlet R; Recolite Fast Red RBL; Sengale Light Red B

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Methylphenidate hydrochloride is a drug used in the treatment of narcolepsy and attention deficit hyperactivity disorders. This drug was nominated for study by the Food and Drug Administration and the National Cancer Institute because of its widespread use in human medicine and because of lack of data on its potential carcinogenicity. Oral administration is the most common route of human exposure. Toxicology and carcinogenicity studies were conducted by administering methylphenidate hydrochloride (USP grade) ad libitum in feed to groups of male and female F344/N rats and B6C3F1, mice for 14 days, 13 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium and in cultured Chinese hamster ovary cells. 14-DAY STUDY IN RATS: Groups of five male and five female F344/N rats were fed diets containing 0, 16, 62, 250, 1,000, or 4,000 ppm methylphenidate hydrochloride for 14 days. All rats survived to the end of the study. The final mean body weights of 4,000 ppm male and female rats were 9% lower than those of the controls. Absolute and relative liver weights of 4,000 ppm males and females were significantly greater than those of the controls. Clinical findings during the first week of the study included hyperactivity in 4,000 ppm males and females, but these animals appeared to be normal during the second week of treatment. No treatment-related gross lesions were observed; however, centrilobular hypertrophy was observed in 4,000 ppm males and females. 14-DAY STUDY IN MICE: Groups of five male and five female B6C3F1, mice were fed diets containing 0, 16, 62, 250, 1,000, or 4,000 ppm methylphenidate hydrochloride for 14 days. Three 4,000 ppm males died during the second week of the study; all other mice survived to the end of the study. The final mean body weight of 4,000 ppm females was 11% lower than that of the controls, and the mean body weight gains of 1,000 and 4,000 ppm males and females were also significantly lower than those of the controls. Absolute and relative liver weights of all exposed groups of males and of 4,000 ppm females were significantly greater than those of the controls. Hyperactivity was observed during the second week of the study in some 4,000 ppm males. Degeneration and necrosis of the renal tubule epithelium were observed in two 4,000 ppm males. Hepatocellular hypertrophy was observed in males and females exposed to 1,000 or 4,000 ppm and in males exposed to 250 ppm. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were fed diets containing 0, 125, 250, 500, 1,000, or 2,000 ppm methylphenidate hydrochloride for 13 weeks. There were no chemical-related effects on survival. Mean body weight gains of 500, 1,000, and 2,000 ppm males and females and of 250 ppm females were significantly lower than those of the controls. Final mean body weights of exposed males and females were similar to those of the controls. During the first week of the study, feed consumption by 2,000 ppm rats was less than that by controls, but during the remainder of the study feed consumption by exposed and control groups was similar. Rats exposed to 125, 250, 500, 1,000, or 2,000 ppm received approximate doses of 8, 15, 30, 70, or 130 mg methylphenidate hydrochloride per kilogram body weight per day (males) or 9, 18, 30, 70, or 150 mg/kg per day (females). Clinical findings in 1,000 and 2,000 ppm females included slight hypersensitivity to touch, hyperactivity, and increased vocalization during handling periods. Absolute and relative liver weights of 2,000 ppm males and females were significantly greater than those of the controls, as were the relative liver weights of 1,000 ppm males and females. No chemical-related differences in bone length, bone density, or nose-to-rump lengths were noted in males or females, nor were there treatment related histopathologic lesions. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1, mice were fed diets containing 0, 125, 250, 500, 1,000, or 2,000 ppm methylphenidate hydrochloride for 13 weeks. There were no chemical-related effects on ed effects on survival. Final mean body weights of males exposed to 250, 500, 1,000, or 2,000 ppm and of 2,000 ppm females were significantly lower than those of the controls. The final mean body weights of other exposed male and female groups were similar to those of the controls. During the first week of the study, feed consumption by 2,000 ppm mice was less than that by controls; feed consumption by exposed groups was similar to that by the controls throughout the remainder of the study. Mice exposed to 125, 250, 500, 1,000, or 2,000 ppm received approximate doses of 15, 30, 70, 115, or 230 mg/kg per day (males) or 15, 30, 70, 125, or 260 mg/kg per day (females). No chemical-related clinical findings were observed. Absolute and relative liver weights of 1,000 and 2,000 ppm males and females were significantly greater than those of the controls, as were the relative liver weights of 125, 250, and 500 ppm males. Centrilobular hypertrophy and hepatocellular degeneration or necrosis were observed in males exposed to 500, 1,000, or 2,000 ppm methylphenidate hydrochloride. 2-YEAR STUDY IN RATS: Based on the increased liver weights and lower body weight gains in 2,000 ppm rats in the 13-week study, the high dose selected for the 2-year rat study was 1,000 ppm. Groups of 70 male and 70 female F344/N rats were fed diets containing 0, 100, 500, or 1,000 ppm methylphenidate hydrochloride for up to 2 years. As many as 10 male and 10 female rats per exposure group were evaluated at 9 or 15 months. Survival, Body Weights, Feed and Compound Consumption, and Clinical Findings: Survival of exposed rats was similar to that of the controls at the end of the study. Mean body weights of 500 and 1,000 ppm males were 3&amp;percnt; to 10&amp;percnt; lower than those of the controls from week 30 to the end of the study; during the same time period, mean body weights of 500 and 1,000 ppm females were 4&amp;percnt; to 24&amp;percnt; less than those of the controls. Final mean body weights of rats exposed to 100, 500, or 1,000 ppm were 102&amp;percnt;, 95&amp;percnt;, or 90&amp;percnt; (males) and 96&amp;percnt;, 89&amp;percnt;, or 78&amp;percnt; (females) those of the controls. Rats exposed to 100, 500, or 1,000 ppm methylphenidate hydrochloride in feed received approximate doses of 5, 25, or 50 mg/kg per day (males and females). The only chemical-related clinical finding was an increased incidence of fighting among group-housed males exposed to 1,000 ppm. Hematology and Clinical Chemistry: No biologically significant differences in hematology or clinical chemistry parameters occurred at 9 or 15 months. Pathology Findings: In female rats exposed to 500 or 1,000 ppm, the incidence of mammary gland fibroadenomas was decreased (0 ppm, 15/49; 100 ppm, 13/50; 500 ppm, 6/ 48; 1,000 ppm, 5/50), and the decrease was considered to be related to chemical administration. No significant chemical-related increases in neoplasm incidences were observed in male or female rats. 2-YEAR STUDY IN MICE: Based on the liver toxicity and lower body weight gains observed in 1,000 and 2,000 ppm mice in the 13-week study, the high dose selected for the 2-year study was 500 ppm. Groups of 70 male and 70 female B6C3F1 mice were fed diets containing 0, 50, 250, or 500 ppm methylphenidate hydrochloride for 2 years. As many as 10 male and 10 female mice per exposure group were evaluated at 9 or 15 months. Survival, Body Weights, Feed and Compound Consumption, and Clinical Findings: Survival of exposed mice was similar to that of the controls at the end of the study. Mean body weights of mice exposed to 250 or 500 ppm were 3&amp;percnt; to 11&amp;percnt; lower than those of the controls throughout much of the study; during the same time period, mean body weights of 250 ppm females were 3&amp;percnt; to 7&amp;percnt; lower than those of the controls. Final mean body weights of mice exposed to 50, 250, or 500 ppm were 97&amp;percnt;, 89&amp;percnt;, or 93&amp;percnt; (males) and 98&amp;percnt;, 93&amp;percnt;, or 97&amp;percnt; (females) that of the controls. Mice exposed to 50, 250, or 500 ppm methylphenidate hydrochloride in feed were estimated to have received 6, 30, or 60 mg/kg body weight per day (males) or 8, 40, or 80 mg/kg per day (females). There were no chemical related clinical findings. Hematology and Clinical Chemistry: No biologically significant differences in hematology or clinical chemistry parameters occurred at 9 or 15 months. Pathology Findings: The principal lesions associated with the administration of methylphenidate hydrochloride occurred in the liver. A few hepatocellular neoplasms were observed in control and exposed male mice at the 9-and 15-month interim evaluations, but the incidences in exposed groups were not significantly increased. At the end of the 2-year study, incidences of eosinophilic foci were increased in 500 ppm males and females. Increased incidences of hepatoblastoma occurred in 500 ppm males (0 ppm, 0/50; 50 ppm, 1/50; 250 ppm, 1/50; 500 ppm, 5/50). Increased incidences of hepatocellular adenoma also occurred in 500 ppm males (18/50, 18/50, 16/50, 29/50) and females (6/49, 10/48, 10/49, 28/50). The incidences of hepatocellular carcinoma were similar among control and exposed mice. GENETIC TOXICOLOGY: Methylphenidate hydrochloride was not mutagenic in Salmonella typhimurium strains TA97, TA98, TA100, TA1535, or TA1537, with or without exogenous metabolic activation (S9). Methylphenidate hydrochloride was also tested for induction of sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells. In the chromosomal aberrations tests, positive results were not consistently dependent upon the presence or absence of S9 activation. Sister chromatid exchanges were not increased in the presence of S9, but one laboratory did obtain a positive response without S9 by testing higher doses than were used in tests With S9. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of methylphenidate hydrochloride in male or female F344/ N rats receiving 100, 500, or 1,000 ppm. There was some evidence of carcinogenic activity of methylphenidate hydrochloride in male and female B6C3F1 mice based on the occurrence of hepatocellular neoplasms. Treatment of female rats with methylphenidate hydrochloride was associated with a decrease in the incidence of mammary gland fibroadenomas. Administration of methylphenidate hydrochloride to male and female mice resulted in increased incidences of eosinophilic foci. Synonyms: a-phenyl-2-piperidineacetic acid methyl ester hydrochloride; methylphenidylacetate hydrochloride; a-phenyl-a-(2-piperidyl)acetic acid methyl ester hydrochloride; methyl a-phenyl-a-(2-piperidyl)acetate hydrochloride

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Nitrofurantoin was studied and evaluated because of its widespread use as a drug for treating urinary tract infections in humans, its structural relationship to known carcinogenic 5-nitrofuran compounds, and the lack of adequate studies to assess its carcinogenicity. Toxicology and carcinogenesis studies of nitrofurantoin were conducted by administering nitrofurantoin (greater than 99% pure) in feed to groups of F344/N rats and B6C3F1 mice of each sex for 14 days, 13 weeks, or 2 years. Fourteen-Day and Thirteen-Week Studies: None of the rats (at dietary concentrations up to 20,000 ppm) died before the end of the 14-day studies. Rats that received 5,000, 10,000, or 20,000 ppm lost weight. Four of five male and 4/5 female mice that received 10,000 ppm and 1/5 females that received 5,000 ppm nitrofurantoin died before the end of the studies. Mice that received 5,000 ppm and male mice that received 10,000 ppm lost weight. In the 13-week studies, final mean body weights of rats that received 2,500, 5,000, or 10,000 ppm were 10%, 34%, or 47% lower than that of the controls for males and 15%, 31%, or 41% lower for females. Feed consumption by dosed and control rats was generally similar. Degeneration of the germinal epithelium of the seminiferous tubules of the testis was observed in male rats that received 2,500 to 10,000 ppm nitrofurantoin. Necrosis of the ovarian follicles was observed in 8/10 female rats that received 10,000 ppm, in 3/10 females that received 5,000 ppm, and in 1/10 that received 2,500 ppm. For mice, final mean body weights of the 5,000-ppm groups were 13% lower than that of the controls for males and 15% lower for females. Two of 10 male mice that received 5,000 ppm and 1/10 males that received 300 ppm died before the end of the 13-week studies. Estimated feed consumption was similar for dosed and control groups. Degeneration of the germinal epithelium of the testis was observed in males that received 1,300 to 5,000 ppm; necrosis of the ovarian follicles was observed in females that received 5,000 ppm but not in the lower dose groups. Necrosis of the renal tubular epithelium was observed in 2/9 males that received 5,000 ppm. Based on these results, 2-year studies of nitrofurantoin were conducted by feeding diets containing 0, 1,300, or 2,500 ppm nitrofurantoin to groups of 50 male F344/N rats and to groups of 50 male and female B6C3F1 mice for 103 weeks. Groups of 50 female F344/N rats were fed diets containing 0, 600, or 1,300 ppm nitrofurantoin on the same schedule. Body Weight and Survival in the Two-Year Studies: Mean body weight and average daily feed consumption of dosed male and female rats were similar to those of the controls throughout the studies. The average amount of nitrofurantoin consumed per day was estimated to be 60 and 110 mg/kg for low and high dose male rats and 30 and 60 mg/kg for low and high dose female rats. No significant differences in the number of rats surviving to the end of the studies were observed between any groups of rats of either sex (male: control, 24/50; low dose, 27/50; high dose, 26/50; female: 25/50; 26/50; 31/50). Mean body weights of high dose male and female mice were up to 12% lower than those of the controls throughout most of the studies. The average daily feed consumption by dosed mice ranged from 93% to 100% that by controls. The average amount of nitrofurantoin consumed per day was estimated to be 280-300 mg/kg and 570-580 mg/kg for low and high dose mice. The survival of the control group of female mice was lower than that of the dosed groups (control, 19/50; low dose, 37/50; high dose, 37/50). The decrease in survival was most likely related to the increase in microbial infection in the reproductive tract observed in the controls. Groups of male mice had similar survival (28/50; 29/50; 34/50). Nonneoplastic and Neoplastic Effects in the Two-Year Studies: Organs showing toxicity from nitrofurantoin exposure identified in the short-term studies were the testis in male rats and mice, the ovary in female rats and mice, and the kidney in male mice. Lesions oband mice, the ovary in female rats and mice, and the kidney in male mice. Lesions observed in the 2-year studies were in the testis in male rats and mice, ovary in female mice, and kidney in male rats. Chronic nephropathy was observed in nearly all rats, but the severity of the lesions was judged to be greater in dosed male rats. Hyperplasia of the transitional cell epithelium (control, 0/50; low dose, 5/50; high dose, 2/50) and hydronephrosis of the renal pelvis (0/50; 5/50; 2/50) were also observed in dosed male rats. In the standard single sections of the left and right kidney from each rat, tubular cell adenomas were observed in one low dose and two high dose males; a tubular cell carcinoma was observed in another high dose male. Because the number of renal tubular cell neoplasms identified by standard procedures in the dosed male rats was low, additional step-sections of the kidney were evaluated. The incidences of tubular cell adenomas derived from the step-sections and original sections (combined) were significantly increased in dosed male rats (adenomas: 3/50; 11/50; 19/50); tubular cell carcinomas occurred in two high dose males only. Lesions considered to be associated with the nephropathy and nitrofurantoin exposure were observed in male rats and included hyperplasia of the parathyroid glands (3/49; 18/47; 23/49), fibrous osteodystrophy of the bone (0/50; 5/50; 5/50), and mineralization of the glandular stomach (1/49; 8/50; 14/50). Atypical cells of the epididymis (0/50; 0/50; 12/50) and degeneration of the testis (0/50; 0/50; 36/50) were observed in high dose male rats. Fibrinoid necrosis of arterioles (1/50; 8/50; 15/50) and perivascular infiltration of mononuclear cells (3/50; 9/50; 19/50) were also observed in the testis of male rats. Interstitial cell adenomas of the testis occurred with a negative trend (47/50; 45/50; 21/50), and no adenomas or carcinomas of the preputial gland were seen in high dose male rats (12/48; 11/50; 0/47). The incidence of clitoral gland neoplasms was increased in low dose female rats (5/44; 10/38; 4/42). Osteosarcomas were observed in the bone of one low dose and two high dose male rats. The historical incidence of osteosarcomas in untreated male F344/N rats is 8/1,937 (0.4&amp;percnt;). The incidences of subcutaneous tissue neoplasms in dosed male rats were greater than that in the controls (1/50; 7/50; 5/50). No neoplastic lesions in dosed female rats or male mice were considered to be compound related at the doses of nitrofurantoin administered. For female mice, ovarian atrophy was observed in 48/50 low dose and 49/50 high dose mice but not in controls. Tubular cell adenomas of the ovary (0/50; 0/50; 5/50), benign mixed tumors (tubular and stromal) (0/50; 0/50; 4/50), and granulosa cell tumors (0/50; 3/50; 2/50)) were observed in dosed female mice. One granulosa cell tumor in the high dose group was malignant. Ovarian abscesses (18/50) and suppurative inflammation of the uterus (11/50) were observed in control female mice but not in dosed female mice and are believed to be related to indigenous microbial infections and most likely were the cause of early deaths in this group. Adenocarcinomas of the uterus were seen in one low dose and in one high dose mouse. Testicular aspermatogenesis (1/49; 1/49; 16/50), degeneration of the germinal epithelium (0/49; 3/49; 23/50), and atypical cells (0/50; 0/49; 26/50) and depletion (1/50; 1/49; 15/50) of the epididymis were observed at increased incidences in high dose male mice. Spindle cell hyperplasia of the adrenal cortex was observed in dosed female mice (3/50; 41/50; 45/50). A spindle cell adenoma (adrenal capsule adenoma) was seen in one low dose female mouse, and a spindle cell carcinoma (adrenal capsule carcinoma) was seen in one low dose male mouse. Mineralization of the renal medulla (male: 0/50; 0/50; 17/50; female: 0/50; 0/50; 7/50) and dilatation of the renal tubules (male: 0/50; 0/50; 14/50) were observed in high dose mice. Hepatocellular neoplasms (adenomas or carcinomas, combined) were observed at an increased incidence in high dose female mice (2/50; 2/50; 8/50). An Ito cell tumor of the liver was observed in one low dose and one high dose female mouse. Malignant lymphomas occurred in female mice (12/50; 19/50; 24/50). Genetic Toxicology: Nitrofurantoin was mutagenic in Salmonella typhimurium strains TA98 and TA100, with and without metabolic activation, but was not mutagenic for strains TA1535 or TA1537. Nitrofurantoin induced forward mutations at the TK+/- locus of L5178Y mouse lymphoma cells in the absence of metabolic activation (it was not tested with activation). Nitrofurantoin induced increased numbers of sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells with and without metabolic activation. Results of the sex-linked recessive lethal assay in Drosophila were negative after administration of nitrofurantoin by feeding or by injection. Conclusions: Under the conditions of these 2-year feed studies, there was some evidence of carcinogenic activity of nitrofurantoin for male F344/N rats as shown by increased incidences of uncommon kidney tubular cell neoplasms. Uncommon osteosarcomas of the bone and neoplasms of the subcutaneous tissue were observed in dosed male rats. Incidences of interstitial cell adenomas of the testis and neoplasms of the preputial gland were decreased in the 2,500-ppm group of male rats. There was no evidence of carcinogenic activity of nitrofurantoin for female F344/N rats fed diets containing 600 ppm or 1,300 ppm for 2 years. Female rats may have been able to tolerate higher doses. There was no evidence of carcinogenic activity of nitrofurantoin for male B6C3F1 mice fed diets containing 1,300 ppm or 2,500 ppm for 2 years. There was clear evidence of carcinogenic activity of nitrofurantoin for female B6C3F1 mice as shown by increased incidences of tubular adenomas, benign mixed tumors, and granulosa cell tumors of the ovary. Nonneoplastic lesions considered related to nitrofurantoin exposure were chronic nephropathy and associated lesions (hyperplasia of the parathyroid gland, fibrous osteodystrophy of the bone, and mineralization of the glandular stomach) in male rats and testicular degeneration in male rats and mice. Ovarian atrophy and hyperplasia of the adrenal cortex spindle cells were observed in dosed female mice. Synonyms: 1-(((5-nitro-2-furanyl)methylene)amino-2,4-imidazolidinedione); 1-(5-nitro-2-furfurylideneamino)-hydantoin; N-(5-nitro-2-furfurlidene)-1-aminohydantoin; 1-((5-nitrofurfurylidene)amino)hydantoin Trade Names: Benkfuran; Benkfurin; Chemiofuran; Cyantin; Dantafur; Furadantin; Furadantine; Furadantoin; Furadonin; Furadonine; Furantoin; Furatoin; Furobactina; Ituran; Macrodantin; Nifurantin; NSC 2107; N-Toin; Orafuran; Parafuran; Urizept; USAF EA-2; Welfurin; Zoofurin

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The Mars Sample Return Planning Group 2 (MSPG2) was tasked with identifying the steps that encompass all the curation activities that would happen within the MSR Sample Receiving Facility (SRF) and any anticipated curation-related requirements. An area of specific interest is the necessary analytical instrumentation. The SRF would be a Biosafety Level-4 facility where the returned MSR flight hardware would be opened, the sample tubes accessed, and the martian sample material extracted from the tubes. Characterization of the essential attributes of each sample would be required to provide enough information to prepare a sample catalog used in guiding the preparation of sample-related proposals by the world's research community and informing decisions by the sample allocation committee. The sample catalog would be populated with data and information generated during all phases of activity, including data derived concurrent with Mars 2020 sample-collecting rover activity, sample transport to Earth, and initial sample characterization within the SRF. We conclude that initial sample characterization can best be planned as a set of three sequential phases, which we have called Pre-Basic Characterization (Pre-BC), Basic Characterization (BC), and Preliminary Examination (PE), each of which requires a certain amount of instrumentation. Data on specific samples and subsamples obtained during sample safety assessments and time-sensitive scientific investigations would also be added to the catalog. There are several areas where future work would be beneficial to prepare for the receipt of samples, which would include the design of a sample tube isolation chamber and a strategy for opening the sample tubes and removing dust from the tube exteriors. Executive Summary All material collected from Mars (gases, dust, rock, regolith) would need to be carefully handled, stored, and analyzed following Earth return to minimize the alteration or contamination that could occur on Earth and maximize the scientific information that can be attained from the samples now and into the future. A Sample Receiving Facility (SRF) is where the Earth Entry System (EES) would be opened and the sample tubes opened and processed after they land on Earth. Samples should be accessible for research in biocontainment for time-sensitive studies and eventually, when deemed safe for release after sterilization or biohazard assessment, should be transferred out of biocontainment for allocation to scientific investigators in outside laboratories. There are two main mechanisms for allocation of samples outside the SRF: 1) Wait until the implementation of the Sample Safety Assessment Protocol (Planetary Protection) results concludes that the samples are non-hazardous, 2) Render splits of the samples non-hazardous by means of sterilization. To make these samples accessible, a series of observations and analytical measurements need to be completed to produce a sample catalog for the scientific community. Specialist members of the Mars Sample Return Planning Group Phase 2 (MSPG2), referred to here as the Curation Focus Group, have identified four curation goals that encompass all of the activities within the SRF: 1.Documentation of the state of the sample tubes and their contents prior to opening, 2.Inventory and tracking of the mass of each sample, 3.Preliminary assessment of lithology and any macroscopic forms of heterogeneity (on all the samples, non-invasive, in pristine isolators), 4.Sufficient characterization of the essential attributes of each sample to prepare a sample catalog and respond to requests by the sample allocation committee (partial samples, invasive, outside of pristine isolators). The sample catalog will provide data for the scientific community to make informed requests for samples for scientific investigations and for the approval of allocations of appropriate samples to satisfy these requests. The sample catalog would be populated with data and information generated during all phases of activity, including data derived from the landed Mars 2020 mission, during sample collection and transport to Earth, and reception within the Sample Receiving Facility. Data on specific samples and subsamples would also be generated during curation activities carried out within the Sample Receiving Facility and during sample safety assessments, time-sensitive studies, and a series of initial sample characterization steps we refer to as Pre-Basic Characterization (Pre-BC), Basic Characterization (BC), and Preliminary Examination (PE) phases. A significant portion of the Curation Focus Group's efforts was to determine which instrumentation would be required to produce a sample catalog for the scientific community and how and when certain instrumentation should be used. The goal is to provide enough information for the PIs to request material for their studies but to avoid facilitating studies that target scientific research that is better left to peer-reviewed competitive processes. We reviewed the proposed scientific objectives of the International MSR Objectives and Samples Team (iMOST) (Beaty <iet al.,</i 2019) to make sure that the instrumentation suggested is sufficient to cover these key science planning questions (Table 1; Section S-6). It was determined that for Pre-Basic Characterization, two instruments are required, a Magnetometer (see Section S-1.1) and an X-ray Computed Tomography scanner (XCT see Section S-1.2). For Basic Characterization, there are four instruments that are considered necessary, which are analytical balance(s) (see Section S-2.1), binocular microscopes (see Section S-2.2), and multispectral imaging and hyperspectral scanning systems (see Section S-2.3). Then in Preliminary Examination, there is a set of instruments that should be available for generating more detailed information for the sample catalog. These are a Variable Pressure-Field Emission Scanning Electron Microscope (VP-FE-SEM see Section S-3.1), Confocal Raman spectrometer (see Section S-3.2), Deep UV Fluorescence (see Section S-3.3), a Fourier Transform Infrared Spectrometer (see Section S-3.4), a Micro X-ray Diffractometer (see Section S-3.5), X-ray Fluorescence Spectrometer (see Section S-3.6), and Petrographic and Stereo Microscope (see Section S-3.7). All instruments are summarized in Table 1. Finally, our Curation Focus Group has outlined several specific findings for sample curation within the SRF to complete the sample catalog prior to sample distribution and made several recommendations for future work (summarized in Section 8.1) to build upon the efforts that generated this report. List of Findings <bMAJOR FINDING C-1: The initial sample characterization in the Sample Receiving Facility of the MSR samples can be broken down into three stages for simplicity as follows: Pre-Basic Characterization (Pre-BC), Basic Characterization (BC), and Preliminary Examination (PE). While the whole collection would be assessed through Pre-BC and BC, only subsets of samples would be used during the PE phase.</b <bFINDING C-2:</b Immediately after Earth landing, the spacecraft would be recovered and placed in a container designed to control and stabilize its physical conditions. The optimum temperature (T<suboptimum</sub) of the sample tubes during transport to the Sample Receiving Facility (SRF) should be the same as the operating temperature of the SRF to avoid unnecessary temperature shock. <bFINDING C-3:</b The Sample Receiving Facility (SRF) should operate at room temperature (∼15-25°C), and the samples should be held at this temperature through all steps of initial sample characterization, with the option for cold storage of subsamples available in the SRF when needed. <bMAJOR FINDING C-4: Measurements on all the sample tubes before they are opened are essential to conduct as the samples could be compromised upon opening of the tubes. This step is called Pre-Basic Characterization (Pre-BC). These are measurements that would inform how the tubes are opened, processed, and subsampled during Basic Characterization (BC).</b <bMAJOR FINDING C-5: Careful collection and storage of the serendipitous dust on the outside of the sample tubes is a critical step in the curation process in the Sample Receiving Facility. The dust collected is a valuable resource to the scientific community.</b <bMAJOR FINDING C-6: Careful collection and storage of the unaltered and unfractionated headspace gas collected from the sample tubes is a critical step in the curation process in the Sample Receiving Facility. The gas collected is a valuable resource to the scientific community.</b <bFINDING C-7:</b To minimize the interaction of Earth atmospheric gases and gases that are in the sealed sample tubes, once the dust is removed from the exterior of the sample tubes, they should be placed into individual sample tube isolation chambers (STIC) as quickly as possible. <bFINDING C-8:</b There are compelling reasons to perform penetrative 3D imaging prior to opening the sample tubes. A laboratory-based X-ray Computed Tomography scanner is the best technique to use and the least damaging to organics of the penetrative imaging options considered. <bMAJOR FINDING C-9: Measurements on all the samples once the sample tubes are opened within the pristine isolators are essential to make initial macroscopic observations such as weighing, photographing, and optical observations. The first step to this stage is removal and collection of the headspace gas, which then starts the clock for time-sensitive measurements. This step is called Basic Characterization (BC).</b <bFINDING C-10:</b To avoid cross contamination between samples, it is recommended that, for processing through the isolators, the samples are organized into groups that have like properties. Given what we know about the geology of Jezero Crater, a reasonable starting assumption is five such groups. <bMAJOR FINDING C-11: Assuming that sample processing rates are reasonable and the samples are organized into five sets for cross contamination avoidance purposes, at least twelve pristine isolators are required to perform Basic Characterization on the MSR samples. This total would increase by two for each additional distinct processing environment.</b <bMAJOR FINDING C-12: More advanced measurements on subsamples, beyond those included in BC, are essential for the allocation of material to the scientific community for investigation, including some measurements that can make irreversible changes to the samples. These types of measurements take place during Preliminary Examination (PE).</b <bFINDING C-13:</b The output of the initial sample characterization, and a key function of the curation activities within the Sample Receiving Facility, is to produce a sample catalog that would provide relevant information on the samples' physical and mineralogical/chemical characteristics (derived from the Pre-Basic Characterization, Basic Characterization, and Preliminary Examination investigations), sample safety assessments, time-sensitive studies, and information derived from mission operations to enable allocation of the most appropriate materials to the scientific community. <bFINDING C-14:</b A staffing model for curation activities, including technical support and informatics/ documentation support, should be developed (as part of ongoing Sample Receiving Facility development) to ensure that the Sample Receiving Facility is staffed appropriately to support sample curation activities. <bFINDING C-15:</b To reduce the risk of catastrophic loss of samples curated in a single facility up to, and including, decadal timescales, the sample collection should be split-once it is possible to do so-and housed in more than one location for the purpose of maximizing the long-term safety of the collection.

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The Diptera genus-group names of Pierre-Justin-Marie Macquart are reviewed and annotated. A total of 399 available genus-group names in 69 families of Diptera are listed alphabetically, for each name giving author, year and page of original publication, originally included species, type species and method of fixation, current status of the name, family placement, and a list of any emendations of it that have been found in the literature. Remarks are given to clarify nomenclatural or taxonomic information. In addition, an index to all the species-group names of Diptera proposed by Macquart (3,611, of which 3,543 are available) is given with bibliographic reference (year and page) to each original citation.        The following type species are designated herein: Agculocera nigra Macquart, 1855 for Onuxicera Macquart, 1855, present designation [Tachinidae]; Trixa imhoffi Macquart, 1834, for Semiomyia Macquart, 1848, present designation [Tachinidae].        The following type species are designated herein with fixation under ICZN Code Art. 70.3.2: Azelia nebulosa Robineau-Desvoidy, 1830 for Atomogaster Macquart, 1835, present designation [Muscidae]; Tachydromia vocatoria Fallén, 1816 for Chelipoda Macquart, 1835, present designation [Empididae]; Eriocera macquarti Enderlein, 1912 for Eriocera Macquart, 1838, present designation [Limoniidae]; Limosina acutangula Zetterstedt, 1847 for Heteroptera Macquart, 1835, present designation [Sphaeroceridae]; Phryxe pavoniae Robineau-Desvoidy, 1830 for Masicera Macquart, 1834, present designation [Tachinidae]; Pachymyia macquartii Townsend, 1916 for Pachymyia Macquart, 1844, present designation [Tachinidae].        Earlier valid subsequent type-species designations have been found in this study for the following: Anisophysa Macquart, 1835 [Sepsidae]; Diphysa Macquart, 1838 [Stratiomyidae]; Pachyrhina Macquart, 1834 [Tipulidae]; Silbomyia Macquart, 1844 [Calliphoridae].        One name is raised from synonymy: Czernyola Bezzi, 1907, n. stat. [Clusiidae].        Names previously treated as available but found in this work to be unavailable include the following: Genus-group names-Anodontina Macquart, 1838, n. stat. [Empididae]; Athricia Macquart, 1834, n. stat. [Tachinidae]; Blepharis Macquart, 1838, n. stat. [Asilidae]; Dichelocera Enderlein, 1922, n. stat. [Tabanidae]; Lepidoselaga Loew, 1869, n. stat. [Tabanidae]; Lemptopeza Macquart, 1828, n. stat. [Hybotidae]; Microphora Zetterstedt, 1842, n. stat. [Dolichopodidae]; Microphorus Macquart, 1834, n. stat. [Dolichopodidae]; Plagiocephala Macquart, 1844, n. stat. [Ulidiidae]; Stratiomyia Macquart, 1838, n. stat. [Stratiomyidae]; Taenioptera Agassiz, 1846, n. stat. [Micropezidae]; Tapigaster Bezzi, 1923, n. stat. [Heleomyzidae]; Trizota Macquart, 1829, n. stat. [Syrphidae]. Species-group names-Microstylum sinense Macquart, 1838, n. stat. [Asilidae].        Corrected or clarified included species and/or corrected or clarified type-species and methods of typification are given for: Anabarhynchus Macquart, 1848 [Therevidae]; Anacanthella Macquart, 1855 [Stratiomyidae]; Apeilesis Macquart, 1846 [Tipulidae]; Aplomera Macquart, 1838 [Empididae]; Aprotheca Macquart, 1851 [Tachinidae]; Ardoptera Macquart, 1828 [Empididae]; Blepharella Macquart, 1851 [Tachinidae]; Brachystylum Macquart, 1855 [Tachinidae]; Cadicera Macquart, 1855 [Tabanidae]; Calobatemyia Macquart, 1855 [Calliphoridae]; Catapicephala Macquart, 1851 [Calliphoridae]; Ceroptera Macquart, 1835 [Sphaeroceridae]; Cheligaster Macquart, 1835 [Sepsidae]; Chetogaster Macquart, 1851 [Tachinidae]; Chlorogaster Macquart, 1851 [Tachinidae]; Cleitamia Macquart, 1835 [Platystomatidae]; Craspedia Macquart, 1838 [Asilidae]; Craspedochoeta Macquart, 1851 [Anthomyiidae]; Crumomyia Macquart, 1835 [Sphaeroceridae]; Dasyomma Macquart, 1840 [Athericidae]; Demoticus Macquart, 1854 [Tachinidae]; Epicerella Macquart, 1851 [Pyrgotidae]; Epicerina Macquart, 1850 [Acroceridae]; Euprosopia Macquart, 1847 [Platystomatidae]; Grapholostylum Macquart, 1851 [Tachinidae]; Graphomyzina Macquart, 1835 [Sciomyzidae]; Gymnostylina Macquart, 1835 [Tachinidae]; Heterometopia Macquart, 1846 [Tachinidae]; Laxenecera Macquart, 1838 [Asilidae]; Leptomyza Macquart, 1835 [Anthomyzidae]; Megistogaster Macquart, 1851 [Tachinidae]; Microtrichodes Macquart, 1846 [Tachinidae]; Microtropesa Macquart, 1846 [Tachinidae]; Ogcodocera Macquart, 1840 [Bombyliidae]; Onuxicera Macquart, 1855 [Tachinidae]; Ozodicera Macquart, 1834 [Tipulidae]; Pachymerina Macquart, 1834 [Empididae]; Pachyrhina Macquart, 1834 [Tipulidae]; Pachystylum Macquart, 1848 [Tachinidae]; Physegaster Macquart, 1847 [Acroceridae]; Plesionevra Macquart, 1855 [Tachinidae]; Rhopalia Macquart, 1838 [Mydidae]; Semiomyia Macquart, 1848 [Tachinidae]; Senostoma Macquart, 1847 [Tachinidae]; Silbomyia Macquart, 1844 [Calliphoridae]; Sumpigaster Macquart, 1855 [Tachinidae]; Tapinocera Macquart, 1838 [Apioceridae]; Teretrophora Macquart, 1851 [Tachinidae]; Toxocnemis Macquart, 1855 [Tachinidae]; Toxotarsus Macquart, 1851 [Calliphoridae]; Trichostylum Macquart, 1851 [Tachinidae]; Trigonometopus Macquart, 1835 [Lauxaniidae]; Tritaxys Macquart, 1847 [Tachinidae]; Vermileo Macquart, 1834 [Vermileonidae].        Acting as First Reviser, the following correct original spellings for multiple original spellings are selected by us-(for genus-group names): Choeteprosopa Macquart, 1851 [Tachinidae]; Dichoetometopia Macquart, 1855 [Sarcophagidae]; Discocerina Macquart, 1835 [Ephydridae]; Dolichocephala Macquart, 1823 [Empididae]; Dolichomerus Macquart, 1850 [Syrphidae]; Graphalostylum Macquart, 1851 [Tachinidae]; Hemilampra Macquart, 1850 [Syrphidae]; Leptomyza Macquart, 1835 [Anthomyzidae]; Microcheilosia Macquart, 1855 [Tachinidae]; Phrissopodia Macquart, 1835 [Sarcophagidae]; Platytainia Macquart, 1851 [Tachinidae]; Polychaeta Macquart, 1851 [Tachinidae]; Stachynia Macquart, 1835 [Conopidae]-(for species-group names): Cadicera rubramarginata Macquart, 1855 [Tabanidae].        Previous First Reviser actions for multiple original spellings that were missed by other workers are given for the following: Amethysa Macquart, 1835 [Ulidiidae]; Anabarhynchus Macquart, 1848 [Therevidae]; Anacanthella Macquart, 1855 [Stratiomyidae]; Aulacigaster Macquart, 1835 [Aulacigastridae]; Cardiacera Macquart, 1847 [Pyrgotidae]; Comptosia Macquart, 1840 [Bombyliidae]; Craspedia Macquart, 1838 [Asilidae]; Cyclorhynchus Macquart, 1840 [Bombyliidae]; Ectinorhynchus Macquart, 1850 [Therevidae]; Euthinevra Macquart, 1836 [Hybotidae]; Gonistylum Macquart, 1851 [Tachinidae]; Heterostylum Macquart, 1848 [Bombyliidae]; Hoplistomera Macquart, 1838 [Asilidae]; Hystricephala Macquart, 1846 [Tachinidae]; Leptoxyda Macquart, 1835 [Tephritidae]; Nemopalpus Macquart, 1838 [Psychodidae]; Senotainia Macquart, 1846 [Sarcophagidae]; Spilogaster Macquart, 1835 [Muscidae]; Spogostylum Macquart, 1840 [Bombyliidae]; Stachynia Macquart, 1835 [Conopidae].        Invoking ICZN Code Article 33.3.1, the following is here considered a correct original spelling by being in prevailing usage: Leptopeza Macquart, 1828 [Empididae].        Reversal of Precedence (ICZN Code Article 23.9) is invoked to promote stability in nomenclature for the following cases of subjective synonymy: Atherigona Rondani, 1856, nomen protectum and Orthostylum Macquart, 1851, nomen oblitum [in Muscidae]; Clusiodes Coquillett, 1904, nomen protectum and Heteronevra Macquart, 1835, nomen oblitum [in Clusiidae]; Senotainia Macquart, 1846, nomen protectum and Megoera Macquart, 1834, nomen oblitum [in Sarcophagidae].        The following genus-group names, not listed in current regional catalogs, are treated here: Diasema Macquart, 1835 [Chloropidae]; Dichromyia Macquart, 1844 [Heleomyzidae]; Elomyia Macquart, 1834 [Tachinidae]; Eriosoma Macquart, 1838 [Acroceridae]; Eurypalpus Macquart, 1835 [Platystomatidae]; Notacanthina Macquart, 1835 [Ephydridae]; Pleurocerina Macquart, 1851[Conopidae]; Pteropexus Macquart, 1846 [Acroceridae]; Semiomyia Macquart, 1848 [Tachinidae]; Teremyia Macquart, 1835 [Lonchaeidae].        The following names are new synonymies of their respective senior synonyms: -genus-group names: Acemyia Macquart, 1834 of Acemya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Acrochoeta Macquart, 1835 of Acrochaeta Wiedemann, 1830, n. syn. [Stratiomyidae]; Atractea Agassiz, 1846 of Atractia Macquart, 1838, n. syn. [Asilidae]; Aulacocephala Brauer, 1863 of Aulacephala Macquart, 1851, n. syn. [Tachinidae]; Beckeriella Williston, 1897 of Notacanthina Macquart, 1834, n. syn. [Ephydridae]; Caenosia Macquart, 1835 of Coenosia Meigen, 1826, n. syn. [Muscidae]; Ceromyia Macquart, 1834 of Ceromya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Chiromysa Macquart, 1835 of Chiromyza Wiedemann, 1820, n. syn. [Stratiomyidae]; Chrisochlora Macquart, 1835 of Chrysochlora Latreille, 1829, n. syn. [Stratiomyidae]; Chrysopyla Macquart, 1840 of Chrysopilus Macquart, 1826, n. syn. [Rhagionidae]; Cleigaster Macquart, 1844 of Cleigastra Macquart, 1835, n. syn. [Scathophagidae]; Clyto Macquart, 1835 of Clytho Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Cordylura Macquart, 1835 of Cordilura Fallén, 1810, n. syn. [Scathophagidae]; Craspedochaeta Marschall, 1873 of Anthomyia Meigen, 1803, n. syn. [Anthomyiidae]; Cyrtonevra Agassiz, 1846 of Graphomya Robineau-Desvoidy, 1830, n. syn. [Muscidae]; Diaphora Macquart, 1834 of Diaphorus Meigen, 1824, n. syn. [Dolichopodidae]; Dichoeta Macquart, 1835 of Dichaeta Meigen, 1830, n. syn. [Ephydridae]; Dichromyia Macquart, 1844 of Dichromya Robineau-Desvoidy, 1830, n. syn. [Heleomyzidae]; Diphysa Macquart, 1838 of Archistratiomys Enderlein, 1913, n. syn. [Stratiomyidae]; Echinomyia Fischer von Waldheim, 1808 of Tachina Meigen, 1803, n. syn. [Tachinidae]; Egina Macquart, 1835 of Eginia Robineau-Desvoidy, 1830, n. syn. [Muscidae]; Hematobia Macquart, 1850 of Haematobia Le Peletier &amp; Audinet-Serville, 1828, n. syn. [Muscidae]; Hemerodromyia Macquart, 1823 of Hemerodromia Meigen, 1822, n. syn. [Empididae]; Heteronevra Macquart, 1835 of Clusiodes Coquillett, 1904, n. syn. [Clusiidae]; Himastima Agassiz, 1846 of Mallota Meigen, 1822, n. syn. [Syrphidae]; Hoematopota Macquart, 1826 of Haematopota Meigen, 1803, n. syn. [Tabanidae]; Homalocephala Agassiz, 1846 of Setellia Robineau-Desvoidy, 1830, n. syn. [Sciomyzidae]; Hydrotoea Macquart, 1844 of Hydrotaea Robineau-Desvoidy, 1830, n. syn. [Muscidae]; Linnemyia Macquart, 1834 of Linnaemya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Lonchoea Macquart, 1835 of Lonchaea Fallén, 1820b, n. syn. [Lonchaeidae]; Macromyia Macquart, 1835 of Macromya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Megarhina Macquart, 1838 of Lynchiella Lahille, 1904, n. syn. [Culicidae]; Meriana Macquart, 1835 of Panzeria Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Microphorus Lundbeck, 1907 of Microphor Macquart, 1834, n. syn. [Dolichopodidae]; Nemoroea Macquart, 1844 of Nemoraea Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Ochthiphila Macquart, 1850 of Chamaemyia Meigen, 1803, n. syn. [Chamaemyiidae]; Ocydromyia Macquart, 1823 of Ocydromia Meigen, 1820, n. syn. [Hybotidae]; Oliviera Macquart, 1835 of Eriothrix Meigen, 1803, n. syn. [Tachinidae]; Ophilia Macquart, 1850 of Metopia Meigen, 1803, n. syn. [Sarcophagidae]; Ornithomyia Fischer von Waldheim, 1808 of Ornithomya Latreille, 1802, n. syn. [Hippoboscidae]; Orthochile Westwood, 1840 of Ortochile Latreille, 1809, n. syn. [Dolichopodidae]; Osmoea Macquart, 1834 of Triarthria Stephens, 1829, n. syn. [Tachinidae]; Pachyrrhina Osten Sacken, 1878 of Pachyrhina Macquart, 1834, n. syn. [Tipulidae]; Palis Macquart, 1850 of Pales Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Phanemia Macquart, 1835 of Clairvillia Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Phrissopoda Macquart, 1851 of Peckia Robineau-Desvoidy, 1830, n. syn. [Sarcophagidae]; Phyllomyia Macquart, 1834 of Phyllomya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Physogenia Loew, 1862 of Physegenua Macquart, 1848, n. syn. [Lauxaniidae]; Physogenua Giglio-Tos, 1895 of Physegenua Macquart, 1848, n. syn. [Lauxaniidae]; Phytomiza Macquart, 1835 of Phytomyza Fallén, 1810, n. syn. [Agromyzidae]; Platipalpus Macquart, 1850 of Platypalpus Macquart, 1828, n. syn. [Hybotidae]; Platipeza Macquart, 1850 of Platypeza Meigen, 1803, n. syn. [Platypezidae]; Platynochoetus Macquart, 1834 of Platynochaetus Wiedemann, 1830 [Syrphidae]; Porphirops Macquart, 1838 of Porphyrops Meigen, 1824, n. syn [Dolichopodidae]; Rhinomyia Macquart, 1835 of Rhinomya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Rhynomyia Macquart, 1834 of Rhinomya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Scathopse Guérin-Méneville, 1839 of Scatopse Geoffroy, 1762, n. syn. [Scatopsidae]; Spherophoria Macquart, 1850 of Sphaerophoria Le Peletier &amp; Audinet-Serville, 1828, n. syn. [Syrphidae]; Sphoerophoria Macquart, 1829 of Sphaerophoria Le Peletier &amp; Audinet-Serville, 1828, n. syn. [Syrphidae]; Stenopteryx Schiner, 1864 of Stenepteryx Leach, 1817, n. syn. [Hippoboscidae]; Stenostoma Mik, 1890 of Senostoma Macquart, 1847, n. syn. [Tachinidae]; Tachydromyia Macquart, 1823 of Tachydromia Meigen, 1803, n. syn. [Hybotidae]; Taenioptera Mik, 1898 of Taeniaptera Macquart, 1835, n. syn. [Micropezidae]; Trinevra Macquart, 1835 of Phora Latreille, 1797, n. syn. [Phoridae]; Uramyia Macquart, 1844 of Uramya Robineau-Desvoidy, 1830, n. syn. [Tachinidae]; Xestomysa Macquart, 1851 of Xestomyza Wiedemann, 1820, n. syn. [Therevidae]; Zygonevra Macquart, 1834 of Zygoneura Meigen, 1803, n. syn. [Sciaridae]. -Species-group names: Calobatemyia nigra Macquart, 1855 of Musca doronici Scopoli, 1763, n. syn. [Calliphoridae]; Cyrtonevra protorum Macquart, 1850 of Musca pratorum Meigen, 1826, n. syn. [Muscidae]; Eumerus oeneus Macquart, 1850 of Eumerus aeneus Macquart, 1829, n. syn. [Syrphidae]; Lucilia ceserion Macquart, 1850 of Musca caesarion Scharfenberg, 1805, n. syn. [Calliphoridae]; Masicera sylvatica Macquart, 1850 of Tachina silvatica Fallén, 1810, n. syn. [Tachinidae]; Ophyra anolis Macquart, 1850 of Ophyra analis Macquart, 1846, n. syn. [Muscidae]; Pegomyia hyosciami Macquart, 1850 of Musca hyoscyami Panzer, 1798, n. syn. [Anthomyiidae]; Prosena syberita Macquart, 1850 of Stomoxys siberita Fabricius, 1775, n. syn. [Tachinidae]; Taxigramma heteronevra Macquart, 1850 of Miltogramma heteroneura Meigen, 1830, n. syn. [Sarcophagidae].

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DANSK RESUMÉ (DANISH SUMMARY): Aldersrelateret makuladegeneration (AMD) er den hyppigste årsag til uopretteligt synstab og blindhed i højindkomstlande. Det er en progredierende nethindesygdom som gradvist fører til ødelaeggelse af de celler som er ansvarlige for vores centralsyn. De tidlige stadier er ofte asymptomatiske, imens senstadie AMD, som opdeles i to former, neovaskulaer AMD (nAMD) og geografisk atrofi (GA), begge udviser gradvist synstab, dog generelt med forskellig hastighed. Tidlig AMD er karakteriseret ved tilstedevaerelsen af druser og pigmentforandringer i nethinden mens nAMD og GA udviser henholdsvis karnydannelse i og atrofi af nethinden. AEtiologien er multifaktoriel og udover alder omfatter patogenesen miljø- og genetiske risikofaktorer. Forskning har specielt fokuseret på lokale forandringer i øjet hvor man har fundet at inflammation spiller en betydelig rolle for udviklingen af sygdommen, men flere studier tyder også på at systemiske forandringer og specielt systemisk inflammation spiller en vaesentlig rolle i patogenesen. De Philadelphia-negative myeloproliferative neoplasier (MPNs) er en gruppe af haematologiske kraeftsygdomme med en erhvervet genetisk defekt i den tidlige pluripotente stamcelle som medfører en overproduktion af en eller flere af blodets modne celler. Sygdommene er fundet at udvikle sig i et biologisk kontinuum fra tidligt cancerstadie, essentiel trombocytose (ET) over polycytaemi vera (PV) og endelig til det sene myelofibrose stadie (PMF). Symptomer hos disse patienter skyldes isaer den aendrede sammensaetning af blodet, hyperviskositet, kompromitteret mikrocirkulation og nedsat vaevsgennemblødning. Den øgede morbiditet og mortalitet beror i høj grad på tromboembolier, blødninger og leukemisk transformation. En raekke mutationer som driver MPN sygdommene er identificeret, bl.a. JAK2V617F-mutationen som medfører en deregulering JAK/STAT signalvejen, der bl.a. har betydning for cellers vaekst og overlevelse. Et tidligere stort registerstudie har vist at patienter med MPNs har en øget risiko for neovaskulaer AMD og et pilotstudie har vist øget forekomst af intermediaer AMD. Dette ønsker vi at undersøge naermere i et større studie i dette Ph.d.- projekt. Flere studier har også vist at kronisk inflammation spiller en vigtig rolle for både initiering og udvikling af den maligne celleklon hos MPNs og herfra er en "Human Inflammationsmodel" blevet udviklet. Siden er MPN sygdommene blevet anvendt som "model sygdomme" for en tilsvarende inflammationsmodel for udvikling af Alzheimers sygdom. I dette Ph.d.-projekt vil vi tilsvarende forsøge at undersøge systemisk inflammation i forhold til forekomst af druser. Det vil vi gøre ved at sammenligne systemiske immunologiske markører som tidligere er undersøgt hos patienter med AMD og sammenligne med MPN. Specielt er vi interesseret i systemiske immunologiske forskelle på patienter med MPN og druser (MPNd) og MPN med normale nethinder (MPNn). Denne afhandling består af to overordnede studier. I Studie I, undersøgte vi forekomsten af retinale forandringer associeret med AMD hos 200 patienter med MPN (artikel I). Studie II, omhandlede immunologiske ligheder ved AMD og MPN, og var opdelt i yderligere tre delstudier hvor vi undersøgte hhv. systemiske markører for inflammation, aldring og angiogenese (artikel II, III og IV). Vi undersøgte markørerne i fire typer af patienter: nAMD, intermediaer AMD (iAMD), MPNd og MPNn. Undersøgelsen af forskelle mellem MPNd og MPNn, vil gøre det muligt at identificere forandringer i immunsystemet som kunne vaere relevante for AMD-patogenesen. Vi vil endvidere sammenholde resultaterne for patienter med MPN med patienter som har iAMD og nAMD. I studie I (Artikel I) fandt vi at patienter med MPN har en signifikant højere praevalens af store druser og AMD tidligere i livet sammenlignet med estimater fra tre store befolkningsundersøgelser. Vi fandt også at forekomst af druser var associeret med højere neutrofil-lymfocyt ratio, hvilket indikerer et højere niveau af kronisk inflammation i patienterne med druser sammenlignet med dem uden druser. I studie II (Artikel II, III og IV) fandt vi flere immunologiske forskelle mellem patienter med MPNd og MPNn. Da vi undersøgte markører for inflammation, fandt vi en højere grad af systemisk inflammation i MPNd end MPNn. Dette blev vist ved en højere inflammationsscore (udregnet på baggrund af niveauer af pro-inflammatoriske markører), en højere neutrofil-lymfocyt ratio, samt indikationer på et dereguleret komplementsystem. Ved undersøgelse af aldringsmarkører fandt vi tegn på accelereret immunaldring hos MPNd i forhold til MPNn, hvilket kommer til udtryk ved en større procentdel af "effector memory T celler". Endelig fandt vi en vaesentlig lavere ekspression af CXCR3 på T celler og monocytter hos patienter med nAMD sammenlignet med iAMD, MPNd og MPNn. Dette er i overensstemmelse med tidligere studier hvor CXCR3 ekspression er fundet lavere end hos raske kontroller. Derudover fandt vi en faldende CXCR3 ekspression på monocytter over det biologiske MPN-kontinuum. Disse studier indikerer en involvering af CXCR3 i både nAMD og PMF, begge sygdomsstadier som er karakteriseret ved angiogenese og fibrose. Ud fra resultaterne af denne afhandling kan vi konkludere at forekomsten af druser og AMD hos MPN er øget i forhold til baggrundsbefolkningen. Endvidere viser vores resultater at systemisk inflammation muligvis spiller en vaesentlig større rolle i udviklingen af AMD end tidligere antaget. Vi foreslår derfor en AMD-model (Figur 18) hvor inflammation kan initiere og accelerere den normale aldersafhaengige akkumulation af affaldsstoffer i nethinden, som senere udvikler sig til druser, medførende øget lokal inflammation og med tiden tidlig og intermediaer AMD. Dette resulterer i den øgede risiko for udvikling til de invaliderende senstadier af AMD. ENGLISH SUMMARY: Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss and blindness in high-income countries. It is a progressive retinal disease leading to damage of the cells responsible for central vision. The early stages of the disease are often asymptomatic, while late-stage AMD, which is divided into two entities, neovascular AMD and geographic atrophy (GA), both show vision loss, though generally with different progression rates. Drusen and pigmentary abnormalities in the retina characterise early AMD, while nAMD and GA show angiogenesis in and atrophy of the retina, respectively. The aetiology is multifactorial and, in addition to ageing, which is the most significant risk factor for developing AMD, environmental- and genetic risk factors are implicated in the pathogenesis. Research has focused on local changes in the eye where inflammation has been found to play an essential role, but studies also point to systemic alterations and especially systemic inflammation to be involved in the pathogenesis. The Philadelphia-negative myeloproliferative neoplasms (MPN) are a group of haematological cancers with an acquired genetic defect of the pluripotent haematopoietic stem cell, characterised by excess haematopoiesis of the myeloid cell lineage. The diseases have been found to evolve in a biological continuum from early cancer state, essential thrombocythemia, over polycythaemia vera (PV), to the advanced myelofibrosis stage (PMF). The symptoms in these patients are often a result of the changes in the blood composition, hyperviscosity, microvascular disturbances, and reduced tissue perfusion. The major causes of morbidity and mortality are thromboembolic- and haemorrhagic events, and leukemic transformation. A group of mutations that drive the MPNs has been identified, e.g., the JAK2V617F mutation, which results in deregulation of the JAK/STAT signal transduction pathway important, for instance, in cell differentiation and survival. A previous large register study has shown that patients with MPNs have an increased risk of neovascular AMD, and a pilot study has shown an increased prevalence of intermediate AMD. We wish to study this further in a larger scale study. Several studies have also shown that systemic inflammation plays an essential role in both the initiation and progression of the malignant cell clone in MPNs. From this knowledge, a "Human inflammation model" has been developed. Since then, the MPNs has been used as model diseases for a similar inflammation model for the development of Alzheimer's disease. In this PhD project, we would like to investigate systemic inflammation in relation to drusen presence. We will do this by comparing systemic immunological markers previously investigated in patients with AMD and compare with MPN. We are primarily interested in systemic immunological differences between patients with MPN and drusen (MPNd) and MPN with normal retinas (MPNn). This thesis consists of two main studies. Study I investigated the prevalence of retinal changes associated with AMD and the prevalence of different AMD stages in 200 patients with MPN (paper I). Study II examined immunological similarities between AMD and MPNs. This study was divided into three substudies exploring systemic markers of inflammation, ageing and angiogenesis, respectively. This was done in four types of patients: nAMD, intermediate AMD (iAMD), MPNd and MPNn. Investigating, differences between MPNd and MPNn, will make it possible to identify changes in the immune system, relevant for AMD pathogenesis. Additionally, we will compare patients with MPNs with patients with iAMD and nAMD. In study I (Paper I), we found that patients with MPNs have a significantly higher prevalence of large drusen and consequently AMD from an earlier age compared to the estimates from three large population-based studies. We also found that drusen prevalence was associated with a higher neutrophil-to-lymphocyte ratio indicating a higher level of chronic low-grade inflammation in patients with drusen compared to those without drusen. In study II (papers II, III and IV), we found immunological differences between patients with MPNd and MPNn. When we investigated markers of inflammation, we found a higher level of systemic inflammation in MPNd than MPNn. This was indicated by a higher inflammation score (based on levels of pro-inflammatory markers), a higher neutrophil-to-lymphocyte ratio, and indications of a deregulated complement system. When examining markers of ageing, we found signs of accelerated immune ageing in MPNd compared to MPNn, shown by more senescent effector memory T cells. Finally, when exploring a marker of angiogenesis, we found a lower CXCR3 expression on monocytes and T cells in nAMD compared to iAMD, MPNd and MPNn, in line with previous studies of nAMD compared to healthy controls. Further, we found decreasing CXCR3 expression over the MPN biological continuum. These studies indicate CXCR3 involvement in both nAMD and PMF, two disease stages characterised by angiogenesis and fibrosis. From the results of this PhD project, we can conclude that the prevalence of drusen and AMD is increased in patients with MPN compared to the general population. Further, our results show that systemic inflammation may play a far more essential role in AMD pathogenesis than previously anticipated. We, therefore, propose an AMD model (Figure 18) where inflammation can initiate and accelerate the normal age-dependent accumulation of debris in the retina, which later evolve into drusen, resulting in increased local inflammation, and over time early- and intermediate AMD. This results in the increased risk of developing the late debilitating stages of AMD.

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An erratum was issued for: Neutron Spin Echo Spectroscopy as a Unique Probe for Lipid Membrane Dynamics and Membrane-Protein Interactions. The Introduction, Protocol, and Representative Results sections have been updated. In the Introduction, the fith pargraph was updated from: Besides direct access to the length and time scale of membrane dynamics, NSE has the inherent capabilities of neutron isotope sensitivity<sup52</sup. Specifically, the ability of neutrons to interact differently with the isotopes of hydrogen, the most abundant element in biological systems, results in a different neutron scattering length density,<sup34</sup or NSLD (the equivalent of the optical index of refraction<sup50</sup), when protium is substituted by deuterium. This enables an approach known as contrast variation, which is commonly used to highlight specific membrane features or conceal others - the latter scenario is referred to as contrast matching. A frequent application of contrast variation/matching is the substitution of water (NSLD = -0.56 × 10<sup-6</sup Å<sup-2</sup) by heavy water or D2O (NSLD = 6.4 × 10<sup-6</sup Å<sup-2</sup) to amplify the neutron signal from protiated lipid membranes (NSLD ~ 2 × 10<sup-6</sup Å<sup-2</sup). This approach is highly effective in studies of membrane structure because the penetration of D2O into the headgroup region of the membrane allows accurate determination of the membrane thicknesses (see Figure 2A, left panel) and of the location of different lipid subgroups when more sophisticated models are applied<sup53</sup <sup,</sup <sup54</sup. This paper highlights some examples on the use of contrast variation for studies of collective dynamics in biomimetic membranes and select membrane features. to: Besides direct access to the length and time scale of membrane dynamics, NSE has the inherent capabilities of neutron isotope sensitivity<sup52</sup. Specifically, the ability of neutrons to interact differently with the isotopes of hydrogen, the most abundant element in biological systems, results in a different neutron scattering length density,<sup34</sup or NSLD (the equivalent of the optical index of refraction<sup50</sup), when protium is substituted by deuterium. This enables an approach known as contrast variation, which is commonly used to highlight specific membrane features or conceal others - the latter scenario is referred to as contrast matching. A frequent application of contrast variation/matching is the substitution of water (NSLD = -0.56 × 10<sup-6</sup Å<sup-2</sup) by heavy water or D2O (NSLD = 6.4 × 10<sup-6</sup Å<sup-2</sup) to amplify the neutron signal from protiated lipid membranes (NSLD ~ 0 × 10<sup-6</sup Å<sup-2</sup). This approach is highly effective in studies of membrane structure because the penetration of D2O into the headgroup region of the membrane allows accurate determination of the membrane thicknesses (see Figure 2A, left panel) and of the location of different lipid subgroups when more sophisticated models are applied<sup53</sup <sup,</sup <sup54</sup. This paper highlights some examples on the use of contrast variation for studies of collective dynamics in biomimetic membranes and select membrane features. In the Protocol, step 1.1 was updated from: For bending fluctuation measurements, make fully protiated liposomes in D2O (D 99.9%) or D2O-buffer (e.g., phosphate buffer prepared with D2O instead of H2O). Use fully protiated DMPC (C36H72NO8P) and DSPC (C44H88NO8P) with 133.4 mg, where XDMPC and XDSPC are the mole fractions of DMPC and DSPC, here set to 0.7 and 0.3, respectively, and MwDMPC and MwDSPC are the molar weights given by 677.9 g/mol and 790.1 g/mol, respectively. Similarly, mDSPC = 66.6 mg. This deuteration scheme increases the scattering contrast between the membrane (NSLD ~ 2 × 10<sup-6</sup Å<sup-2</sup) and the deuterated buffer (NSLD ~ 6.4 × 10<sup-6</sup Å<sup-2</sup) and amplifies the signal from membrane undulations (see Figure 2A left panel). to: For bending fluctuation measurements, make fully protiated liposomes in D2O (D 99.9%) or D2O-buffer (e.g., phosphate buffer prepared with D2O instead of H2O). Use fully protiated DMPC (C36H72NO8P) and DSPC (C44H88NO8P) with 133.4 mg, where XDMPC and XDSPC are the mole fractions of DMPC and DSPC, here set to 0.7 and 0.3, respectively, and MwDMPC and MwDSPC are the molar weights given by 677.9 g/mol and 790.1 g/mol, respectively. Similarly, mDSPC = 66.6 mg. This deuteration scheme increases the scattering contrast between the membrane (NSLD ~ 0 × 10<sup-6</sup Å<sup-2</sup) and the deuterated buffer (NSLD ~ 6.4 × 10<sup-6</sup Å<sup-2</sup) and amplifies the signal from membrane undulations (see Figure 2A left panel). In the Representative Results, the fist pagargaph was updted from: NSE studies accessing bending fluctuations are typically performed over a Q-range of ~ (0.04 - 0.2) Å<sup-1</sup. This Q-range corresponds to intermediate length scales between the membrane thickness and the liposomal radius, where bending dynamics dominate. Measurement over an extended Q-range can give access to additional dynamic modes, including liposomal diffusion and intramembrane dynamics. For more details on the cross-over in membrane dynamics accessed by NSE, check these relevant publications<sup25</sup <sup,</sup <sup71</sup. It is important to emphasize that NSE signals are proportional to: , where Icoh and Iinc are, respectively, the coherent and incoherent scattering intensity from the sample. Therefore, it is advisable to prepare NSE liposomal samples in deuterated buffers (i.e., buffers prepared with D2O instead of H2O) to minimize the incoherent scattering signal, mainly contributed by the hydrogen content of the sample. However, in some cases intermediate deuteration schemes (i.e., using mixtures of D2O and H2O) might be necessary to obtain optimal contrast conditions. Typically, NSE measurements of membrane bending fluctuations are performed on fully protiated liposomes in deuterated buffer, referred to as fully contrasted liposomes in Figure 5. This deuteration scheme results in a large NSLD difference between the membrane core (~2 × 10<sup-6</sup Å<sup-2</sup) and its deuterated fluid environment (~6.4 × 10<sup-6</sup Å<sup-2</sup), which significantly enhances the scattering signal from the liposomal membranes and improves the measurement statistics of bending dynamics. This contrast scheme (Figure 2A left panel) is frequently utilized in studies of bending rigidity of lipid membranes with single<sup38</sup <sup,</sup <sup72</sup and multiple<sup39</sup <sup,</sup <sup66</sup lipid components and in studies of membrane softening/stiffening by biological inclusions (e.g., cholesterol, drug molecules, peptides/proteins)<sup36</sup <sup,</sup <sup37</sup <sup,</sup <sup73</sup <sup,</sup <sup74</sup <sup,</sup <sup75</sup, and synthetic additives (e.g., nanoparticles)<sup76</sup <sup,</sup <sup77</sup. to: NSE studies accessing bending fluctuations are typically performed over a Q-range of ~ (0.04 - 0.2) Å<sup-1</sup. This Q-range corresponds to intermediate length scales between the membrane thickness and the liposomal radius, where bending dynamics dominate. Measurement over an extended Q-range can give access to additional dynamic modes, including liposomal diffusion and intramembrane dynamics. For more details on the cross-over in membrane dynamics accessed by NSE, check these relevant publications<sup25</sup <sup,</sup <sup71</sup. It is important to emphasize that NSE signals are proportional to: , where Icoh and Iinc are, respectively, the coherent and incoherent scattering intensity from the sample. Therefore, it is advisable to prepare NSE liposomal samples in deuterated buffers (i.e., buffers prepared with D2O instead of H2O) to minimize the incoherent scattering signal, mainly contributed by the hydrogen content of the sample. However, in some cases intermediate deuteration schemes (i.e., using mixtures of D2O and H2O) might be necessary to obtain optimal contrast conditions. Typically, NSE measurements of membrane bending fluctuations are performed on fully protiated liposomes in deuterated buffer, referred to as fully contrasted liposomes in Figure 5. This deuteration scheme results in a large NSLD difference between the membrane core (~0 × 10<sup-6</sup Å<sup-2</sup) and its deuterated fluid environment (~6.4 × 10<sup-6</sup Å<sup-2</sup), which significantly enhances the scattering signal from the liposomal membranes and improves the measurement statistics of bending dynamics. This contrast scheme (Figure 2A left panel) is frequently utilized in studies of bending rigidity of lipid membranes with single<sup38</sup <sup,</sup <sup72</sup and multiple<sup39</sup <sup,</sup <sup66</sup lipid components and in studies of membrane softening/stiffening by biological inclusions (e.g., cholesterol, drug molecules, peptides/proteins)<sup36</sup <sup,</sup <sup37</sup <sup,</sup <sup73</sup <sup,</sup <sup74</sup <sup,</sup <sup75</sup, and synthetic additives (e.g., nanoparticles)<sup76</sup <sup,</sup <sup77</sup. In the Representative Reults, Figure 2 was updated from: Figure 2: Examples of possible deuteration schemes in NSE experiments on lipid membranes. (A) Left: Fully contrasted membranes, e.g., protiated membranes in deuterated buffer, showing the NSLD profile along the normal to the membrane surface. The difference in the NSLD between the headgroup (~2 × 10<sup-2</sup Å<sup-2</sup) and tail region (~4.5 × 10<sup-6</sup Å<sup-2</sup) of the membrane is due to the headgroup hydration with deuterated buffer. Right: Tail-contrast matched membranes such that the hydrocarbon tail region of the membrane has the same NSLD as the buffer, as shown in the corresponding NSLD profile along the membrane normal. (B) Domain-forming membranes with two neutron contrast schemes where the domains (center) or the matrix (left) are contrast-matched to the buffer, enabling selective studies of matrix or domain dynamics, respectively. This figure has been modified from Nickels et al., JACS 2015<sup41</sup. (C) Asymmetric membranes prepared by cyclodextrin exchange between protiated and deuterated lipid vesicles, resulting in the deuteration of one membrane leaflet while keeping the other leaflet protiated. This allows studies of the bending dynamics of the protiated leaflet and provides insights into the mechanical coupling between opposing leaflets in asymmetric membranes. This figure has been modified from Rickeard et al., Nanoscale 2020<sup40</sup. Please click here to view a larger version of this figure. to: Figure 2: Examples of possible deuteration schemes in NSE experiments on lipid membranes. (A) Left: Fully contrasted membranes, e.g., protiated membranes in deuterated buffer, showing the NSLD profile along the normal to the membrane surface. The difference in the NSLD between the tail region (~0 × 10<sup-2</sup Å<sup-2</sup) and headgroup region (~4.5 × 10<sup-6</sup Å<sup-2</sup) of the membrane is due to the headgroup hydration with deuterated buffer. Right: Tail-contrast matched membranes such that the hydrocarbon tail region of the membrane has the same NSLD as the buffer, as shown in the corresponding NSLD profile along the membrane normal. (B) Domain-forming membranes with two neutron contrast schemes where the domains (center) or the matrix (left) are contrast-matched to the buffer, enabling selective studies of matrix or domain dynamics, respectively. This figure has been modified from Nickels et al., JACS 2015<sup41</sup. (C) Asymmetric membranes prepared by cyclodextrin exchange between protiated and deuterated lipid vesicles, resulting in the deuteration of one membrane leaflet while keeping the other leaflet protiated. This allows studies of the bending dynamics of the protiated leaflet and provides insights into the mechanical coupling between opposing leaflets in asymmetric membranes. This figure has been modified from Rickeard et al., Nanoscale 2020<sup40</sup. Please click here to view a larger version of this figure.

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Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects. • To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification). Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded. A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo. We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353. We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

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Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels. Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases. However, AQP-4-antibody-positive NMOSD coexisting with ankylosing spondylitis (AS) is rare. AS is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27. In this study, a 35-year-old Indian man with an undiagnosed progressive axial spondyloarthropathy (i.e., AS) is reported presenting with acute-onset longitudinally extensive transverse myelitis, a clinical subset of NMOSD. Neuromyelitis optica spectrum disorder (NMOSD), a primary demyelinating disorder of the central nervous system (CNS), is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels, which manifests with optic neuritis, longitudinally extensive transverse myelitis (LETM), area-postrema syndrome, brainstem syndrome diencephalic syndrome, and cerebral syndrome.<sup1-4</sup Ankylosing spondylitis (AS) is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27.<sup5,6</sup AS characteristically targets the axial skeleton, peripheral joints, entheses (connective tissues between tendons/ligaments and bones), and gut.<sup5,6</sup Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases.<sup7</sup For example, cases with NMOSD and multiple sclerosis, which are other autoimmune primary demyelinating disorders of the CNS, have been reported.<sup8,9</sup However, concurrent existence of AS and NMOSD in the same patient even over years of disease course is rare.<sup10,11</sup In addition, studies describing neurological manifestations of AS are limited,<sup12</sup and they focus on joint inflammation and long-standing bony pathology (ankylosis) related to compressive myelopathy, myelo-radiculopathy, and cauda equina syndromes.<sup12,13</sup The authors present a case of a young Indian man with an undiagnosed progressive AS (misdiagnosed and mismanaged by an indigenous medical practitioner) presenting with acute-onset LETM variant of AQP4-positive NMOSD. A 35-year-old healthy, non-comorbid man from rural India came to the outpatient department with complaints of persistent tingling, numbness, and weakness of both lower limbs (right more than left) for 10 days. The clinical picture showed acute-onset urinary retention, which was relieved by urinary catheterization. An indigenous medical practitioner had prescribed drugs to treat a urinary tract infection. His weakness gradually progressed over the following week, causing him to become bedridden. During the removal of the catheter, he felt urgency, increased frequency of micturition, and overt urinary incontinence. He gave no history suggestive of any girdle-like sensations, root/radicular/tract pain, vertebral pain, trauma, recent vaccination, and diarrheal or febrile illness. For the last 8 months, he had a complaint of an insidious-onset, persistent, bilateral, dull aching pain in the gluteal region accompanied by low-back pain and morning stiffness up to 1 h, which markedly improved with activity and reoccurred following long periods of inactivity. He sometimes had to rise in the middle of the night because of excruciating pain, which could be relieved after moving around the room and corridors for half an hour. He was taking over-the-counter diclofenac tablets for pain relief prescribed by some indigenous medical practitioners who told him that it was due to overwork in agricultural fields, that is, mechanical back pain. He also had a normal X-ray of the lumbosacral spine. He had no addiction liabilities, and none of the family members had ever suffered from a similar kind of illness. He had never consulted any trained medical practitioner, as his previous back-pain-related symptoms responded well to the tablets prescribed by the indigenous medical practitioner(s). During examination, he was found to have recent-onset, asymmetric spastic paraparesis (right more than left) with upper motor neuron-type urinary bladder symptoms. Cognitive assessment (assessed by the Montreal cognitive assessment test) was normal, and posterior column sensations were preserved. Sensory system examination revealed no definite sensory level. Except for the paretic lower limbs, cerebellar functions were normal in other regions. Neuro-ophthalmological examinations were also normal, and no signs of meningeal irritation were observed. The history and course of the disease and clinical examinations were analyzed. Selective tractopathy (early and predominant motor and autonomic tract affection) was suggested for an intramedullary demyelinating pathology affecting the anterior central cord. This case was initially classified as acute-onset non-compressive myelopathy at the lower cervical/upper dorsal region level in a patient with a pre-existing axial spondyloarthropathy. Complete blood cell count; liver, kidney, and thyroid function tests; and plasma glucose and electrolytes were normal, except for an increased erythrocyte sedimentation rate (66 mm in the first hour). Magnetic resonance imaging (MRI) of the spinal cord revealed a demyelinating LETM from C5 to D4 level (Figure 1). Meanwhile, an MRI of the sacroiliac joints revealed bilateral sacroiliitis. Brain and orbital MRIs were devoid of any lesions. Anti-aquaporin 4 (AQP-4) antibodies were tested by cell-based assay in serum and cerebrospinal fluid (CSF), and both were positive. CSF further revealed lymphocytic pleocytosis and increased intrathecal protein production. Visually evoked potential recordings were also normal. In addition, anti-myelin oligodendrocyte glycoprotein antibodies were negative. Anti-nuclear antibody (ANA), ANA-profile, autoimmune vasculitis profile (c-ANCA, p-ANCA), neurovirus panel (i.e., polymerase chain reaction for adenovirus, Epstein-Barr virus, herpes simplex viruses 1 and 2, human herpesviruses 6 and 7, cytomegalovirus, enteroviruses, varicella-zoster virus, Japanese encephalitis, and dengue virus), CSF-polymerase chain reaction for <iMycobacterium tuberculosis</i, angiotensin-converting enzyme, anti-phospholipid, and anti-thyroid antibodies were negative. Anti-CCP-antibody and rheumatoid factor were also negative, including creatine phosphokinase level and serum vitamin B12. Moreover, serologies for hepatitis B, C, human immunodeficiency virus, and scrub typhus were negative. However, HLA-B27 assay was positive. The final diagnosis was AQP4-positive NMOSD associated with AS. He was placed on pulse intravenous methylprednisolone (1 g/day for 5 days). Consequently, his lower limb power improved remarkably. Cyclical rituximab therapy was initiated to prevent relapses. At 3-month follow-up, he had no residual neurological deficit except for persistence of paresthesias. Neuroimaging and visually evoked potential studies revealed no active or new lesions. After 6 months of therapy, a subjective and objective improvement was observed in disease severity based on the Ankylosing Spondylitis Disease Activity Score. Our patient satisfied the new Assessment of SpondyloArthritis International Society diagnostic/classification criteria for AS and the Wingerchuk criteria for NMOSD,<sup4,14</sup an association that has been rarely reported.<sup10,11</sup Amid the extra-articular complications of long-standing AS, neurological manifestations are considered infrequent.<sup15</sup However, subclinical neurological complications may be frequent in AS.<sup12</sup Common neurological manifestations result from bony (vertebral) ankylosis, subluxation of joints, ossification of anterior and posterior longitudinal ligaments, secondary spinal canal stenosis, bony (vertebral) fractures, and subsequent compressions over nerve radicles/roots/cauda equina, and inflammation-related (entrapment) peripheral neuropathies.<sup12,16,17</sup Acute transverse myelitis can occur as a subset of several primary demyelinating disorders of the CNS (i.e., multiple sclerosis, NMOSD, myelin oligodendrocyte glycoprotein antibody disease, and acute disseminated encephalomyelitis) and various systemic autoimmune connective tissue disorders (i.e., systemic lupus erythematosus, mixed connective tissue disease, Sjögren syndrome, inflammatory bowel disease, and neurosarcoidosis).<sup18</sup Acute transverse myelitis (short or long segment) is an infrequent extra-articular complication of AS.<sup18</sup It has been reported to evolve either as a distinct neurological complication of AS, or it may develop secondary to TNF-alpha-inhibitor therapy for the treatment of AS.<sup18,19</sup AS is a heritable inflammatory spondyloarthropathy that primarily affects the axial skeleton, which is mediated by T-cells; B-cells only play a minor role.<sup5</sup On the contrary, the key for the pathogenesis of NMOSD is the production of autoantibodies against AQP-4 channels expressed on astrocytes, leading to complement-mediated damage, with ensuing demyelination. Myelitis usually shows high signal intensity on the tbl2-weighted image and contrast enhancement in the spinal cord.<sup1-4</sup Despite the difference in molecular mechanisms, the diagnosis of these diseases in the same individual may not be coincidental. Recent evidence has shown T-cell-mediated inflammatory responses in cases of NMOSD.<sup20</sup In particular, Th17 and Th2-related cytokines are elevated in the CSF of NMO patients.<sup20</sup Environmental factors such as <iEscherichia coli</i have also been proven to aggravate autoimmunity in AS and NMOSD (however, body fluid cultures for <iEscherichia coli</i, performed in our patient, showed similar association, and they were found negative two times).<sup21,22</sup Although large-scale epidemiological studies investigating the underlying pathogenesis related to these diseases are lacking, studies have demonstrated an increased incidence of optic neuritis among patients with AS.<sup23</sup Systemic sclerosis and mixed and undifferentiated connective tissue diseases were excluded after expert opinions (from two board-certified rheumatologists and two dermatologists) because of the lack of suggestive clinical findings (e.g., absence of skin thickening, salt-and-pepper appearance, nail changes, Mauskopf facies, sclerodactyly, calcinosis cutis, Raynaud's phenomenon, other cutaneous manifestations, pulmonary arterial hypertension/interstitial lung disease, dysphagia, muscular pain/weakness renal impairments, absence of ANA, anti-centromere antibodies, anti-Scl-70, PM-Scl antibodies, anti-ds DNA, PCNA, CENP-B, anti-nucleosomes, anti-Smith, anti-U1-RNP, anti-Jo1, anti-Mi2, anti-Ro52, anti-La antibodies, and normal C3 and C4 complement levels) (The European League Against Rheumatism and the American College of Rheumatology classification criteria 2019).<sup24</sup Finally, our patient was treated with intravenous steroids followed by rituximab infusions, a monoclonal anti-CD20 antibody directed against B-cells. In particular, this patient clinically and radiologically responded to immunomodulatory drugs, which might support a possible common pathogenic basis of the two processes. TNF-alpha inhibitors are commonly used as novel therapeutics in AS; however, they can potentially result in serious complications, that is, secondary demyelinating disorders.<sup25</sup However, such inhibitors in this patient were not used. When used in cases of AS, they show satisfactory results.<sup25,26</sup Therefore, it was decided to treat him with rituximab only without adding any second immunomodulatory. Other possible therapeutic options include cyclophosphamide and mycophenolate mofetil, but they were not used because of their low efficacy-safety balance. Moreover, plasmapheresis was not available in our specific setting, despite solid evidence that early treatment with therapeutic strategy (5-7 courses) provides good long-term outcomes in patients with NMOSD.<sup27</sup Therefore, when dealing with a case of acute non-compressive myelopathy, history and clinical examination are important to determine the potential underlying etiology and identify an undermined systemic disorder with apparently unrelated non-specific features. Connective tissue disorders should always be considered as a differential diagnosis and be ruled out in all cases of either seropositive or seronegative NMOSD. A diagnosis of AS should be considered in relevant circumstances when dealing with a case of isolated seronegative LETM. Moreover, early diagnosis and treatment of AS are quintessential to prevent lifelong distressing disabilities. However, whether patients with AS have any extra predilection to develop NMOSD throughout their life requires further studies.

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Benzene ranks 16th in production volume for chemicals produced in the United States, with approximately 9.9 billion pounds being produced in 1984, 9.1 billion pounds in 1983, and 7.8 billion pounds in 1982. This simplest aromatic chemical in used in the synthesis of styrene (polystyrene plastics and synthetic rubber), phenol (phenolic resins), cyclohexane (nylon), aniline, maleic anhydride (polyester resins), alkylbenzenes (detergents), chlorobenzenes, and other products used in the production of drugs, dyes, insecticides, and plastics. Benzene, along with other light, high-octane aromatic hydrocarbons, such as toluene and xylenes, is a component of motor gasoline. Benzene is also used as a solvent, but for most applications, it has been replaced by less hazardous solvents. During the 17-week studies, groups of 10 or 15 male and female F344/N rats and B6C3F1 mice were gavaged 5 days per week with benzene in corn oil (5 ml/kg) at doses of 0 to 600 mg/kg. No benzene-related deaths occurred; in rats that received benzene, final mean body weights were 14%-22% lower compared with vehicle controls and in mice, slight dose-related reductions were observed (less than 10% differences). Doses for the 2-year studies were selected based on clinical observations (tremors in higher dosed mice), on clinical pathologic findings (lymphoid depletion in rats and leukopenia in mice), and on body weight effects. Two-year toxicology and carcinogenesis studies of benzene (greater than 99.7% pure) were conducted in groups of 50 F344/N rats and 50 B6C3F1 mice of each sex and for each dose. Doses of 0, 50, 100, or 200 mg/kg body weight benzene in corn oil (5 ml/kg) were administered by gavage to male rats, 5 days per week, for 103 weeks. Doses of 0, 25, 50, or 100 mg/kg benzene in corn oil were administered by gavage to female rats and to male and female mice for 103 weeks. Ten additional animals in each of the 16 groups were killed at 12 months and necropsies were performed. Hematologic profiles were performed at 3-month intervals. These studies were designed and conducted because of large production volume and potential human exposure, because of the epidemiologic association with leukemia, and because previous experiments were considered inadequate or inconclusive for determining potential carcinogenicity in laboratory animals. In the 2-year studies, mean body weights of the 200 mg/kg male rats (-23%) and the 100 mg/kg mice (-14% to -19%) were lower than those of the vehicle controls, and survival of dosed groups decreased with increasing dose (rats--male: vehicle control, 32/50; low dose, 29/50; mid dose, 25/50; high dose, 16/50; female: 46/50; 38/50; 34/50; 25/50; mice--male: 28/50; 23/50; 18/50; 7/50; female: 30/50; 26/50; 24/50; 18/50). At week 92 for rats and week 91 for mice, survival was greater than 60% in all groups; most of the dosed animals that died before week 103 had neoplasia. Compound-related nonneoplastic or neoplastic effects on the hematopoietic system, Zymbal gland, forestomach, and adrenal gland were found both for rats and mice. Further, the oral cavity was affected in rats, and the lung, liver, harderian gland, preputial gland, ovary, and mammary gland were affected in mice. Significantly increased (P&lt;0.05) incidences of neoplasms were observed at multiple sites for male and female rats and for male and female mice. Primary neoplasms observed in rats and mice are summarized in Table 1 (see page 12 of the Technical Report). Hematologic data from vehicle control and dosed rats and mice were obtained at 3-month intervals from 0 to 24 months. Reliably identifiable hematologic effects were limited to lymphocytopenia and associated leukocytopenia in benzene-dosed rats and mice. These effects were seen from 3 to 18 months in dosed male rats and in dosed male mice; a similar but less pronounced response was observed in dosed female rats during this same time period. The effect in female mice was limited to 12-18 months. The technical quality of certain of these data was questionable; thus, more detailed analyses (e.g., investig questionable; thus, more detailed analyses (e.g., investigation of the association between hematologic and pathologic changes) are deemed inappropriate for these data. Benzene increased the frequency of micronucleated normchromatic peripheral erythrocytes in male and female mice (rats were not examined); males were more sensitive than females. The hematopoietic system of rats and mice of each sex was affected by benzene in the 2-year studies. The incidences of malignant lymphomas in all dosed groups of mice were greater than those in the vehicle controls (male: 4/49; 9/48; 9/50; 15/49; female: 15/49; 24/45; 24/50; 20/49). Lymphoid depletion of the splenic follicles (rats) and thymus (male rats) was observed at increased incidences. Bone marrow hematopoietic hyperplasia was observed at increased incidences in dosed mice of each sex (male: 0/49; 11/48; 10/50; 25/49; female: 3/49; 14/45; 8/50; 13/49). The incidences of Zymbal gland carcinomas in mid and high dose male rats and in dosed female rats were greater than those in the vehicle controls (male: 2/32; 6/46; 10/42; 17/42; female: 0/45; 5/40; 5/44; 14/46). The incidences of Zymbal gland carcinomas in mid and high dose male mice and in high dose female mice were greater than those in the vehicle controls (male: 0/43; 1/34; 4/40; 21/39; female: 0/43; 0/32; 1/37; 3/31). In mid and high dose male mice and in high dose female mice, the incidences of epithelial hyperplasia of the Zymbal gland were also increased (male: 0/43; 3/34; 12/40; 10/39; female: 1/43; 1/32; 2/37; 6/31). Hyperplasia of the adrenal capsule was observed at increased incidences in dosed mice of each sex (male: 2/47; 32/48; 14/49; 4/46; female: 5/49; 19/44; 34/50; 30/48). The incidence of pheochromocytomas in mid dose male mice was greater than that in the vehicle controls (male: 1/47; 1/48; 7/49; 1/46), whereas the incidences in dosed female mice were lower than that in the vehicle controls (female: 6/49; 1/44; 1/50; 1/48). Hyperplasia of the zona fasciculata of the adrenal cortex was observed at increased incidences in low dose rats of each sex (male: 0/50; 13/49; 0/48; 2/49; female: 0/50; 17/50; 0/47; 0/49). Benzene was associated with increased incidences of neoplasms of the skin and oral cavity of rats. The incidences of squamous cell papillomas and squamous cell carcinomas of the skin in high dose male rats were greater than those in the vehicle controls (squamous cell papilloma: 0/50; 2/50; 1/50; 5/50; squamous cell carcinoma: 0/50; 5/50; 3/50; 8/50). Increased incidences of uncommon squamous cell papillomas or squamous cell carcinomas (combined) of the oral cavity were observed in dosed male and female rats (male: 1/50; 9/50; 16/50; 19/50; female: 1/50; 5/50; 12/50; 9/50). Incidences of squamous cell papillomas or carcinomas (combined) (male: 2/45; 2/42; 3/44; 5/38; female: 1/42; 3/40; 6/45; 5/42), hyperkeratosis, and epithelial hyperplasia of the forestomach were increased in some dosed groups of male and female mice; incidences of hyperkeratosis and acanthosis were increased in high dose male rats. Compound-related effects in the lung, harderian gland, preputial gland, ovary, mammary gland, and liver were seen in mice but not in rats. Administration of benzene was associated with increased incidences of alveolar epithelial hyperplasia in mid and high dose mice (male: 2/49; 3/48; 7/50; 10/49; female: 1/49; 1/42; 9/50; 6/49). Increased incidences of alveolar/bronchiolar carcinomas and alveolar/bronchiolar adenomas or carcinomas (combined) were observed in high dose male mice (carcinomas: 5/49; 11/48; 12/50; 14/49; adenomas or carcinomas: 10/49; 16/48; 19/50; 21/49). Alveolar/bronchiolar adenomas were seen at increased incidences in high dose female mice (4/49; 2/42; 5/50; 9/49), as were alveolar/bronchiolar carcinomas (0/49; 3/42; 6/50; 6/49) and alveolar/bronchiolar adenomas or carcinomas combined (4/49; 5/42; 10/50; 13/49) in mid and high dose female mice. The incidences of focal or diffuse hyperplasia of the harderian gland were increased in dosed mice of each sex (male: 0/49; 5/46; 11/49; 7/48; female: 6/48; 10/44; 11/50; 10/47). The incidences of harderian gland adenomas (0/49; 9/46; 13/49; 11/48) in dosed male mice were greater than that in the vehicle controls. A marginal increase in the incidence of adenomas or carcinomas (combined) of the harderian gland was seen in high dose female mice (5/48; 6/44; 10/50; 10/47). The administration of benzene to male mice was associated with increased incidences of hyperplasia (1/21; 18/28; 9/29; 1/35) and squamous cell carcinomas (0/21; 3/28; 18/29; 28/35) of the preputial gland. Increased incidences of mammary gland carcinomas were found in mid dose and high dose female mice (0/49; 2/45; 5/50; 10/49) and carcinosarcomas in high dose female mice (0/49; 0/45; 1/50; 4/49). Increased incidences of various uncommon neoplastic and nonneoplastic lesions of the ovary (papillary cystadenoma, luteoma, granulosa cell tumor, tubular adenoma, benign mixed tumor, epithelial hyperplasia, and senile atrophy) were associated with the administration of benzene to female mice. In mid and high dose female mice, the incidences of granulosa cell tumors (1/47; 1/44; 6/49; 7/48) and benign mixed tumors (0/47; 1/44; 12/49; 7/48) were greater than those in the vehicle controls. Increased incidences of hepatocellular adenomas were observed in low dose female mice (1/49; 8/44; 5/50; 4/49) and hepatocellular adenomas or carcinomas (combined) in low dose and mid dose female mice (4/49; 12/44; 13/50; 7/49). An audit of the experimental data was conducted for these 2-year carcinogenesis studies on benzene. No data discrepancies were found that influenced the final interpretations. Under the conditions of these 2-year gavage studies, there was clear evidence of carcinogenicity of benzene for male F344/N rats, for female F344/N rats, for male B6C3F1 mice, and for female B6C3F1 mice. For male rats, benzene caused increased incidences of Zymbal gland carcinomas, squamous cell papillomas and squamous cell carcinomas of the oral cavity, and squamous cell papillomas and squamous cell carcinomas of the skin. For female rats, benzene caused increased incidences of Zymbal gland carcinomas and squamous cell papillomas and squamous cell carcinomas of the oral cavity. For male mice, benzene caused increased incidences of Zymbal gland squamous cell carcinomas, malignant lymphomas, alveolar/bronchiolar carcinomas and alveolar/bronchiolar adenomas or carcinomas (combined), harderian gland adenomas, and squamous cell carcinomas of the preputial gland. For female mice, benzene caused increased incidences of malignant lymphomas, ovarian granulosa cell tumors, ovarian benign mixed tumors, carcinomas and carcinosarcomas of the mammary gland, alveolar/bronchiolar adenomas, alveolar/bronchiolar carcinomas, and Zymbal gland squamous cell carcinomas. Dose-related lymphocytopenia was observed for male and female F344/N rats and male and female B6C3F1 mice. Synonyms: benzol, cyclohexatriene, pyrobenzol

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Sustainable employability (SE) is an important topic as it deals with employees' abilities to function adequately at work and in the labor market throughout their working lives. However, until now there has been only one attempt to define SE in the international literature (1). This first definition is a valuable contribution to the field as it rightfully describes SE as a multidimensional concept, recognizes the importance of both employee and work characteristics, and acknowledges the inherently longitudinal nature of SE. Despite these merits, we argue that this definition of SE has some serious omissions that are important in capturing SE comprehensively. Specifically, we argue that the definition could be improved in various ways, namely, it should: (i) clarify which aspects of employment constitute someone's SE; (ii) not counterintuitively treat SE as a characteristic of both the job and the employee simultaneously; (iii) not be based on the insufficiently tested assumption that achieving value in work inherently leads to SE; (iv) be formulated in a way that SE can also apply to unemployed individuals; and (v) adequately specify how the inherently longitudinal dimension of SE should be addressed. We would like to contribute to the discussion by providing guidelines for a new adjusted definition of SE that could facilitate further research on this important concept and its determinants. Introduction SE is a topic of vital importance to individual employees, organizations and society alike. It generally refers to employees' capacities to function in work throughout their working life. As participation in work is important for individuals, organizations, and society as a whole, individuals' ability to function in work is essential. For individuals, work provides meaning, financial security as well as social contacts. Organizations need productive employees to survive. Also from a societal perspective, it is important that as many people as possible participate in the labor market to maintain economic welfare (1). Moreover, as a consequence of population aging (2-6), longevity, rapid changes in technology (7, 8) and changes in the nature of work (1), both the need to promote sustainable employability of individuals in society and the complexity to succeed in doing so increase even further. Only recently, van der Klink et al provided the first definition of the concept in the international scientific literature (1, p74): "Sustainable employability means that throughout their working lives, workers can achieve tangible opportunities in the form of a set of capabilities. They also enjoy the necessary conditions that allow them to make a valuable contribution through their work, now and in the future, while safeguarding their health and welfare. This requires, on the one hand, a work context that facilitates this for them and, on the other, the attitude and motivation to exploit these opportunities." This definition is accompanied by an equally recent operationalization of SE as a set of capabilities (9). Moreover, the definition itself also appeared in an earlier Dutch publication (10), which other international publications about SE most commonly refer to [ie, in comparison with other definitions in the non-international (eg, Dutch) literature] (11-13). As mentioned, the present paper provides a critical reflection on van der Klink et al's aforementioned definition of SE (1). Merits Van der Klink et al's definition of SE (1) has three important merits. First, SE is seen as a multidimensional construct. It is presented as consisting of a broad set of opportunities for employees to create value for themselves and for their employer that cover various aspects of working. Moreover, the individual's health and well-being as well as attitudinal and motivational aspects are included in the definition as well. This acknowledgement of the multidimensionality of SE is favorable, as it illustrates the complexity of the construct and of what constitutes functioning in work. This is in accordance with the International Classification of Functioning, Disability and Health (ICF) (14), in which functioning is seen from three different perspectives (body, activities, and participation). The ICF underlines the multifaceted and complex nature of functioning in which disease, environmental factors, and personal factors play a role. Similarly, the multifaceted nature of functioning is also illustrated by the fact that different disciplines focus on different aspects to understand functioning at work (15, 16). Second, SE is (partially) defined as the degree to which (i) employees are able to work throughout their entire working lives, and (ii) their work context enables them to do so. This suggests that SE is a set of interacting characteristics of the employee and the work context that codetermine the opportunities and conditions affecting employees' capacity to participate in the labor market throughout their working lives. As such, the definition describes an equal responsibility for employee and employer to maintain the employee's ability to work. This could be considered as a great merit, as research shows how strongly an employee's ability to function is influenced by both the individual, work and work-contextual factors (17). Third, van der Klink et al's definition recognizes that SE is an inherently longitudinal construct as clearly embedded in the words "throughout their working lives". This is essential as "sustainable" necessarily implies a time dimension. Need for further development Despite the aforementioned merits, there are important needs for improvement of van der Klink et al's definition of SE. First, it is not immediately clear from the definition what particular element(s) of the work situation constitute(s) SE. The paper provides some clarity by equating SE with the capability set it propagates, as evidenced by these statements: "… in an accompanying paper also published in this issue, we report on the development and validation of a questionnaire that allows for the assessment of sustainable employability based on the concept of capability" (1, p72) and "This [capability] set, in our view, represents the best possible operationalization of sustainable employability" (1, p74). However, in the paper, SE is also referred to as being determined by a worker's capability: "this model holds that an individual's sustainable employability is determined by how he or she succeeds in converting resources into capabilities, and subsequently into work functioning, in such a way that values such as security, recognition and meaning are met"(1, p72). As it is not feasible that SE is predicted by itself in the form of a capability set, perhaps the capability set does not actually refer to SE itself but rather to a favorable employment situation that may cause SE. More clarity on this issue is needed. Second, the definition seems to treat SE as a characteristic of both the job and the individual at the same time. This is counterintuitive and problematic as the job and work context may predict an individual's ability to be sustainably employed, but they can never be aspects that are part of SE. Instead, employability is a characteristic of the individual alone. Of course the individual's ability to be employed does depend on work and work-contextual factors, but these should be predictors and not be embedded in the construct itself. For an adequate definition of SE, it is essential to disentangle these relationships between causes (employment) and effects (employability). Moreover, future approaches should treat SE as an individual characteristic that is an outcome of the complex interaction between other individual, work, and work-contextual characteristics. Third, the definition and operationalization of SE assume that achieving value in work inherently predicts SE and that, therefore, SE can be conceptualized as achieving value in work. This is problematic, as before such claims can be made, such relationships need to be tested with SE as criterion. This is, however, impossible within the approach van der Klink et al provides. (1), as SE is equated with its predictor(s). Therefore, similar to the first conceptual issue, it seems unlikely that the capability set adequately reflects SE. Fourth, the definition by van der Klink et al (1) suggests that SE only applies to individuals who are employed. In the Abma et al publication (9), which accompanies van der Klink's definition paper as a validation paper, this is shown by the way in which capabilities are measured. Moreover, the definition also suggests this because individuals can only be considered to be sustainably employable if their work context enables them to achieve tangible opportunities. However, individuals who are not currently working can still be highly employable and even sustainably so, but just be between jobs. It is therefore not required for individuals to be enabled by their employer to be sustainably employable. Consequently, in line with our aforementioned points on improving the definition, being enabled by an employer to achieve value may be an important predictor of SE, but it is not necessarily part of SE itself. Moreover, future approaches to SE should define the concept in such a way that it is applicable to every individual regardless of employment status. Finally, the definition and operationalization of SE in the form of a capability set do not include any specification on how the longitudinal aspect of SE should be captured. The definition rightfully acknowledges the longitudinal dimension of SE, but its operationalization focuses solely on achieving value. Although achieving value at work may be an important predictor of SE, a complete operationalization and definition should include its longitudinal nature as well. Outlook In conclusion, while van der Klink et al's definition of SE (1) does have strong merits, it requires further improvement. The approach's main drawback is that capabilities seem more apt at describing a potentially important set of predictor(s) of SE than at capturing the construct itself. Either way, future developments in conceptualizing SE should build on the aforementioned merits, but also define SE in a way that (i) clearly labels which aspects of the employment situation constitute SE; (ii) explicitly separates causes and effects; (iii) treats SE as an individual characteristic that may be affected by other employment characteristics at the individual, work, and work-contextual levels; (iv) makes the concept applicable to any individual regardless of their employment status; and (v) clearly addresses the longitudinal nature of SE as embedded in the word "sustainable". These guidelines should not only enable the development of an appropriate definition of SE but also a conceptually sound way of measuring the construct.

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t -Butylhydroquinone is used as an antioxidant in cosmetic products such as lipsticks, eye shadows, perfumes, blushers, and skin care preparations at concentrations ranging from 0.1% to 1.0%; the chemical is also used at concentrations up to 0.02% in oils, fats, and meat products to prevent rancidity, and as a polymerization inhibitor for various polyunsaturated polyesters (CIR, 1986). t-Butylhydroquinone was nominated for toxicity and carcinogenicity testing by the Food and Drug Administration. Toxicology and carcinogenicity studies were conducted in F344/N rats and B6C3F(1) mice. Mice were exposed to t-butyl hydroquinone (99% pure) in feed for 13 weeks or 2 years. For rats, exposure to t-butylhydroquinone began in utero and continued through lactation. After weaning, pups were fed diets containing the same levels of t-butylhydroquinone as those given to their respective dams for 13 weeks or for up to 30 months. The oral route of administration was selected for these studies because t-butylhydroquinone is used as a food additive and human exposure occurs predominantly through this route. In addition to the oral route of exposure, rats were exposed prenatally because perinatal exposure to butylated hydroxytoluene (a structurally related chemical) induced hepatocellular neoplasms in rats. Genetic toxicology studies were conducted in Salmonella typhimurium and cultured Chinese hamster ovary cells in vitro and in mouse bone marrow cells in vivo. 13-WEEK STUDY IN RATS: In the perinatal exposure phase of the 13-week study, groups of 10 female rats (F(0)) were fed 0, 2,500, 5,000, 10,000, 20,000, or 40,000 ppm t-butylhydroquinone from 2 weeks prior to cohabitation until the F(1) pups were weaned. F(0) females exposed to 20,000 or 40,000 ppm did not litter. The number of pup deaths in the 5,000 and 10,000 ppm groups was greater than that in the control group, and the average number of surviving pups per litter in the 10,000 ppm group was less than that in the control group. Mean body weights of pups exposed perinatally to 5,000 or 10,000 ppm were lower than that of the controls at the time of weaning. Groups of 10 male and 10 female F(1) rats continued to receive diets containing 0, 2,500, 5,000, or 10,000 ppm t-butylhydroquinone for 13 weeks fol lowing weaning. These dietary levels corresponded to approximately 200, 400, or 800 mg t-butylhydro quinone/kg body weight (males) or 200, 400, or 750 mg/kg (females) per day. All rats survived to the end of the study. The final mean body weights of males and females in the 5,000 and 10,000 ppm groups were significantly lower than those of the controls, as was the mean body weight gain of males exposed to 10,000 ppm. However, interpretation of these findings was complicated by the significantly lower initial mean body weights of the 10,000 ppm groups. Differences in initial body weights were due to in utero exposure to t-butylhydroquinone. Feed consumption by exposed groups of rats was lower than that by controls at week 2, and feed consumption by 5,000 and 10,000 ppm males and 10,000 ppm females was slightly lower than that by controls at the end of the study. Hair discoloration in all exposed groups of rats, except females exposed to 2,500 ppm, was the only clinical observation considered related to chemical exposure. The mean spermatid count, spermatid heads per testis, and spermatid heads per gram of testis were significantly decreased in males exposed to 5,000 ppm. The estrous cycles of females exposed to 2,500 or 5,000 ppm were significantly longer than that of the controls. There were no biologically significant changes in clinical pathology parameters or in organ weights. Increased incidences of hyperplasia of the nasal respiratory epithelium were observed in males exposed to 5,000 ppm and males and females exposed to 10,000 ppm, and an increased incidence of nasal exudate was observed in males in the 10,000 ppm group. Increased incidences of pigmentation were observed in the spleen of male and female rats exposed to 5,000 or 10,000 ppm. Based on lower final mean body weights wer final mean body weights and decreased feed consumption in males and females exposed to 10,000 ppm t-butylhydroquinone, exposure concentrations selected for the long-term rat study were 1,250, 2,500, and 5,000 ppm. 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were fed diets containing 0, 2,500, 5,000, 10,000, 20,000, or 40,000 ppm t-butylhydroquinone for 13 weeks. These dietary levels corresponded to approximately 440, 880, 1,950, 4,000, and 8,400 mg t-butylhydro quinone/kg body weight (males) or 500, 1,100, 2,200, 4,600, and 9,000 mg/kg body weight (females) per day. There were no exposure-related deaths. Final mean body weights and body weight gains of males and females exposed to 10,000, 20,000, or 40,000 ppm were significantly less than those of the controls. Feed consumption by exposed mice appeared to be similar to that by controls, but there was excessive scatter of feed by mice exposed to 10,000, 20,000, or 40,000 ppm. Therefore, feed consumption by male and female mice in these groups was likely less than that by controls. Significant increases in segmented neutrophil counts occurred at week 3 and at the end of the study in females exposed to 10,000 ppm and males and females exposed to 20,000 or 40,000 ppm. Left caudal, left epididymis, and left testis weights of males exposed to 10,000 or 40,000 ppm were generally significantly lower than those of the controls. The estrous cycle of females exposed to 40,000 ppm was significantly longer than that of the control group. There were no biologically significant differences in organ weights. Increased incidences and severities of mucosal hyperplasia were observed in the forestomach of males exposed to 20,000 or 40,000 ppm and in females exposed to 10,000, 20,000, or 40,000 ppm, and increased incidences of inflammation were observed in the nose and skin of males and females exposed to 10,000, 20,000, or 40,000 ppm. Increased incidences of hyperplasia also occurred in the skin of males and females exposed to 10,000, 20,000, or 40,000 ppm. Based on lower final mean body weights, increased incidences of inflammation of the nose and skin, increased incidences of forestomach mucosal hyperplasia, and increased severity of nonneoplastic lesions observed in mice exposed to 10,000, 20,000, or 40,000 ppm, exposure concentrations selected for the 2-year study were 1,250, 2,500, and 5,000 ppm. LONG-TERM STUDY IN RATS: In the perinatal exposure phase of the long-term study, groups of 60 female F(0) rats were fed diets containing 0, 1,250, 2,500, or 5,000 ppm t-butyl hydroquinone, beginning 2 weeks prior to cohabitation and continuing until F(1) pups were weaned. Following weaning, groups of 70 male and 70 female F(1) rats continued to receive diets containing 0, 1,250, or 5,000 ppm, and groups of 68 male and 68 female rats continued to receive diets containing 2,500 ppm. The duration of dosing in feed was 123 weeks post-weaning for males and 129 weeks for females. These exposure concentrations resulted in daily doses of approximately 50, 100, and 200 mg t-butylhydro quinone/kg body weight (males) or 60, 120, and 240 mg/kg (females). Ten male and ten female F(1) rats from each exposure group were evaluated at 3 months. Survival, Body Weights, Feed Consumption, and Clinical Findings: Survival of females exposed to 5,000 ppm was significantly greater than that of the control group. The mean body weights of males and females exposed to 5,000 ppm were generally less than those of the controls throughout the study. Feed consumption by exposed groups was similar to that by controls. Clinical findings of hair discoloration in exposed groups of males and females were considered to be related to chemical exposure. Pathology Findings: No increased neoplasm incidences in male or female rats were attributed to t-butylhydroquinone exposure. The incidences of mammary gland fibroadenoma and fibroadenoma or adenoma (combined) were significantly decreased in males exposed to 1,250 ppm and in all exposed groups of females; and combined incidences of mammary gland fibroadenoma, adenoma, or carcinoma were significantly decreased in all groups of exposed females. The decreases occurred with significant negative trends. Incidences of renal cysts and inflammation were generally increased in exposed groups of male rats. 2-YEAR STUDY IN MICE: Groups of 60 male and 60 female mice received 0, 1,250, 2,500, or 5,000 ppm t-butylhydroquinone in feed for 104 to 105 weeks. These exposure concentrations resulted in daily doses of approximately 150, 300, or 600 mg t-butylhydroquinone/kg body weight (males) or 150, 300, or 700 mg/kg (females). As many as 10 males and 10 females from each exposure group were evaluated at 15 months. Survival, Body Weights and Feed Consumption: Survival of all exposed groups of males and females was similar to that of the control groups. Mean body weights of the 5,000 ppm groups were generally lower than those of the control groups from week 13 until the end of the study. Feed consumption by exposed groups of males and females was similar to that by the controls. There were no biologically significant differences in clinical pathology parameters between control and exposed groups of mice. Pathology Findings: No increased incidences of neoplasms or nonneoplastic lesions in male or female mice were considered to be related to t-butylhydroquinone exposure. GENETIC TOXICOLOGY: t-Butylhydroquinone was not mutagenic in any of four strains of Salmonella typhimurium, with or without liver S9 metabolic activation enzymes. It did, however, induce sister chromatid exchanges and chromosomal aberrations in cultured Chinese hamster ovary cells in the presence, but not the absence, of S9. No increase in the frequency of micronucleated erythrocytes was observed in bone marrow of male mice treated with t-butylhydroquinone. CONCLUSIONS: Under the conditions of this long-term feed study, there was no evidence of carcinogenic activity of t-butylhydroquinone in male or female F344/N rats exposed to 1,250, 2,500, or 5,000 ppm. Under the conditions of this 2-year feed study, there was no evidence of carcinogenic activity of t-butylhydroquinone in male or female B6C3F(1) mice exposed to 1,250, 2,500, or 5,000 ppm. Exposure of rats to t-butylhydroquinone in feed resulted in decreased incidences of mammary gland neoplasms in males and females. Synonyms: Tert-butyl-hydroquinone; 2-(1,1-dimethylethyl)-1,4-benzenediol; 2-tert-butylhydroquinone; mono-tert-butylhydroquinone; tert-butyl-1,4-benzenediol: mono-tertiarybutylhydroquinone; 2-tert-butyl-1,4-benzenediol; 2-(1,1-dimethyl)hydroquinone; 2-(tert-butyl)-p-hydroquinone; TBHQ; MTBHQ Trade Names: Sustane; Tenox TBHQ; Banox 20BA

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The genus Olios Walckenaer, 1837 is revised, a generic diagnosis is given and an identification key to eight species groups is provided. Olios in its revised sense includes 87 species and is distributed in Africa, southern Europe and Asia. Three species groups are revised in this first part, an identification key to species for each group is provided, five new species are described and all included species are illustrated. The Olios argelasius-group includes O. argelasius Walckenaer, 1806, O. canariensis (Lucas, 1838), O. pictus (Simon, 1885), O. fasciculatus Simon, 1880 and O. kunzi spec. nov. (male, female; Namibia, Zambia, South Africa); it is distributed in the Mediterranean region, northern Africa including Canary Islands, in the Middle East, South Sudan, East Africa, and southern Africa. The Olios coenobitus-group includes O. angolensis spec. nov. (male; Angola), O. coenobitus Fage, 1926, O. denticulus spec. nov. (male; Java), O. erraticus Fage, 1926, O. gambiensis spec. nov. (male, female; Gambia), O. milleti (Pocock, 1901b), O. mordax (O. Pickard-Cambridge, 1899) and O. pusillus Simon, 1880; it is distributed in Africa (Gambia, Angola, Tanzania, Madagascar) and Asia (India, Sri Lanka, Indonesia: Java). The Olios auricomis-group includes only O. auricomis (Simon, 1880), distributed in Africa south of 10°N. Other species groups are introduced briefly and will be revised in forthcoming revisions. The Olios correvoni-group includes currently O. claviger (Pocock, 1901a), O. correvoni Lessert, 1921, O. correvoni choupangensis Lessert, 1936, O. darlingi (Pocock, 1901a), O. faesi Lessert, 1933, O. freyi Lessert, 1929, O. kassenjicola Strand, 1916b, O. kruegeri (Simon, 1897a), O. quadrispilotus (Simon, 1880) comb. nov., O. lucieni comb. nov. nom. nov., O. sjostedti Lessert, 1921 and O. triarmatus Lessert, 1936; it is distributed in Africa (Zimbabwe, Tanzania incl. Zanzibar, Angola, Congo, Central Africa, South Africa, Botswana; O. darlingi was recorded from Zimbabwe and Botswana and not from South Africa). The Olios rossettii-group includes: O. baulnyi (Simon, 1874), O. bhattacharjeei (Saha Raychaudhuri, 2007), O. brachycephalus Lawrence, 1938, O. floweri Lessert, 1921, O. jaldaparaensis Saha Raychaudhuri, 2007, O. japonicus Jäger Ono, 2000, O. kolosvaryi (Caporiacco, 1947b) comb. nov., O. longipes (Simon, 1884b), O. lutescens (Thorell, 1894), O. mahabangkawitus Barrion Litsinger, 1995, O. obesulus (Pocock, 1901b), O. rossettii (Leardi, 1901), O. rotundiceps (Pocock, 1901b), O. sericeus (Kroneberg, 1875), O. sherwoodi Lessert, 1929, O. suavis (O. Pickard-Cambridge, 1876), O. tarandus (Simon, 1897d), O. tener (Thorell, 1891) and O. tiantongensis (Zhang Kim, 1996); it is distributed in the Mediterranean region, in Africa (especially eastern half) and Asia (Middle East and Central Asia to Japan, Philippines and Java). The Olios nentwigi-group includes O. diao Jäger, 2012, O. digitatus Sun, Li Zhang, 2011, O. jaenicke Jäger, 2012, O. muang Jäger, 2012, O. nanningensis (Hu Ru, 1988), O. nentwigi spec. nov. (male, female; Indonesia: Krakatau), O. perezi Barrion Litsinger, 1995, O. scalptor Jäger Ono, 2001 and O. suung Jäger, 2012; it is distributed in Asia (Thailand, Laos, Vietnam, Cambodia, China, Taiwan, Indonesia, Philippines), Papua New Guinea and Mariana Islands. Olios diao is newly recorded from Cambodia and Champasak Province in Laos. The Olios stimulator-group includes O. admiratus (Pocock, 1901b), O. hampsoni (Pocock, 1901b), O. lamarcki (Latreille, 1806) and O. stimulator Simon, 1897c; it is distributed in Africa (Madagascar, Seychelles), Middle East and South Asia (United Arab Emirates, Iraq, Afghanistan, Pakistan, India, Maldives, Sri Lanka). The Olios hirtus-group includes O. bungarensis Strand, 1913b, O. debalae (Biswas Roy, 2005), O. ferox (Thorell, 1892), O. hirtus (Karsch, 1879a), O. igraya (Barrion Litsinger, 1995) comb. nov., O. menghaiensis (Wang Zhang, 1990), O. nigrifrons (Simon, 1897b), O. punctipes Simon, 1884a, O. punctipes sordidatus (Thorell, 1895), O. pyrozonis (Pocock, 1901b), O. sungaya (Barrion Litsinger, 1995) comb. nov., O. taprobanicus Strand, 1913b and O. tikaderi Kundu et al., 1999; it is distributed in South, East and Southeast Asia (Sri Lanka, India, Nepal, Bangladesh, Myanmar, China, Laos, Thailand, Cambodia, Vietnam, Malaysia, Indonesia, Philippines). Nineteen synonyms are recognised: Nisueta Simon, 1880, Nonianus Simon, 1885, both = Olios syn. nov.; O. spenceri Pocock, 1896, O. werneri (Simon, 1906a), O. albertius Strand, 1913a, O. banananus Strand, 1916a, O. aristophanei Lessert, 1936, all = O. fasciculatus; O. subpusillus Strand, 1907c = O. pusillus; O. schonlandi (Pocock, 1900b), O. rufilatus Pocock, 1900c, O. chiracanthiformis Strand, 1906, O. ituricus Strand, 1913a, O. isongonis Strand, 1915, O. flavescens Caporiacco, 1941 comb. nov., O. pacifer Lessert, 1921, all = O. auricomis; Olios sanguinifrons (Simon, 1906b) = O. rossettii Leardi, 1901; O. phipsoni (Pocock, 1899), Sparassus iranii (Pocock, 1901b), both = O. stimulator; O. fuligineus (Pocock, 1901b) = O. hampsoni. Nine species are transferred to Olios: O. gaujoni (Simon, 1897b) comb. nov., O. pictus comb. nov., O. unilateralis (Strand, 1908b) comb. nov. (all three from Nonianus), O. affinis (Strand, 1906) comb. nov., O. flavescens Caporiacco, 1941 comb. nov., O. quadrispilotus comb. nov., O. similis (Berland, 1922) comb. nov. (all four from Nisueta), O. sungaya (Barrion Litsinger, 1995) comb. nov., O. igraya (Barrion Litsinger, 1995) comb. nov. (both from Isopeda L. Koch 1875). Olios lucieni nom. nov. comb. nov. is proposed for Nisueta similis Berland, 1922, which becomes a secondary homonym. The male of O. quadrispilotus comb. nov. is described for the first time. Sixteen species are currently without affiliation to one of the eight species groups: O. acolastus (Thorell, 1890), O. alluaudi Simon, 1887a, O. batesi (Pocock, 1900c), O. bhavnagarensis Sethi Tikader, 1988, O. croseiceps (Pocock, 1898b), O. durlaviae Biswas Raychaudhuri, 2005, O. gentilis (Karsch, 1879b), O. gravelyi Sethi Tikader, 1988, O. greeni (Pocock, 1901b), O. inaequipes (Simon 1890), O. punjabensis Dyal, 1935, O. ruwenzoricus Strand, 1913a, O. senilis Simon, 1880, O. somalicus Caporiacco, 1940, O. wroughtoni (Simon, 1897c) and O. zulu Simon, 1880. Five of these species are illustrated in order to allow identification of the opposite (male) sex and to settle their systematic placement. Thirty-seven species are considered nomina dubia, mostly because they were described from immatures, three of them are illustrated: O. abnormis (Blackwall, 1866), O. affinis (Strand, 1906) comb. nov., O. africanus (Karsch, 1878), O. amanensis Strand, 1907a, O. annandalei (Simon, 1901), O. bivittatus Roewer, 1951, O. ceylonicus (Leardi, 1902), O. conspersipes (Thorell, 1899), Palystes derasus (C.L. Koch, 1845) comb. nov., O. detritus (C.L. Koch, 1845), O. digitalis Eydoux Souleyet, 1842, O. exterritorialis Strand, 1907b, O. flavovittatus (Caporiacco, 1935), O. fugax (O. Pickard-Cambridge, 1885), O. guineibius Strand, 1911c, O. guttipes (Simon, 1897a), O. kiranae Sethi Tikader, 1988, O. longespinus Caporiacco, 1947b, O. maculinotatus Strand, 1909, O. morbillosus (MacLeay, 1827), O. occidentalis (Karsch, 1879b), O. ornatus (Thorell, 1877), O. pagurus Walckenaer, 1837, O. patagiatus (Simon, 1897b), O. praecinctus (L. Koch, 1865), O. provocator Walckenaer, 1837, O. quesitio Moradmand, 2013, O. quinquelineatus Taczanowski, 1872, O. sexpunctatus Caporiacco, 1947a, Heteropoda similaris (Rainbow, 1898) comb. rev., O. socotranus (Pocock, 1903), O. striatus (Blackwall, 1867), O. timidus (O. Pickard-Cambridge, 1885), Remmius variatus (Thorell, 1899) comb. nov., O. vittifemur Strand, 1916b, O. wolfi Strand, 1911a and O. zebra (Thorell, 1881). Eighty-nine species are misplaced in Olios but cannot be affiliated to any of the known genera. They belong to the subfamilies Deleninae Hogg, 1903, Sparassinae Bertkau, 1872 and Palystinae Simon, 1897a, nineteen of them are illustrated: O. acostae Schenkel, 1953, O. actaeon (Pocock, 1898c), O. artemis Hogg, 1915, O. atomarius Simon, 1880, O. attractus Petrunkevitch, 1911, O. auranticus Mello-Leitão, 1918, O. benitensis (Pocock, 1900c), O. berlandi Roewer, 1951, O. biarmatus Lessert, 1925, O. canalae Berland, 1924, O. caprinus Mello-Leitão, 1918, O. chelifer Lawrence, 1937, O. chubbi Lessert, 1923, O. clarus (Keyserling, 1880), O. coccineiventris (Simon, 1880), O. corallinus Schmidt, 1971, O. crassus Banks, 1909, O. debilipes Mello-Leitão, 1945, O. discolorichelis Caporiacco, 1947a, O. erroneus O. Pickard-Cambridge, 1890, O. extensus Berland, 1924, O. fasciiventris Simon, 1880 , O. feldmanni Strand, 1915, O. fimbriatus Chrysanthus, 1965, O. flavens Nicolet, 1849, O. fonticola (Pocock, 1902), O. formosus Banks, 1929, O. francoisi (Simon, 1898a), O. fulvithorax Berland, 1924, O. galapagoensis Banks, 1902, O. gaujoni (Simon, 1897b) comb. nov., O. giganteus Keyserling, 1884, O. hoplites Caporiacco, 1941, O. humboldtianus Berland, 1924, O. insignifer Chrysanthus, 1965, O. insulanus (Thorell, 1881), O. keyserlingi (Simon, 1880), O. lacticolor Lawrence, 1952, O. lepidus Vellard, 1924, O. longipedatus Roewer, 1951, O. machadoi Lawrence, 1952, O. macroepigynus Soares, 1944, O. maculatus Blackwall, 1862, O. marshalli (Pocock, 1898a), O. mathani (Simon, 1880), O. minensis Mello-Leitão, 1917, O. monticola Berland, 1924, O. mutabilis Mello-Leitão, 1917, O. mygalinus Doleschall, 1857, O. mygalinus cinctipes Merian, 1911, O. mygalinus nirgripalpis Merian, 1911, O. neocaledonicus Berland, 1924, O. nigristernis (Simon, 1880), O. nigriventris Taczanowski, 1872, O. oberzelleri Kritscher, 1966, O. obscurus (Keyserling, 1880), O. obtusus F.O. Pickard-Cambridge, 1900, O. orchiticus Mello-Leitão, 1930, O. oubatchensis Berland, 1924, O. paraensis (Keyserling, 1880), O. pellucidus (Keyserling, 1880), O. peruvianus Roewer, 1951, O. pictitarsis Simon, 1880, O. plumipes Mello-Leitão, 1937, O. princeps Hogg, 1914, O. pulchripes (Thorell, 1899), O. puniceus (Simon, 1880), O. roeweri Caporiacco, 1955a, O. rubripes Taczanowski, 1872, O. rubriventris (Thorell, 1881), O. rufus Keyserling, 1880, O. sanctivincenti (Simon, 1898b), O. similis (O. Pickard-Cambridge, 1890), O. simoni (O. Pickard-Cambridge, 1890), O. skwarrae Roewer, 1933, O. spinipalpis (Pocock, 1901a), O. stictopus (Pocock, 1898a), O. strandi Kolosváry, 1934, O. subadultus Mello-Leitão, 1930, O. sulphuratus (Thorell, 1899), O. sylvaticus (Blackwall, 1862), O. tamerlani Roewer, 1951, O. tigrinus (Keyserling, 1880), O. trifurcatus (Pocock, 1900c), O. trinitatis Strand, 1916a, O. velox (Simon, 1880), O. ventrosus Nicolet, 1849, O. vitiosus Vellard, 1924 and O. yucatanus Chamberlin, 1925. Seventeen taxa are transferred from Olios to other genera within Sparassidae, eight of them are illustrated: Adcatomus luteus (Keyserling, 1880) comb. nov., Eusparassus flavidus (O. Pickard-Cambridge, 1885) comb. nov., Palystes derasus (C.L. Koch, 1845) comb. nov., Heteropoda similaris (Rainbow, 1898) comb. rev., Remmius variatus (Thorell, 1899) comb. nov., Nolavia audax (Banks, 1909) comb. nov., Nolavia antiguensis (Keyserling, 1880) comb. nov., Nolavia antiguensis columbiensis (Schmidt, 1971) comb. nov., Nolavia fuhrmanni (Strand, 1914) comb. nov., Nolavia helva (Keyserling, 1880) comb. nov., Nolavia stylifer (F.O. Pickard-Cambridge, 1900) comb. nov., Nolavia valenciae (Strand, 1916a) comb. nov., Nungara cayana (Taczanowski, 1872) comb. nov., Polybetes bombilius (F.O. Pickard-Cambridge, 1899) comb. nov., Polybetes fasciatus (Keyserling, 1880) comb. nov., Polybetes hyeroglyphicus (Mello-Leitão, 1918) comb. nov. and Prychia paalonga (Barrion Litsinger, 1995) comb. nov. One species is transferred from Olios to the family Clubionidae Wagner, 1887: Clubiona paenuliformis (Strand, 1916a) comb. nov.

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Sodium xylenesulfonate is used as a hydrotrope, an organic compound that increases the ability of water to dissolve other molecules. Sodium xylenesulfonate is a component in a variety of widely used shampoos and liquid household detergents where it can constitute up to 10% of the total solution. Because of its widespread use, the potential for human exposure to sodium xylenesulfonate is great. Male and female F344/N rats and B6C3F1 mice were administered sodium xylenesulfonate in water or 50% ethanol dermally for 17 days, 14 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, L5178Y mouse lymphoma cells, and cultured Chinese hamster ovary cells. 17-DAY STUDY IN RATS: Groups of five male and five female rats were administered 300 mL of 0, 5, 15, 44, 133, or 400 mg/mL sodium xylenesulfonate in distilled water by dermal application 5 days per week for 17 days. All rats survived to the end of the study. Final mean body weights and body weight gains of dosed rats were similar to those of the control groups. Dermal applications of 300 mL of 5, 15, 44, 133, and 400 mg/mL delivered average daily doses of approximately 10, 30, 90, 260, and 800 mg sodium xylenesulfonate/kg body weight to males and 13, 40, 120, 330, and 1,030 mg/kg to females. Clinical findings generally involved the skin of dosed animals and included tan or brown skin discoloration and crusty white deposits (presumed to be dried chemical) at the site of application. Neither of these observations were considered significant findings. The relative liver weights of 133 and 400 mg/mL male and female rats were significantly greater than those of the control groups, but the absolute liver weights were not increased and the biological significance of the relative differences in liver weight was unclear. In males and females, the few lesions observed grossly and microscopically were generally attributed to repeated clipping and were not considered related to chemical administration. 17-DAY STUDY IN MICE: Groups of five male and five female mice were administered 100 mL of 0, 5, 15, 44, 133, or 400 mg/mL sodium xylenesulfonate in distilled water by dermal application 5 days per week for 17 days. All mice survived to the end of the study. Final mean body weights and body weight gains of dosed mice were similar to those of the controls. Dermal applications of 5, 15, 44, 133, and 400 mg/mL delivered average daily doses of approximately, 20, 60, 190, 540, and 1,600 mg sodium xylenesulfonate/kg body weight to males and 26, 80, 220, 680, and 2,000 mg/kg to females. Clinical findings included crusty white deposits (presumed to be dried chemical) at the site of application in two 133 mg/mL males and in all 400 mg/mL males and females. The absolute and relative liver weights of 15 and 44 mg/mL males and 400 mg/mL males and females were significantly greater than those of the control groups, but the biological significance of these differences was unclear. The few skin lesions observed grossly and microscopically in males and females were generally attributed to repeated clipping and were not considered related to chemical administration. 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were administered 300 mL of 0, 5, 15, 44, 133, or 400 mg/mL sodium xylenesulfonate in 50% ethanol by dermal application for 14 weeks. For special hematology and clinical pathology studies, additional groups of 10 male and 10 female rats were administered 0, 5, 15, 44, 133, or 400 mg/mL sodium xylenesulfonate in 50% ethanol by dermal application for 14 weeks. All rats survived to the end of the study. Final mean body weights and body weight gains of dosed male and female rats were similar to those of the control groups. Dermal applications of 5, 15, 44, 133, and 400 mg/mL delivered average daily doses of approximately 6, 20, 60, 170, and 500 mg sodium xylenesulfonate/kg body weight to males and 10, 30, 90, 260, and 800 mg/kg to females. The only notable clinical finding was brown discoloration of the skin at the site of application in dosed animals. Hemaation in dosed animals. Hematology and clinical chemistry parameters of dosed groups of males and females were significantly different from those of the controls in several instances, but these differences were sporadic and did not demonstrate a treatment relationship. The absolute and relative liver weights of males receiving 44, 133, or 400 mg/mL were significantly less than those of the control group, but the biological significance of these differences was unclear, and there were no treatment-related histopathologic effects in the liver. There were no significant differences in liver weights in female rats. Minimal hyperplasia of the epidermis at the site of application occurred in both male and female rats in the control group as well as most dosed groups. The incidence of epidermal hyperplasia in 400 mg/mL males was possibly chemical related. 14-Week Study in Mice: Groups of 10 male and 10 female mice were administered 100 mL of 0, 5, 15, 44, 133, or 400 mg/mL sodium xylenesulfonate in 50&amp;percnt; ethanol by dermal application for 14 weeks. There were no chemical-related deaths. The mean body weight gain of the 400 mg/mL males was significantly greater than that of the control group. Dermal applications of 5, 15, 44, 133, and 400 mg/mL delivered average daily doses of approximately 17, 40, 140, 440, and 1,300 mg sodium xylenesulfonate/kg body weight to males and 20, 60, 170, 530, and 1,630 mg/kg to females. There were no clinical findings related to sodium xylenesulfonate administration. Epidermal hyperplasia occurred in one 44 mg/mL female, two 133 mg/mL males, five 400 mg/mL males, and four 400 mg/kg females. Hyperplasia of the epidermis in 400 mg/mL males and females was probably related to chemical administration. Chronic inflammation of the skin occurred primarily in the control groups of males and females. These lesions consisted of mononuclear inflammatory cells in the dermis. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female rats were dermally administered 0, 60, 120, or 240 mg sodium xylenesulfonate/kg body weight in 50&amp;percnt; ethanol for 104 weeks. Survival, Body Weights, and Clinical Findings: Survival of dosed males and females was similar to that of the control groups. Mean body weights of dosed males and females were similar to those of the controls throughout the study. In male groups, there were no clinical findings considered treatment related. In females, clinical findings were limited to irritation at the site of application in one control female, four 120 mg/kg females, and two 240 mg/kg females. Pathology Findings: There were no neoplasms at any site (including the skin) that were considered treatment related.Low incidences of hyperplasia of the epidermis at the site of application occurred in males in the 60, 120, and 240 mg/kg groups. Low incidences of hyperplasia of the epidermis at the site of application also occurred in females in the 120 and 240 mg/kg groups, and they occurred with a significant positive trend. Low incidences of hyperplasia of the sebaceous gland occurred in control and 60 mg/kg males and in control, 120 mg/kg, and 240 mg/kg females. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice were dermally administered 0, 182, 364, or 727 mg sodium xylenesulfonate/kg body weight in 50&amp;percnt; ethanol for 104 to 105 weeks. Survival, Body Weights, and Clinical Findings: Survival of dosed males and females was similar to that of the control groups. Mean body weights of dosed males and females were generally similar to those of the controls throughout the study; however, the mean body weights of 727 mg/kg females were greater than those of the control group from week 85 to week 97. With the exception of irritation at the site of application in one 364 mg/kg female, there were no clinical findings related to sodium xylenesulfonate administration. Pathology Findings: There were no neoplasms at any site (including the skin) that were considered treatment related.Hyperplasia of the epidermis occurred in control,364 mg/kg, and 727 mg/kg males and in control and dosed females. In male mice, the incidences occurred with a significant positive trend. Focal ulceration occurred in one 727 mg/kg male and in one female in each dose group. In males and females from control and dosed groups, the incidences of hepatocellular adenoma, hepatocellular carcinoma, and hepato- cellular adenoma or carcinoma (combined) were generally higher than those expected by spontaneous occurrence. The incidences of hepatocellular neoplasms in some groups of males and females exceeded the NTP historical control range. Male mice had a pattern of nonneoplastic liver lesions along with silver stained positive helical organisms within the liver which suggests an infection with Helicobacter hepaticus. The findings in this study of sodium xylenesulfonate were not considered to have been significantly impacted by the infection with H. hepaticus or its associated hepatitis. GENETIC TOXICOLOGY: Sodium xylenesulfonate was not mutagenic in Salmonella typhimurium strain TA98, TA100, TA1535, or TA1537 with or without induced liver S9. Equivocal results were obtained in a mutation assay with mouse lymphoma cells in the presence of induced S9; no evidence of mutagenicity was noted without S9 in this assay. In cytogenetic tests with sodium xylenesulfonate in cultured Chinese hamster ovary cells, significant increases in sister chromatid exchanges were observed in the absence of S9 only, and no increases in chromosomal aberrations were observed with or without S9. CONCLUSIONS: Under the conditions of these 2-year dermal studies, there was no evidence of carcinogenic activity of sodium xylenesulfonate in male or female F344/N rats administered 60, 120, or 240 mg/kg or in male or female B6C3F1 mice administered 182, 364, or 727 mg/kg. Increased incidences of epidermal hyperplasia in female rats and male mice may have been related to exposure to sodium xylenesulfonate. Synonyms: Benzenesulfonic acid, dimethyl-, sodium salt; xylenesulfonic acid, sodium salt; sodium dimethylbenzenesulfonate; xylenesulfonic acid, sodium salt Trade names: Conco SXS; Cyclophil; SXS 30; Eletesol SX 30; Naxonate; Naxonate G; Richonate SXS; Stepanate SXS; Stepanate X; SXS 40; Ultrawet 40SX

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Little was written in the stars above the city of Tabriz in Iran on March 15, 1938 indicating that a newborn citizen would immigrate to America and become a master of modern mo-lecular imaging with a sharp focus on <sup18</supF-FDG PET to the benefit of millions of people around the world. Nonetheless, that's what happened. A gifted boy who lost his farther early and grew up with his uneducated mother and two siblings in humble circumstances to become a premium student, nationally no. 1 in mathematics while in school, and later a medical doctor before he decided in 1966 to seek his fortune in the US. Here he started education in internal medicine, hematology and oncology, albeit found this unsatisfactory due to tradition and rote learning. He turned to radiology and nuclear medicine in a search for new knowledge and better methods to benefit patients and society, an attitude he had been taught from early childhood. The very same attitude has been the beacon for Alavi's activities throughout his professional life, instead of money, power and social status. He married into a highly academic environment. His wife, Jane Bradley Alavi, was a specialist in hematology and oncology and is still his life partner. They never had children, so their many students and the numerous medical doctors, physicists and other academics they coached became their family. While Jane Alavi retired some years ago, Abass Alavi continued his professional career and has no plans of retirement when he turns 80 on March 15, 2018 after 46 years in nuclear medicine at the University of Pennsylvania and with an admirable network of pupils and colleagues across all five continents. On the contrary, Alavi has probably never been busier, his scientific work goes on, his multinational scientific "family" steadily increases all over the world as does the appli-cation of PET in the shape of PET/CT or PET/MRI. Alavi's contributions to the scientific literature has more than doubled within the last decade making him one of the most cited researchers at the University of Pennsylvania with a production of more than 1,200 articles, a similar number of published abstracts and close to 58,000 citations according to Google Scholar, of which about 20,000 since 2012 when he was 74. This is just part of an amazing story. Having turned to nuclear medicine in 1971, Alavi entered into one of the World's most ingenious and productive medical research en-vironments comprising collaboration of experts in nuclear medicine (David Kuhl) and neurology (Martin Reivich) at Penn, and in physiology and pharmacology (Louis Sokoloff) at the NIH, all of whom contributed significantly to the development of PET. Focus was on cerebral research with beta-emitting <sup14</supC-labeled deoxyglucose for mapping regional cerebral glucose metabolism by means of autoradiography. Alavi became a junior member of this collaboration in which the idea of labeling deoxyglucose with a gamma-emitting isotope arose to allow in vivo examination of the normal and diseased human brain. They contacted Alfred Wolf at Brookhaven National Laboratory who had an interest in synthesizing positron-emitting compounds. He suggested labeling instead with <sup18</supF-FDG and in 1975 Wolf's group including Tatsuo Ido and Joanna Fowler succeeded in synthesizing <sup18</supF-FDG. In the meantime, investigators at Penn had developed high energy collimators for the Mark IV scanner to allow imaging with <sup18</supF-FDG, so in August 1976, two normal volunteers were the first to receive a dose of <sup18</supF-FDG for tomographic brain imaging showing concentration of <sup18</supF-FDG in the gray matter while in one volunteer a "whole-body" scan from the top of the scull to mid-thigh was also obtained. A year before, investigators at Washington University, i.e., Michel Ter-Pogossian in collaboration with Michael Phelps, Edward Hoffmann, and Nizar Mullani had developed what they termed a positron-emission transaxial tomograph for nuclear imaging, i.e. a machine which was the starting point of today's PET scanners. Alavi understood from the beginning the potential of PET and in particular <sup18</supF-FDG PET even if PET images at that time were blurry and difficult to interpret, a circum-stance which for a quarter of a century brought the method in poor standing in the minds of many. Alavi started as a brain researcher, but training in internal medicine, hematology, radiology and nuclear medicine broadened his scope and over the years there are few diseases and clinical specialties in which Alavi has not provided results obtained with molecular imaging. He was a pioneer in using iodine-123 in thyroid cancer, MIBG in pheochromocytoma, radiolabeled white blood cells in infection, and <sup99m</supTc for the detection of gastrointestinal bleeds, and together with his wife <sup18</supF-FDG PET for the demonstration of recurrent brain tumors. Thus, Alavi has contributed often very successfully by promoting new ideas and their implementation to achieve improved ways of examining a variety of medical disorders. Alavi has been accused of seeing <sup18</supF-FDG as the only useful PET tracer. In a way this is true. FDG became the dominant tracer and has remained so for over 40 years now. In his 2008 SNM Highlight Lecture, Henry N. Wagner, Jr. called FDG the "tracer molecule of the 20<supth</supth century". According to a recent forecast of the Global Nuclear Medicine Radioisotopes Market, the global <sup18</supF-FDG market is expected to grow from an estimated $1.233 billion in 2014 to $2.148 billion in 2019 and the vast majority of this growth is due to a continued increase in the use of <sup18</supF-FDG, indicating that this tracer may remain the tracer molecule of at least the first half of the 21<supst</sup century. The world calls for more specific tracers than <sup18</supF-FDG, and like others Dr. Alavi has constantly been looking for these, but with time, it became apparent that our body holds few organ or disease specific targets, so that the concept of very specific disease-characterizing tracers is not as rosy as previously assumed. Thus, in cancer, genetic profiling has demonstrated that tumors are genetically often a mixture of cellular clones and that these are not necessarily also present in local, regional or remote metastases, meaning that ultra-specific PET tracers for cancer diagnosis and staging may be more a utopian vision than a realistic future possibility. This, together with inborn limitations of the PET technique has made Abass Alavi more prudent and hesitant toward reports of highly promising new PET tracers and an advocate of timely carefulness when using our limited financial resources. Teaching and education of talented young individuals is one of Alavi's main academic missions. Thus, with Gerald Mandell, MD, he established the Alavi-Mandell Award, presented for the first time at the SNM meeting in 1999 to a candidate selected from among all those in a given year who were trainees at the time their names appeared as first authors of papers in JNM. Together with his wife Jane, Alavi established the Bradley-Alavi Student Fellowship which was presented for the first time in 2001 and is given to the top students selected by the SNMMI Education and Research Foundation. Alavi himself is a recipient of multiple awards, including the Georg Charles de Hevesy Nuclear Pioneer Award (2004), the Benedict Cassen Prize for Research in Nuclear Medicine (2012), the Honorary Citizenship of his native town Tabriz (2015) and the Gold Medal of the National Institute for Medical Research Development, Tehran (2015). In addition, he has received the Honorary PhD Degree in Molecular Biology of the University of Shiraz (2007), and the Honorary Doctoral Degrees of the University of Bologna (2007), the University of the Sciences in Philadelphia (2008), the Medical University of Gdansk (2016), and the University of Southern Denmark (2016). Since January 2011, Alavi has been a frequent guest in the city of Odense, Denmark. Its University Hospital holds one of the biggest departments of nuclear medicine and PET in Northern Europe. From being behind, Denmark has become the country in the world with the highest relative number of PET/CT scanners and PET scans, i.e., an estimated 0.7 and 1000, respectively, per 100 000 inhabitants in 2017. At 17 consecutive interdisciplinary Abass Alavi Meetings in Odense, he has been inspirer and initiator of multi-disciplinary scientific projects that have resulted in more than 100 publications and as many scientific presentations. Abass Alavi personifies the polymath, a species rarely found today. He discusses and produces science in as diverse areas as brain, cardiovascular, and musculoskeletal diseases, inflammation, cancer and many more disorders that plague humanity, and he has a clear eye to make results clinically useful. Had the Noble Prize been awarded not only for single inventions but also for the cumulated contribution of an outstanding researcher to patients who suffer and mankind as a whole, Dr. Abass Alavi would be on top of the candidate list. What may such an experienced birthday-person foretell about the future? He would probably say that the gamma camera and SPET will be entirely substituted by PET, that skeletal metastases are bone marrow and not bone metastases and that all indirect methodologies for imaging of skeletal metastases, including bone scintigraphy and CT, will be replaced by PET imaging with <sup18</supF-FDG or more cancer specific tracers. Also that motion and partial volume correction will be satisfactorily dealt with to allow calculation of a global disease score representing the total burden of disease in the body, whether caused by cancer, atherosclerosis or other severe disorders, and that, thus, PET will take its lead position as the diagnostic imaging modality of the 21<supst</sup century. It is hard to say how many of these predictions will come true while Dr. Alavi is still going strong. What is certain is that very few persons, if any, has contributed so significantly to the development and clinical implementation of PET imaging worldwide as have this 80 year old giant in modern nuclear and molecular medicine! Abass Alavi currently holds appointments as Professor and Director of Research Education in the Department of Radiology, Perelman School of Medicine, of the University of Pennsylvania and as Honorary Fellow of the International Society of Medical Olympicus Association in Greece.

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As of December, 1<supst</sup, 2020, coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2, resulted in more than 1 472 917 deaths worldwide and death toll is still increasing exponentially. Many COVID-19 infected people are asymptomatic or experience moderate symptoms and recover without medical intervention. However, older people and those with comorbid hypertension, diabetes, obesity, or heart disease are at higher risk of mortality. Because current therapeutic options for COVID-19 patients are limited specifically for this elderly population at risk, Biophytis is developing BIO101 (20-hydroxyecdysone, a Mas receptor activator) as a new treatment option for managing patients with SARS-CoV-2 infection at the severe stage. The angiotensin converting enzyme 2 (ACE2) serves as a receptor for SARS-CoV-2. Interaction between ACE2 and SARS-CoV2 spike protein seems to alter the function of ACE2, a key player in the renin-angiotensin system (RAS). The clinical picture of COVID-19 includes acute respiratory distress syndrome (ARDS), cardiomyopathy, multiorgan dysfunction and shock, all of which might result from an imbalance of the RAS. We propose that RAS balance could be restored in COVID-19 patients through MasR activation downstream of ACE2 activity, with 20-hydroxyecdysone (BIO101) a non-peptidic Mas receptor (MasR) activator. Indeed, MasR activation by 20-hydroxyecdysone harbours anti-inflammatory, anti-thrombotic, and anti-fibrotic properties. BIO101, a 97% pharmaceutical grade 20-hydroxyecdysone could then offer a new therapeutic option by improving the respiratory function and ultimately promoting survival in COVID-19 patients that develop severe forms of this devastating disease. Therefore, the objective of this COVA study is to evaluate the safety and efficacy of BIO101, whose active principle is 20-hydroxyecdysone, in COVID-19 patients with severe pneumonia. Randomized, double-blind, placebo-controlled, multi-centre, group sequential and adaptive which will be conducted in 2 parts. Part 1: Ascertain the safety and tolerability of BIO101 and obtain preliminary indication of the activity of BIO101, in preventing respiratory deterioration in the target population Part 2: Re-assessment of the sample size needed for the confirmatory part 2 and confirmation of the effect of BIO101 observed in part 1 in the target population. The study is designed as group sequential to allow an efficient run-through, from obtaining an early indication of activity to a final confirmation. And adaptive - to allow accumulation of early data and adapt sample size in part 2 in order to inform the final design of the confirmatory part of the trial. Inclusion criteria 1. Age: 45 and above 2. A confirmed diagnosis of COVID-19 infection, within the last 14 days, prior to randomization, as determined by PCR or other approved commercial or public health assay, in a specimen as specified by the test used. 3. Hospitalized, in observation or planned to be hospitalized due to COVID-19 infection symptoms with anticipated hospitalization duration ≥3 days 4. With evidence of pneumonia based on all of the following: a. Clinical findings on a physical examination b. Respiratory symptoms developed within the past 7 days 5. With evidence of respiratory decompensation that started not more than 4 days before start of study medication and present at screening, meeting one of the following criteria, as assessed by healthcare staff: a. Tachypnea: ≥25 breaths per minute b. Arterial oxygen saturation ≤92% c. A special note should be made if there is suspicion of COVID-19-related myocarditis or pericarditis, as the presence of these is a stratification criterion 6. Without a significant deterioration in liver function tests: a. ALT and AST ≤ 5x upper limit of normal (ULN) b. Gamma-glutamyl transferase (GGT) ≤ 5x ULN c. Total bilirubin ≤ 5×ULN 7. Willing to participate and able to sign an informed consent form (ICF). Or, when relevant, a legally authorized representative (LAR) might sign the ICF on behalf of the study participant 8. Female participants should be: at least 5 years post-menopausal (i.e., persistent amenorrhea 5 years in the absence of an alternative medical cause) or surgically sterile; OR a. Have a negative urine pregnancy test at screening b. Be willing to use a contraceptive method as outlined in inclusion criterion 9 from screening to 30 days after last dose. 9. Male participants who are sexually active with a female partner must agree to the use of an effective method of birth control throughout the study and until 3 months after the last administration of the investigational product. (Note: medically acceptable methods of contraception that may be used by the participant and/or partner include combined oral contraceptive, contraceptive vaginal ring, contraceptive injection, intrauterine device, etonogestrel implant, each supplemented with a condom, as well as sterilization and vasectomy). 10. Female participants who are lactating must agree not to breastfeed during the study and up to 14 days after the intervention. 11. Male participants must agree not to donate sperm for the purpose of reproduction throughout the study and until 3 months after the last administration of the investigational product. 12. For France only: Being affiliated with a European Social Security. Exclusion criteria 1. Not needing or not willing to remain in a healthcare facility during the study 2. Moribund condition (death likely in days) or not expected to survive for &gt;7 days - due to other and non-COVID-19 related conditions 3. Participant on invasive mechanical ventilation via an endotracheal tube, or extracorporeal membrane oxygenation (ECMO), or high-flow Oxygen (delivery of oxygen at a flow of ≥16 L/min.). 4. Participant is not able to take medications by mouth (as capsules or as a powder, mixed in water). 5. Disallowed concomitant medication: Consumption of any herbal products containing 20-hydroxyecdysone and derived from Leuzea carthamoides; Cyanotis vaga or Cyanotis arachnoidea is not allowed (e.g. performance enhancing agents). 6. Any known hypersensitivity to any of the ingredients, or excipients of the study medication, BIO101. 7. Renal disease requiring dialysis, or known renal insufficiency (eGFR≤30 mL/min/1.73 m2, based on Cockcroft &amp; Gault formula). 8. In France only: a. Non-affiliation to compulsory French social security scheme (beneficiary or right-holder). b. Being under tutelage or legal guardianship. Participants will be recruited from approximately 30 clinical centres in Belgium, France, the UK, USA and Brazil. Maximum patients' participation in the study will last 28 days. Follow-up of participants discharged from hospital will be performed through post-intervention phone calls at 14 (± 2) and 60 (± 4) days. Two treatment arms will be tested in this study: interventional arm 350 mg b.i.d. of BIO101 (AP 20-hydroxyecdysone) and placebo comparator arm 350 mg b.i.d of placebo. Administration of daily dose is the same throughout the whole treatment period. Participants will receive the study medication while hospitalized for up to 28 days or until a clinical endpoint is reached (i.e., 'negative' or 'positive' event). Participants who are officially discharged from hospital care will no longer receive study medication. Primary study endpoint: The proportion of participants with 'negative' events up to 28 days. 'Negative' events are defined as respiratory deterioration and all-cause mortality. For the purpose of this study, respiratory deterioration will be defined as any of the following: Requiring mechanical ventilation (including cases that will not be intubated due to resource restrictions and triage). Requiring extracorporeal membrane oxygenation (ECMO). Requiring high-flow oxygen defined as delivery of oxygen at a flow of ≥16 L/min. Only if the primary endpoint is significant at the primary final analysis the following Key secondary endpoints will be tested in that order: Proportion of participants with events of respiratory failure at Day 28 Proportion of participants with 'positive' events at Day 28. Proportion of participants with events of all-cause mortality at Day 28 A 'positive' event is defined as the official discharge from hospital care by the department due to improvement in participant condition. Secondary and exploratory endpoints: In addition, a variety of functional measures and biomarkers (including the SpO2 / FiO2 ratio, viral load and markers related to inflammation, muscles, tissue and the RAS / MAS pathways) will also be collected. Randomization is performed using an IBM clinical development IWRS system during the baseline visit. Block-permuted randomization will be used to assign eligible participants in a 1:1 ratio. In part 1, randomization will be stratified by RAS pathway modulator use (yes/no) and co-morbidities (none vs. 1 and above). In Part 2, randomization will be stratified by centre, gender, RAS pathway modulator use (yes/no), co-morbidities (none vs. 1 and above), receiving Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) at study entry (Yes/No) and suspicion of COVID-19 related myocarditis or pericarditis (present or not). Participants, caregivers, and the study team assessing the outcomes are blinded to group assignment. All therapeutic units (TU), BIO101 b.i.d. or placebo b.i.d., cannot be distinguished in compliance with the double-blind process. An independent data-monitoring committee (DMC) will conduct 2 interim analyses. A first one based on the data from part 1 and a second from the data from parts 1 and 2. The first will inform about BIO101 safety, to allow the start of recruitment into part 2 followed by an analysis of the efficacy data, to obtain an indication of activity. The second interim analysis will inform about the sample size that will be required for part 2, in order to achieve adequate statistical power. Numbers to be randomised (sample size) Number of participants randomized: up to 465, in total Part 1: 50 (to obtain the proof of concept in COVID-19 patients). Part 2: 310, potentially increased by 50% (up to 465, based on interim analysis 2) (to confirm the effects of BIO101 observed in part 1). The current protocol Version is V 10.0, dated on 24.09.2020. The recruitment that started on September 1<supst</sup 2020 is ongoing and is anticipated to finish for the whole study by March2021. The trial was registered before trial start in trial registries: EudraCT , No. 2020-001498-63, registered May 18, 2020; and Clinicaltrials.gov, identifier NCT04472728 , registered July 15, 2020. The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

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1,2,3-Trichloropropane is a colorless liquid used as a paint and varnish remover, solvent, and degreasing agent, and as a crosslinking agent in the synthesis of polysulfides and hexafluoropropylene. 1,2,3-Trichloropropane may be found as an impurity in certain nematocides and soil fumigants and as a contaminant of drinking and ground water. Studies on the toxic and carcinogenic effects of 1,2,3-trichloropropane were initiated because of the close structural relationship of this chemical to other short-chain halogenated compounds that were demonstrated to be carcinogenic in experimental animals, and because of the potential for human exposure. Toxicology and carcinogenicity studies were conducted by administering 1,2,3-trichloropropane (greater than 99% pure) in corn oil by gavage to groups of F344/N rats and B6C3FI mice for 17 weeks and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium strains, mouse lymphoma cells, and Chinese hamster ovary cells. 17-Week Studies: Groups of 20 male and 20 female rats received 1,2,3-trichloropropane in corn oil by gavage at doses of 8, 16, 32, 63, 125, or 250 mg/kg body weight 5 days per week for up to 17 weeks; 30 male and 30 female rats received corn oil alone and served as controls. Animals were evaluated at 8 or 17 weeks. All rats in the 250 mg/kg groups died by week 5. One male and four female rats in the 125 mg/kg groups died during the study. The mean body weight gains and final mean body weights of males receiving 63 mg/kg and of males and females receiving 125 mg/kg were lower than those of the controls. Hematocrit values, hemoglobin concentrations, and erythrocyte counts decreased with dose in males and females. Serum alanine aminotransferase, aspartate aminotransferase, and sorbitol dehydrogenase activities were significantly increased in some female rats receiving 125 mg/kg. Serum pseudocholinesterase activity decreased with dose in females. Increases in kidney and liver weights were related to chemical administration. The principal toxic lesions associated with the administration of 1,2,3-trichloropropane to rats were hepatocellular necrosis, karyomegaly, and biliary hyperplasia of the liver; renal tubule necrosis, regeneration, and karyomegaly of the kidney; and necrosis and inflammation of the nasal olfactory and respiratory epithelium. Groups of 20 male and 20 female mice received 1,2,3-trichloropropane in corn oil by gavage at doses of 8, 16, 32, 63, 125, or 250 mg/kg 5 days per week for up to 17 weeks; 30 male and 30 female mice received corn oil alone and served as controls. Sixteen male and seven female mice in the 250 mg/kg groups died by week 4. The final mean body weights and mean body weight gains of dosed mice were similar to those of the controls, except those of 250 mg/kg males, which were lower than those of controls. The principal toxic lesions associated with the administration of 1,2,3-trichloropropane were hepatocellular necrosis and karyomegaly of the liver; necrosis, regeneration, and hyperplasia of the bronchiolar epithelium in the lung; and acanthosis (hyperplasia) and hyperkeratosis of the forestomach epithelium. 2-Year Studies: Groups of 60 male and 60 female rats received 0, 3, 10, or 30 mg 1,2,3-trichloropropane/kg body weight in corn oil by gavage 5 days per week for up to 104 weeks. Selection of 30 mg/kg as the high dose in these studies was based on the following chemical-related effects in the 17-week studies: deaths and liver and kidney lesions at 125 and 250 mg/kg and reduced final mean body weights and mean body weight gains at 63 mg/kg or greater. Groups of 60 male and 60 female mice received 0, 6, 20, or 60 mg 1,2,3-trichloropropane/kg body weight in corn oil by gavage 5 days per week for up to 104 weeks. Selection of 60 mg/kg as the high dose was based on chemical-related deaths and lesions of the liver, lung, and forestomach at 125 and 250 mg/kg in the 17-week studies. 15-Month Interim Evaluations: Up to 10 rats and 10 mice from each dose group were evaluated at 15 months. Absolute and relative liver and kidned kidney weights of dosed rats were significantly greater than those of the controls. Chemical-related nonneoplastic lesions and neoplasms of the forestomach, oral mucosa, pancreas (males), kidney, mammary gland (females), preputial gland, and clitoral gland were observed in dosed rats. Chemical-related nonneoplastic lesions and neoplasms of the forestomach and liver (females) were observed in dosed mice. Survival and Body Weight in the 2-Year Studies: Survival of male and female rats receiving 10 or 30 mg/kg 1,2,3-trichloropropane was significantly lower than that of controls. Two-year survival rates of male rats were: control, 34/50; 3 mg/kg, 32/50; 10 mg/kg, 14/49; 30 mg/kg, 0/52; and of females were: 31/50, 30/49, 8/52, 0/52. At 30 mg/kg, survival was markedly reduced due to chemical-related neoplasms, and survivors were killed in weeks 67 (females) or 77 (males). Final mean body weights of 30 mg/kg rats were 13&amp;percnt; lower for males and 12&amp;percnt; lower for females than those of controls; mean body weights of 3 and 10 mg/kg rats were similar to controls. Survival rates of mice receiving 6, 20, or 60 mg/kg 1,2,3-trichloropropane were also significantly lower than those of controls. Two-year survival rates of male mice were: 42/52, 18/51, 0/54, 0/56; and of female mice were: 41/50, 13/50, 0/51, 0/55. Because of reduced survival at 20 and 60 mg/kg due to chemical-related neoplasms, survivors were killed in weeks 73 (60 mg/kg females), 79 (60 mg/kg males), or 89 (20 mg/kg males and females). Final mean body weights were 16&amp;percnt; lower for 60 mg/kg males, 18~ lower for 60 mg/kg females, and 13&amp;percnt; lower for 20 mg/kg males than those of controls. Final mean body weights of 6 mg/kg males and females and 20 mg/kg females were similar to controls. Neoplasms and Nonneoplastic Lesions in the 2-Year Studies: Administration of 1,2,3-trichloropropane to rats induced benign and malignant neoplasms of the oral mucosa (pharynx and tongue), forestomach, and preputial and clitoral glands in males and females; benign neoplasms of the exocrine pancreas and kidney in males, and malignant neoplasms of the mammary gland in females. The incidences of squamous cell papillomas and carcinomas of the oral mucosa were significantly increased in 10 and 30 mg/kg rats, while the incidences of squamous cell papillomas or carcinomas (combined) of the forestomach were significantly increased in all dosed groups. The incidence of pancreatic acinar adenoma was significantly increased in dosed males, but not in dosed females. Similarly, the incidence of adenoma of the kidney was significantly increased in 10 and 30 mg/kg male rats only. The incidences of adenoma or carcinoma (combined) of the preputial gland in 30 mg/kg males and of the clitoral gland in 10 and 30 mg/kg females (homologous organs) were significantly increased. The incidence of adenocarcinoma of the mammary gland was significantly increased in the 10 and 30 mg/kg females. The incidences of Zymbal's gland carcinomas were increased in 30 mg/kg males and females. Adenocarcinomas of the intestine occurred in small numbers of dosed rats and may have been chemical related. In mice, the incidence of squamous cell carcinoma of the oral mucosa was significantly increased only in 60 mg/kg females. In contrast, the incidences of squamous cell papilloma and carcinoma of the forestomach were significantly increased in all groups of dosed mice. The incidences of hepatocellular adenoma or carcinoma (combined) were significantly increased in all dosed groups of males and 60 mg/kg females. The incidences of harderian gland adenoma were significantly increased in 20 mg/kg males and in 60 mg/kg males and females. The incidences of uterine adenoma, adenocarcinoma, and stromal polyp were significantly increased in 60 mg/kg females. Genetic Toxicology: 1,2,3-Trichloropropane was mutagenic in vitro in the presence of S9 metabolic activation. At two laboratories, positive responses were obtained for mutagenicity in Salmonella typhimurium strains TA97, TA98, TA100, and TA1535 in the presence of S9; no mutagenic activity was observed in TA1537, with or without S9. 1,2,3-Trichloropropane induced trifluorothymidine resistance in L5178Y mouse lymphoma cells with, but not without, S9. In cultured Chinese hamster ovary cells, sister chromatid exchanges and chromosomal aberrations were induced by 1,2,3-trichloropropane; however, significant increases in the endpoints of both cytogenetic effects occurred only in the presence of S9. Conclusions: Under the conditions of these 2-year gavage studies, there was clear evidence of carcinogenic activity of 1,2,3-trichloropropane in male F344/N rats based on increased incidences of squamous cell papillomas and carcinomas of the oral mucosa and forestomach, adenomas of the pancreas and kidney, adenomas or carcinomas of the preputial gland, and carcinomas of the Zymbal's gland. Adenomatous polyps and adenocarcinomas of the intestine may have been related to chemical administration. There was clear evidence of carcinogenic activity of 1,2,3-trichloropropane in female F344/N rats based on increased incidences of squamous cell papillomas and carcinomas of the oral mucosa and forestomach, adenomas or carcinomas of the clitoral gland, adenocarcinomas of the mammary gland, and carcinomas of the Zymbal's gland. Adenocarcinomas of the intestine may have been related to chemical administration. There was clear evidence of carcinogenic activity of 1,2,3-trichloropropane in male B6C3F1 mice based on increased incidences of squamous cell papillomas and carcinomas of the forestomach, hepatocellular adenomas or carcinomas of the liver, and harderian gland adenomas. Squamous cell papillomas of the oral mucosa may have been related to chemical administration. There was clear evidence of carcinogenic activity of 1,2,3-trichloropropane in female B6C3F1, mice based on increased incidences of squamous cell carcinomas of the oral mucosa, squamous cell papillomas and carcinomas of the forestomach, hepatocellular adenomas or carcinomas of the liver, harderian gland adenomas, and uterine adenomas, adenocarcinomas, and stromal polyps. Nonneoplastic lesions associated with exposure to 1,2,3-trichloropropane included increased severity of nephropathy in male rats and increased incidences of basal cell and squamous hyperplasia of the forestomach, acinar hyperplasia of the pancreas, renal tubule hyperplasia, and preputial or clitoral gland hyperplasia in male and female rats. Increased incidences of squamous hyperplasia of the forestomach and eosinophilic foci in the liver in male and female mice were chemical related. Synonyms: Allyl trichloride, glycerol tnchlorohydrin, glyceryl tnchlorohydrin, trichlorohydrin

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Because of signs of tuberculous lesions in old skeletons it can be stated with certainty that tuberculosis has occurred in the country shortly after the settlement. From that time and up to the seventeenth century, little or nothing is known about the occurrence of the disease. A few preserved descriptions of diseases and deaths indicate that tuberculosis has existed in the country before the advent of qualified physicians in 1760. On the basis of papers and reports from the first physicians and the first tuberculosis registers the opinions is set forth that the disease has been rare up to the latter part of the nineteenth century. During the two last decades of that century the disease began to spread more rapidly and increased steadily up to the turn of the century. Although reporting of the disease was started in the last decade of the nineteenth century the reporting was first ordered by law with the passage of the first tuberculosis Act in the year 1903. With this legislation official measures for tuberculosis control work really started in the country. The first sanatorium was built in 1910. In 1921 the tuberculosis Act was revised and since then practically all the expenses for the hospitalization and treatment of tuberculous cases has been defrayed by the state. In the year 1935 organized tuberculosis control work was begun and a special physician appointed to direct it. From then on systematic surveys were made, partly in health centers i.e. tuberculosis clinics, which were established in the main towns, and partly by means of transportable X ray units in outlying rural areas of the country. In 1939 the tuberculosis Act was again revised with special reference to the surveys and the activities of the tuberculosis clinics. This act is still in force. Some items of it are described. The procedure of the surveys and the methods of examination are described. The great majority of subjects were tuberculin tested and all positive reactors X rayed. Furthermore, X ray examination was made in all cases where tuberculin examination had not been made or was incomplete. The negative reactors were not X rayed. The tuberculin tests were percutaneous, cutaneous and intracutaneous. The X ray examination during the first years was performed by means of fluoroscopy and roentgenograms were made in all doubtful cases. In 1945 when the survey of the capital city of Reykjavík was made and comprised a total of 43,595 persons photoroentgenograms were made. After 1948 only this method together with tuberculin testing was used in all the larger towns in the country. During the period 1940-1945 such surveys were carried out in 12 medical districts, or parts thereof and included 58,837 persons or 47 percent of the entire population. The attendance in these surveys ranged from 89.3 percent to 100 percent of those considered able to attend. In the capital city, Reykjavík, the attendance was 99.32 percent. The course and prevalence of tuberculosis in Iceland from 1911 to 1970 are traced on the basis of tuberculosis reporting registers, mortality records which were ordered by law in 1911, tuberculin surveys and post mortem examinations. The deficiencies of these sources are pointed out. Since 1939 the morbidity rates are accurate. The number of reported cases of tuberculosis increases steadily up to the year 1935, when 1.6 percent of the population is reported to have active tuberculosis at the end of that year. Thereafter it begins to decline gradually the first years but abruptly in 1939, then without doubt because of the revision of the tuberculosis legislation and more exact reporting regulations. After that year the fall is almost constant with rather small fluctuations as regards new cases, relapses and total number of reported cases remaining on register at the end of each year. In 1950 the new cases are down to 1.6 per thousand and at the end of the year the rate for those remaining on register is 6.9 per thousand. In the year 1954 there is a noteworthy drop both in new cases and the total number reported, doubtless because of the new specific medication which began in 1952. In 1960 the new cases are down to 0.4, relapses 0.2 and the rate for those remaining on register at the end of the year 2.4 per thousand. And in 1970 the rate for the same categories are: new 0.2, relapses 0.06, and remaining at the end of the year 0.5 per thousand. At the beginning of the period, when registration of deaths was initiated, tuberculosis mortality was found to be about 150 per 100,000 population. During the next two decades it increases, irregularly but persistently, to reach a peak of 217 in 1925. It remained high for the next seven years, dropped suddenly to 154 in 1933, and then, apart from a slight temporary increase during the years of the second world war, continued to fall rapidly reaching 20 per 100,000 population in 1950. In the period from 1930-50 the tuberculous death rate thus dropped a little over 90 percent. In the year 1952, when specific tuberculosis medical treatment was initiated (streptomycin, isoniazid and PAS) the death rate dropped to 14 per 100,000 population and the next year further down to 9 and since 1956 it never exceeded 5 per 100,000. From the year 1962 the tuberculosis mortality has never been over 2 per 100,000 population. The mortality rates have been broken down to reveal the role of age and sex specific death rates over some selected five year periods. Also the rates are shown according to different forms of the disease, pulmonary, meningeal and other forms. The highest proportionate mortality (60%) was observed in the 15-19 year age group between 1926 and 1930. From 1911 to 1930 tuberculous meningitis caused a remarkably high number of deaths, fluctuating between 20 and 50 per 100,000 population. Since 1956 not a single death from this form of the disease has occurred. Up to that year the highest meningitis death-rate consistently occurred in infancy and early childhood. Sex-specific tuberculosis death rates indicate that in every age-group the disease is more dangerous to women. Between 1941 and 1945, when the combined mortality-rate began to drop sharply, it was the rate for the males, which was first affected. Due to the very steep decline in tuberculosis mortality especially from 1952 tuberculosis mortality figures can no longer be considered the right criterion for the spread and course of the disease. The infection and morbidity rates are from then on the best measures of the prevalence and course of the disease. Tuberculosis infection-rates obtained through tuberculin testing on a comparatively broad scale, especially in school children 7-13 years of age, show a progressive reduction in tuberculosis infection in the country as a whole. These tuberculin surves on school children were initiated by the district health officers in the second decade of the century and therefore now extend over 60 years. The procedure of the tuberculin surveys and the methods used are mentioned. The shortcomings of these surveys and their importance are discussed. The value of the surveys is considered doubtful as long as the examinations are performed without any guidance or coordination. About the year 1930 the total percentage tuberculin tested in the age group 7-13 years was a little over 10 percent. In the year 1935 the director of tuberculosis control sent all the health officers instructions on how to perform the tuberculin testing together with some encouragement to perform such surveys. That year about 43 percent of the 7-13 years population was tested and in 1945 the percentage was 75. Between 1965 and 1970 the attendance percentage was 85. The tested 7-13 years age group showed in 1935 26.1 percent positive reaction, in 1945 10.1 percent, in 1955 5.3 percent and in 1970 0.7 percent. In 1970 0.2 percent of the 7 years old children reacted positively and 1.1 percent of those 13 years of age. the decline of the infection rate in this age group is remarkable. The very few BCG vaccinated children were excluded from the surveys. In the tuberculosis surveys made in the years 1940-1945, which covered 12 medical districts or parts thereof, extensive tuberculin examinations were performed. The results of these surveys showed that the infection rate was higher among male adults than females. This difference was notable after the age of 15 and especially in isolated and thinly populated rural districts. In urban and more thickly populated rural districts the infection rate was much higher. BCG vaccination was first used in Iceland in 1945. Only few persons were vaccinated in the first two years. In 1948 a systematic vaccination was proposed in the country to supplement the tuberculosis-control plan. The vaccination was particularly meant for the age group 12-29 where the risk of infection appeared to be greatest. However, at the end of the year 1950 a total of only about 6,900 persons had been vaccinated mostly groups of school children, young adults and contacts of tuberculosis cases. Most of the children and adults were born between the years 1929 and 1936 but in none of these years did the vaccination exceed 15 percent of those born in any one of the years concerned. Because of the rapid decline in the tuberculosis infection rate, morbidity and mortality in the country this vaccination plan was abandoned and changed at the end of the year 1950. After that only few groups of people were vaccinated, i.e. tuberculosis contacts, medical students, student nurses, adults studying abroad and persons who asked for vaccination. Between 1950 and 1970 only about 7,000 people have been vaccinated. So the total number of BCG vaccinations up to the end of 1970 has not exceeded 14,000 in the country. Therefore it seems most unlikely that the relatively few BCG vaccinations, given in recent years can be expected to have had much influence in speeding up the downward trend of the disease in the country. (ABSTRACT TRUNCATED)

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It is currently thought that most-but not all-individuals infected with SARS-CoV-2 develop symptoms, but that the infectious period starts on average two days before the first overt symptoms appear. It is estimated that pre- and asymptomatic individuals are responsible for more than half of all transmissions. By detecting infected individuals before they have overt symptoms, wearable devices could potentially and significantly reduce the proportion of transmissions by pre-symptomatic individuals. Using laboratory-confirmed SARS-CoV-2 infections (detected via serology tests [to determine if there are antibodies against the SARS-CoV-2 in the blood] or SARS-CoV-2 infection tests such as polymerase chain reaction [PCR] or antigen tests) as the gold standard, we will determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the following two algorithms to detect first time SARS-CoV-2 infection including early or asymptomatic infection: the algorithm using Ava bracelet data when coupled with self-reported Daily Symptom Diary data (Wearable + Symptom Data Algo; experimental condition) the algorithm using self-reported Daily Symptom Diary data alone (Symptom Only Algo; control condition) In addition, we will determine which of the two algorithms has superior performance characteristics for detecting SARS-CoV-2 infection including early or asymptomatic infection as confirmed by SARS-CoV-2 virus testing. The trial is a randomized, single-blinded, two-period, two-sequence crossover trial. All subjects will participate in an initial Learning Phase (varying from 2 weeks to 3 months depending on enrolment date), followed by two contiguous 3-month test phases, Period 1 and Period 2. Each subject will undergo the experimental condition (the Wearable + Symptom Data Algo) in one of these periods and the control condition (Symptom Only Algo) in the other period. The order will be randomly assigned, resulting in subjects being allocated 1:1 to either Sequence 1 (experimental condition first) or Sequence 2 (control condition first). Based on demographics, medical history and/or profession, each subject will be stratified at baseline into a high-risk and normal-risk group within each sequence. The trial will be conducted in the Netherlands. A target of 20,000 subjects will be enrolled. Based on demographics, medical history and/or profession, each subject will be stratified at baseline into a high-risk and normal-risk group within each sequence. This results in approximately 6,500 normal-risk individuals and 3,500 high-risk individuals per sequence. Subjects will be recruited from previously studied cohorts as well as via public campaigns and social media. All data for this study will be collected remotely through the Ava COVID-RED app, the Ava bracelet, surveys in the COVID-RED web portal, and self-sampling serology and PCR kits. During recruitment, subjects will be invited to visit the COVID-RED web portal ( www.covid-red.eu ). After successfully completing the enrolment questionnaire, meeting eligibility criteria and indicating interest in joining the study, subjects will receive the subject information sheet and informed consent form. Subjects can enrol in COVID-RED if they comply with the following inclusion and exclusion criteria. Resident of the Netherlands At least 18 years old Informed consent provided (electronic) Willing to adhere to the study procedures described in the protocol Must have a smartphone that runs at least Android 8.0 or iOS 13.0 operating systems and is active for the duration of the study (in the case of a change of mobile number, study team should be notified) Be able to read, understand and write Dutch Exclusion criteria: Previous positive SARS-CoV-2 test result (confirmed either through PCR/antigen or antibody tests; self-reported) Previously received a vaccine developed specifically for COVID-19 or in possession of an appointment for vaccination in the near future (self-reported) Current suspected (e.g., waiting for test result) COVID-19 infection or symptoms of a COVID-19 infection (self-reported) Participating in any other COVID-19 clinical drug, vaccine, or medical device trial (self-reported) Electronic implanted device (such as a pacemaker; self-reported) Pregnant at time of informed consent (self-reported) Suffering from cholinergic urticaria (per the Ava bracelet's User Manual; self-reported) Staff involved in the management or conduct of this study INTERVENTION AND COMPARATOR: All subjects will be instructed to complete the Daily Symptom Diary in the Ava COVID-RED app daily, wear their Ava bracelet each night and synchronise it with the app each day for the entire period of study participation. Provided with wearable sensor and/or self-reported symptom data within the last 24 hours, the Ava COVID-RED app's underlying algorithms will provide subjects with a real-time indicator of their overall health and well-being. Subjects will see one of three messages, notifying them that: no seeming deviations in symptoms and/or physiological parameters have been detected; some changes in symptoms and/or physiological parameters have been detected and they should self-isolate; or alerting them that deviations in their symptoms and/or physiological parameters could be suggestive of a potential COVID-19 infection and to seek additional testing. We will assess intraperson performance of the algorithms in the experimental condition (Wearable + Symptom Data Algo) and control conditions (Symptom Only Algo). The trial will evaluate the use and performance of the Ava COVID-RED app and Ava bracelet, which uses sensors to measure breathing rate, pulse rate, skin temperature, and heart rate variability for the purpose of early and asymptomatic detection and monitoring of SARS-CoV-2 in general and high-risk populations. Using laboratory-confirmed SARS-CoV-2 infections (detected via serology tests, PCR tests and/or antigen tests) as the gold standard, we will determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each of the following two algorithms to detect first-time SARS-CoV-2 infection including early or asymptomatic infection: the algorithm using Ava Bracelet data when coupled with the self-reported Daily Symptom Diary data, and the algorithm using self-reported Daily Symptom Diary data alone. In addition, we will determine which of the two algorithms has superior performance characteristics for detecting SARS-CoV-2 infection including early or asymptomatic infection as confirmed by SARS-CoV-2 virus testing. The protocol contains an additional seventeen secondary outcomes which address infection incidence rates, health resource utilization, symptoms reported by SARS-CoV-2 infected participants, and the rate of breakthrough and asymptomatic SARS-CoV-2 infections among individuals vaccinated against COVID-19. PCR or antigen testing will occur when the subject receives a notification from the algorithm to seek additional testing. Subjects will be advised to get tested via the national testing programme, and report the testing result in the Ava COVID-RED app and a survey. If they cannot obtain a test via the national testing programme, they will receive a nasal swab self-sampling kit at home, and the sample will be tested by PCR in a trial-affiliated laboratory. In addition, all subjects will be asked to take a capillary blood sample at home at baseline (Month 0), and at the end of the Learning Phase (Month 3), Period 1 (Month 6) and Period 2 (Month 9). These samples will be used for SARS-CoV-2-specific antibody testing in a trial-affiliated laboratory, differentiating between antibodies resulting from a natural infection and antibodies resulting from COVID-19 vaccination (as vaccination will gradually be rolled out during the trial period). Baseline samples will only be analysed if the sample collected at the end of the Learning Phase is positive, and samples collected at the end of Period 1 will only be analysed if the sample collected at the end of Period 2 is positive. When subjects obtain a positive PCR/antigen or serology test result during the study, they will continue to be in the study but will be moved into a so-called "COVID-positive" mode in the Ava COVID-RED app. This means that they will no longer receive recommendations from the algorithms but can still contribute and track symptom and bracelet data. The primary analysis of the main objective will be executed using data collected in Period 2 (Month 6 through 9). Within this period, serology tests (before and after Period 2) and PCR/antigen tests (taken based on recommendations by the algorithms) will be used to determine if a subject was infected with SARS-CoV-2 or not. Within this same time period, it will be determined if the algorithms gave any recommendations for testing. The agreement between these quantities will be used to evaluate the performance of the algorithms and how these compare between the study conditions. All eligible subjects will be randomized using a stratified block randomization approach with an allocation ratio of 1:1 to one of two sequences (experimental condition followed by control condition or control condition followed by experimental condition). Based on demographics, medical history and/or profession, each subject will be stratified at baseline into a high-risk and normal-risk group within each sequence, resulting in equal numbers of high-risk and normal-risk individuals between the sequences. In this study, subjects will be blinded as to study condition and randomization sequence. Relevant study staff and the device manufacturer will be aware of the assigned sequence. The subject will wear the Ava bracelet and complete the Daily Symptom Diary in the Ava COVID-RED app for the full duration of the study, and they will not know if the feedback they receive about their potential infection status will only be based on data they entered in the Daily Symptom Diary within the Ava COVID-RED app or based on both the data from the Daily Symptom Diary and the Ava bracelet. 20,000 subjects will be recruited and randomized 1:1 to either Sequence 1 (experimental condition followed by control condition) or Sequence 2 (control condition followed by experimental condition), taking into account their risk level. This results in approximately 6,500 normal-risk and 3,500 high-risk individuals per sequence. Protocol version: 1.2, dated January 22<supnd</sup, 2021 Start of recruitment: February 22<supnd</sup, 2021 End of recruitment (estimated): April 2021 End of follow-up (estimated): December 2021 TRIAL REGISTRATION: The trial has been registered at the Netherlands Trial Register on the 18<supth</sup of February, 2021 with number NL9320 ( https://www.trialregister.nl/trial/9320 ) FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

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2-Butoxyethanol is a member of a family of ethylene glycol monoalkyl ethers. It is used extensively as a solvent in surface coatings such as lacquers, enamels, varnishes, and latex paint; in paint thinners, paint stripping formulations, and inks; and in degreasers and industrial and household cleaners. 2-Butoxyethanol was nominated for study because of its widespread use in industrial and consumer applications, the potential for exposure to workers and the general population, and the absence of chronic toxicity data. Male and female F344/N rats and B6C3F1 mice were exposed to 2-butoxyethanol (greater than 99% pure) by inhalation (primary route of human exposure) for 14 weeks or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, cultured Chinese hamster ovary cells, and the bone marrow of male F344/N rats and B6C3F1 mice. 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were exposed to 2-butoxyethanol by inhalation at concentrations of 0, 31, 62.5, 125, 250, or 500 ppm, 6 hours per day, 5 days per week for 14 weeks. One female rat in the 250 ppm group was killed moribund during week 8; four females in the 500 ppm group were killed moribund during week 1 and one during week 5. Final mean body weights of females exposed to 500 ppm were significantly less than those of the chamber controls. Clinical findings included abnormal breathing, pallor, red urine stains, nasal and eye discharge, lethargy, and increased salivation and/or lacrimation. Due to vascular thrombosis and infarction in the tail vertebrae of 500 ppm female rats, the tails became necrotic and either sloughed off or were chewed off. The primary effect on the hematopoietic system was an anemia characterized as macrocytic, normochromic, and regenerative in males exposed to 125 ppm or greater and, to a greater extent, in all exposed groups of females. Compared to the chamber controls, kidney weights of males exposed to 500 ppm and females exposed to 125 ppm or greater and liver weights of males exposed to 250 or 500 ppm and females exposed to 125 ppm or greater were significantly increased, and thymus weights of females exposed to 500 ppm were significantly less. In female rats killed moribund, there was considerable histologic evidence of thrombosis in tissues and organs including the nasal cavity, incisors, liver, lung, and heart. In addition to thrombosis, infarction occurred in the vertebrae of the tail resulting in necrosis and loss of the distal portion of the tail. There were also inflammation, necrosis, and ulceration of the forestomach; necrosis and centrilobular degeneration of the liver; renal tubule degeneration; and atrophy of the spleen and thymus. Exposure-related increases in the incidences of Kupffer cell pigmentation, forestomach inflammation and epithelial hyperplasia, bone marrow hyperplasia, splenic hematopoietic cell proliferation, and renal tubule pigmentation were observed in male and/or female rats surviving to the end of the study. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were exposed to 2-butoxyethanol by inhalation at concentrations of 0, 31, 62.5, 125, 250, or 500 ppm, 6 hours per day, 5 days per week for 14 weeks. Two male and two female mice exposed to 500 ppm died and two males and two females were killed moribund during the first 2 weeks of the study. Final mean body weights of 125, 250, and 500 ppm male mice were significantly less than those of the chamber controls. Clinical findings were observed only in 500 ppm males and females that died or were killed moribund and included abnormal breathing, red urine stains, and lethargy. Hematologic evaluation indicated an anemia that was characterized as normocytic, normochromic, and regenerative in mice exposed to 62.5 ppm or greater; the anemia was more pronounced in females. Liver weights of males exposed to 500 ppm were significantly greater than the chamber controls. In mice either dying early or killed moribund, there were inflammation, necrosis, and ulceration of the forestomach; mediastinal pleura and peritoneal inflammationmmation associated with the forestomach lesions; liver necrosis; renal tubule degeneration; atrophy of the spleen, thymus, and mandibular and mesenteric lymph nodes; and degeneration of the testis. Exposure-related increases in the incidences of hematopoietic cell proliferation and hemosiderin pigmentation of the spleen, Kupffer cell hemosiderin pigmentation of the liver, inflammation and epithelial hyperplasia of the forestomach, and renal tubule hemosiderin pigmentation occurred in male and/or female mice surviving to the end of the study. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female rats were exposed to 2-butoxyethanol by inhalation at concentrations of 0, 31.2, 62.5, or 125 ppm, 6 hours per day, 5 days per week for 104 weeks. For hematology and bone marrow analyses, additional groups of 27 male and 27 female rats were exposed to 0, 62.5, or 125 ppm for evaluation at 3, 6, and 12 months and nine male and nine female rats were exposed to 31.2 ppm for evaluation at 3 (hematology only) and 6 months. Survival and Body Weights: Survival of exposed male and female rats was similar to the chamber control groups. The mean body weights of females exposed to 125 ppm were generally less than the chamber control group. Hematology and Bone Marrow Cellularity: The most consistent exposure-related effect on the hematopoietic system was an exposure concentration-related mild macrocytic, normochromic, regenerative anemia present at 3, 6, and 12 months, with females more affected than males. Significant increases in bone marrow cellularity and decreases in the myeloid/erythroid ratio relative to the chamber controls were observed at all time points in females exposed to 125 ppm, and a decrease in the myeloid/erythroid ratio was observed in males exposed to 125 ppm at 12 months. Pathology Findings: The incidence of benign or malignant pheochromocytoma (combined) of the adrenal medulla in females exposed to 125 ppm was not significantly increased compared to the chamber controls but exceeded the historical control range. Exposure-related increases in the incidences of hyaline degeneration of the olfactory epithelium and Kupffer cell pigmentation of the liver were observed in male and female rats. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice were exposed to 2-butoxyethanol by inhalation at concentrations of 0, 62.5, 125, or 250 ppm, 6 hours per day, 5 days per week for 104 weeks. For hematology and bone marrow analyses, additional groups of 30 male and 30 female mice were exposed to 0, 62.5, 125, or 250 ppm for evaluation at 3, 6, and 12 months. Survival and Body Weights: Survival of male mice exposed to 125 or 250 ppm was significantly less than that of the chamber control group. The mean body weights of exposed males were generally less than those of the chamber control group during the last 6 months of the study. The mean body weights of exposed female mice were less than those of the chamber control group; the reductions were greater and occurred earlier than those observed in males. Hematology: The most consistent exposure-related effect on the hematopoietic system was an exposure concentration-related minimal normocytic, normochromic, regenerative anemia present at 3, 6, and 12 months, with females affected slightly more than males. Pathology Findings: In females exposed to 250 ppm, incidences of forestomach squamous cell papilloma and squamous cell papilloma or carcinoma (combined) were significantly increased relative to the chamber controls, and these incidences exceeded the ranges in historical chamber controls. In 2-butoxyethanol exposed males, there were possible exposure-related increases in the incidences of squamous cell papilloma of the forestomach, although the increases were not significant and the incidences were within the historical control range for chamber controls. Accompanying these neoplasms in females and, to a lesser extent, in males were exposure-related increases in the incidences of ulcer and epithelial hyperplasia of the forestomach. In male mice exposed to 250 ppm, the incidence of hemangiosarcoma of the liver was significantly increased relative to chamber controls and exceeded the range in historical controls; in addition, there were possible exposure-related increases in the incidence of hepatocellular carcinoma. Incidences of hemosiderin pigmentation in the Kupffer cells were significantly increased in 125 and 250 ppm males and all exposed groups of females. The incidences of splenic hematopoietic cell proliferation and hemosiderin pigmentation were generally increased in males and females, and the incidences of bone marrow hyperplasia were increased in males. The incidences of hyaline degeneration of the olfactory and respiratory epithelia of the nose were increased in female mice. GENETIC TOXICOLOGY: 2-Butoxyethanol did not induce mutations in any of the S. typhimurium strains tested, with or without induced hamster or rat liver S9. 2-Butoxyethanol induced cycle delay but did not induce either sister chromatid exchanges or chromosomal aberrations in cultured Chinese hamster ovary cells with or without S9. 2-Butoxyethanol did not induce micronuclei in bone marrow cells of male rats or mice administered the chemical by intraperitoneal injection three times at 24-hour intervals. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was no evidence of carcinogenic activity of 2-butoxyethanol in male F344/N rats exposed to 31.2, 62.5, or 125 ppm. There was equivocal evidence of carcinogenic activity of 2-butoxyethanol in female F344/N rats based on the increased combined incidences of benign or malignant pheochromocytoma (mainly benign) of the adrenal medulla. There was some evidence of carcinogenic activity of 2-butoxyethanol in male B6C3F1 mice based on increased incidences of hemangiosarcoma of the liver. A marginal increase in the incidences of forestomach squamous cell papilloma and an increase in the incidences of hepatocellular carcinoma may have been exposure related. There was some evidence of carcinogenic activity of 2-butoxyethanol in female B6C3F1 mice based on increased incidences of fore stomach squamous cell papilloma or carcinoma (mainly papilloma). Increased incidences of forestomach neoplasms in male and female mice occurred in groups in which ulceration and hyperplasia were also present. Exposure to 2-butoxyethanol caused a mild regenerative anemia and effects secondary to the anemia. Synonyms: 2-Butoxy-1-ethanol; m-butyl ether; butyl glycol; ethylene glycol monobutyl ether Trade name: Butyl Cellosolve

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Bromodichloromethane is a by-product of the chlorination of drinking water. It is formed by the halogen substitution and oxidation reactions of chlorine and naturally occurring organic matter (e.g., humic or fluvic acids) in water containing bromide. Bromodichloromethane was nominated to the NTP by the United States Environmental Protection Agency for toxicology and carcinogenicity studies. Male and female Tg.AC hemizygous mice received bromodichloromethane (at least 98%pure) by dermal application for 26 or 39 weeks, in drinking water for 26 or 42 weeks, or by gavage for 26 or 41 weeks. p53 Haploinsufficient mice received bromodichloromethane in drinking water for 26 or 42 weeks or by gavage for 26 or 41 weeks. Genetic toxicology studies were conducted in mouse peripheral blood erythrocytes. 26- and 39-WEEK DERMAL STUDIES IN Tg.AC HEMIZYGOUS MICE: Groups of 15 male and 15 female Tg.AC hemizygous mice were dermally administered 0, 64, 128, or 256 mg bromodichloromethane/kg body weight in acetone, 5 days per week for 26 weeks, and groups of 10 male and 10 female Tg.AC hemizygous mice were dermally administered the same doses 5 days per week for 39 weeks. The survival and mean body and organ weights of all dosed groups of males and females were similar to those of the vehicle controls. There were no statistically or biologically significant increases in the incidences of neoplasms or nonneoplastic lesions. 26- AND 42-WEEK DRINKING WATER STUDIES IN TG.AC HEMIZYGOUS MICE: Groups of 15 male and 15 female Tg.AC hemizygous mice were exposed to drinking water containing 0, 175, 350, or 700 mg/L bromodichloromethane for 26 weeks (equivalent to average daily doses of approximately 20, 36, or 61 mg bromodichloromethane/kg body weight to males and 31, 61, or 130 mg/kg to females). The survival of exposed males and females was similar to that of the control groups. Mean body weights of males exposed to 350 or 700 mg/L were less than those of the controls during most of the study. Mean body weights of 175, 350, and 700 mg/L females were greater than those of the controls after weeks 10, 22, and 23, respectively. In exposed males, water consumption declined with increasing exposure concentration. Water consumption by exposed females was less at the beginning of the study, but was similar to that by controls at the end of the study. The decreased water consumption was related to poor palatability. Absolute heart and right kidney weights of exposed males were significantly less than those of the control group. The incidences of hepatocyte fatty change and hypertrophy in 350 and 700 mg/L females and cytoplasmic vacuolization in 700 mg/L females were significantly greater than those in the control group. Incidences of renal tubule dilatation in males exposed to 175 mg/L or greater, renal tubule hypertrophy in 350 and 700 mg/L males, and nephropathy and renal tubule degeneration in 700 mg/L males were also increased. Groups of 10 male and 10 female Tg.AC hemizygous mice were exposed to drinking water containing 0, 175, 350, or 700 mg/L bromodichloromethane for 42 weeks (equivalent to average daily doses of approximately 18, 33, or 64 mg/kg to males and 28, 49, or 111 mg/kg to females). The survival of exposed males and females was similar to that of the control groups. Mean body weights of 350 and 700 mg/L males were less than those of the controls at the end of the study. Due to poor palatability, water consumption decreased with increasing exposure concentration. Absolute right kidney weights of 350 and 700 mg/L males were significantly less than those of the control group. The incidences of hepatocyte fatty change in all exposed groups of females, renal tubule dilatation in all exposed groups of males, and nephropathy in 700 mg/L males were significantly increased. 26- AND 41-WEEK GAVAGE STUDIES IN TG.AC HEMIZYGOUS MICE: Groups of 15 male and 15 female Tg.AC hemizygous mice were administered 0, 25, 50, or 100 mg bromodichloromethane/kg body weight in corn oil by gavage, 5 days per week for 26 weeks. The survival of dosed males and females was similar to that of the vehicle control groups. Mean body weights of dosed females were generally greater than those of the vehicle controls at the end of the study. The incidence of multiple squamous cell papilloma of the forestomach in 100 mg/kg females was significantly greater than that in the vehicle controls. The incidences of hepatocyte fatty change in all dosed groups of females, hepatocyte cytoplasmic vacuolization in 25 and 50 mg/kg females, renal tubule hypertrophy in 100 mg/kg females, and renal tubule degeneration in 100 mg/kg males were significantly increased. Groups of 10 male and 10 female Tg.AC hemizygous mice were administered 0, 25, 50, or 100 mg/kg in corn oil by gavage, 5 days per week for 41 weeks. The survival of dosed males and females was similar to that of the control groups. Mean body weights of 25 mg/kg males and 100 mg/kg females were greater than those of the vehicle controls at the end of the study. The incidences of multiple squamous cell papilloma of the forestomach in 25 and 100 mg/kg females and of all squamous cell papillomas of the forestomach in 100 mg/kg females were significantly greater than those of the vehicle controls. The incidences of hepatocyte cytoplasmic vacuolization in 50 mg/kg females and hepatocyte fatty change in 50 and 100 mg/L females were significantly increased; the incidences of renal tubule degeneration in 100 mg/kg males was also significantly greater than that in the vehicle control group. 26- AND 42-WEEK DRINKING WATER STUDIES IN P53 HAPLOINSUFFICIENT MICE: Groups of 15 male and 15 female p53 haploinsufficient mice were exposed to drinking water containing 0, 175, 350, or 700 mg/L bromodichloromethane for 26 weeks (equivalent to average daily doses of approximately 16, 31, or 65 mg/kg to males and 26, 50, or 100 mg/kg to females). The survival of exposed males and females was similar to that of the control groups. Mean body weights of 350 and 700 mg/L males were less than those of the controls throughout most of the study. Mean body weights of 175, 350, and 700 mg/L females were less than control body weights after weeks 15, 23, and 18, respectively. In exposed males, water consumption declined with increasing exposure concentration. Water consumption by exposed females was similar to that by controls by the end of the study. The absolute heart weight of 700 mg/L males and absolute right kidney and liver weights of 350 and 700 mg/L males were significantly less than those of the control group. The incidences of renal tubule dilatation in all exposed groups of males, renal tubule degeneration in 350 and 700 mg/L males, and the incidence of fatty change in hepatocytes of 700 mg/L females were significantly greater than those in the control groups. Groups of 10 male and 10 female p53 haploinsufficient mice were exposed to drinking water containing 0, 175, 350, or 700 mg/L for 42 weeks (equivalent to approximately 14, 30, or 55 mg/kg to males and 22, 43, or 98 mg/kg to females). The survival of exposed males and females was similar to that in the control groups. Mean body weights of males exposed to 350 or 700 mg/L were less than those of the controls. Mean body weights in 700 mg/L females were less during the last three weeks of the study. Water consumption by exposed males was less than that by controls. The absolute right kidney weights in 350 and 700 mg/L males were significantly less than those of the control group. The incidences of renal tubule degeneration in 350 and 700 mg/L males were significantly greater than that in the control group. 26- AND 41-WEEK GAVAGE STUDIES IN P53 HAPLOINSUFFICIENT MICE: Groups of 15 male and 15 female p53 haploinsufficient mice were administered 0, 25, 50, or 100 mg bromodichloromethane/kg body weight in corn oil by gavage for 26 weeks. The survival of dosed males and females was similar to that of the vehicle control groups. The mean body weights of males administered 50 or 100 mg/kg and females administered 50 mg/kg were less than those of the vehicle controls during most of the study. The absolute heart, right kidney, and right testis weights in 100 mg/kg males were significantly less than those of the vehicle controls. The absolute liver weight of 100 mg/kg females was significantly greater. The incidences of fatty change in hepatocytes of 100 mg/kg females and renal tubule degeneration in 100 mg/kg males were significantly greater than those in the vehicle control groups. Groups of 10 male and 10 female p53 haploinsufficient mice were administered 0, 25, 50, or 100 mg/kg in corn oil by gavage for 41 weeks. The survival of dosed males and females was similar to that of the vehicle control groups. Mean body weights of 50 and 100 mg/kg males were less than those of the vehicle controls throughout the study and those of 25, 50, and 100 mg/kg females were less after weeks 9, 14, and 24, respectively. The absolute liver weight of 100 mg/kg females was increased with respect to the vehicle controls, and the absolute heart and right kidney weights of 100 mg/kg males were decreased. The incidences of hepatocyte fatty change in 100 mg/kg males and females and renal tubule degeneration and nephropathy in 100 mg/kg males were significantly greater than those in the vehicle controls. Peripheral blood micronucleus tests on male and female Tg.AC hemizygous and p53 haploinsufficient mice exposed to bromodichloromethane in drinking water, by dermal application, and by gavage for 26 weeks yielded mixed results but no clearly positive responses. Results in Tg.AC hemizygous mice were judged to be equivocal for both males and females in the drinking water study, equivocal in males and negative in females treated by dermal application, and negative in males and females treated by gavage. (ABSTRACT TRUNCATED)

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Tetralin is used as an industrial solvent primarily for naphthalene, fats, resins, oils, and waxes; as a solvent and stabilizer for shoe polishes and floor waxes; as a solvent for pesticides, rubber, asphalt, and aromatic hydrocarbons (e.g., anthracene); as a dye solvent carrier in the textile industry; as a substitute for turpentine in lacquers, paints, and varnishes; in paint thinners and as a paint remover; in alkali-resistant lacquers for cleaning printing ink from rollers and type; as a constituent of motor fuels and lubricants; for the removal of naphthalene in gas distribution systems; and as an insecticide for clothes moths. Tetralin was nominated by the National Cancer Institute for carcinogenicity and disposition studies because of its structure, high production volume, and high potential for worker and consumer exposure. Male and female F344/N rats and B6C3F1 mice were exposed to tetralin (at least 97% pure) by inhalation for 2 weeks, 3 months, or 2 years; male NCI Black Reiter (NBR) rats were exposed to tetralin by inhalation for 2 weeks. Male NBR rats do not produce 2u-globulin; the NBR rats were included to study the relationship of 2u-globulin and renal lesion induction. Genetic toxicology studies were conducted in Salmonella typhimurium, Escherichia coli, and mouse peripheral blood erythrocytes. 2-WEEK STUDY IN RATS: Groups of five male (F344/N and NBR) and five female (F344/N) rats were exposed to tetralin at air concentrations of 0, 7.5, 15, 30, 60, or 120 ppm, 6 hours plus T90 (12 minutes) per day, 5 days per week for 12 exposures. All rats survived to the end of the studies. The final mean body weight of female rats exposed to 120 ppm and mean body weight gains of female rats exposed to 30 ppm or greater were significantly less than those of the chamber controls. Final mean body weights of exposed groups of male NBR rats and mean body weight gains of all exposed groups of male rats were significantly less than those of the chamber controls. Dark-stained urine was observed in all 120 ppm rats. Squinting, weeping, or matted fur around the eyes were noted in the majority of F344/N rats exposed to 120 ppm. The 2u-globulin concentrations in the kidney of male F344/N rats were significantly greater in all exposed groups than in the chamber control group. The absolute kidney weight of 60 ppm females and the relative kidney weights of male F344/N rats exposed to 30 ppm or greater and female rats exposed to 15 ppm or greater were significantly increased. The absolute liver weight of 120 ppm NBR male rats and the relative liver weights of male and female rats exposed to 60 or 120 ppm were significantly increased. In the nose, the incidences of mononuclear cell cellular infiltration were generally significantly increased in all exposed groups of rats, and incidences of olfactory epithelium degeneration and glandular hypertrophy occurred in all male F344/N rats exposed to 120 ppm. 2-WEEK STUDY IN MICE: Groups of five male and five female mice were exposed to tetralin at air concentrations of 0, 7.5, 15, 30, 60, or 120 ppm, 6 hours plus T90 (12 minutes) per day, 5 days per week for 13 exposures. All mice survived to the end of the study. Mean body weights of male and female mice were similar to those of the chamber controls. Dark-stained urine was observed in most of the exposed mice. The absolute and relative liver weights of 60 and 120 ppm males and 30 and 120 ppm females and the relative liver weights of 60 ppm females were significantly greater than those of the chamber controls. In the nose, the incidences of olfactory epithelium atrophy were significantly increased in 60 and 120 ppm males and females. Glandular dilatation occurred in all 120 ppm females, and glandular hyperplasia occurred in all 120 ppm males and females. 3-MONTH STUDY IN RATS: Groups of 10 male and 10 female rats were exposed to tetralin at air concentrations of 0, 7.5, 15, 30, 60, or 120 ppm, 6 hours plus T90 (12 minutes) per day, 5 days per week for 14 weeks. The same exposure concentrations were given to additional groups of 10 male and 10 female clinical pathology study rats for up to 6 weeks and five male renal toxicity rats for 2 weeks. All rats survived to the end of the study. During the first 4 weeks of exposure, dark-stained urine was observed in the catch pans of rats exposed to 30, 60, or 120 ppm. Tetralin induced a minimal decrease in the erythron in both sexes that resulted in a hematopoietic response. Tetralin increased urine aspartate aminotransferase and urine lactate dehydrogenase activities (males and females) and glucose/creatinine ratio (males), suggestive of renal injury. The absolute kidney weights of 60 and 120 ppm females and the relative kidney weights of males and females exposed to 15 ppm or greater were significantly greater than those of the chamber controls. Concentrations of 2u-globulin in the kidney of exposed male rats were generally greater than those of the chamber controls at all time points and greater at 6 and 14 weeks than at 2 weeks. There were significantly increased incidences of olfactory epithelium necrosis in rats exposed to 30 ppm or greater and of olfactory epithelium regeneration in 60 and 120 ppm rats. 3-MONTH STUDY IN MICE: Groups of 10 male and 10 female mice were exposed to tetralin at air concentrations of 0, 7.5, 15, 30, 60, or 120 ppm, 6 hours plus T90 (12 minutes) per day, 5 days per week for 14 weeks. All mice survived to the end of the study. Mean body weights of 120 ppm males were significantly less than those of the chamber controls. Dark-stained urine was observed in the catch pans of mice exposed to 30, 60, or 120 ppm during the first month of the study. Tetralin induced a minimal decrease in the erythron in both sexes that resulted in a hematopoietic response. The relative liver weights of 120 ppm males and 30 ppm or greater females were significantly greater than those of the chamber controls. Incidences of olfactory epithelium metaplasia in 60 and 120 ppm males and females, respiratory epithelium hyaline droplet accumulation in 120 ppm males and 60 and 120 ppm females, cytoplasmic eosinophilic granules within the transitional epithelium lining the urinary bladder in all exposed groups of males and females, and ovarian atrophy and uterine atrophy in 60 and 120 ppm females were significantly increased. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female rats were exposed to tetralin at air concentrations of 0, 30, 60, or 120 ppm, 6 hours plus T90 (12 minutes) per day, 5 days per week for 105 weeks. Additional groups of five male and five female rats were exposed to the same concentrations for 12 months. Survival of all exposed groups of rats was similar to that of the chamber controls. Mean body weights of 120 ppm females were 6% less than those of the chamber controls after week 29. Dark-stained urine was observed in all exposed groups of rats. Creatinine-adjusted levels of all urinary metabolites increased with increasing exposure concentration in males and females. In the standard evaluation of the kidney, there were slightly increased incidences of cortical renal tubule adenoma in male rats. In the combined analysis of single and step sections, the incidence of cortical renal tubule adenoma was significantly increased in the 120 ppm group. In the combined analysis, there was also a significantly increased incidence of renal tubule hyperplasia in the 120 ppm group. In 120 ppm males in the standard evaluation, the severity of chronic nephropathy was increased and the incidence of transitional epithelial hyperplasia in the renal pelvis was significantly increased. Three hepatocellular adenomas occurred in 120 ppm females, and one hepatocellular carcinoma each was observed in the 60 and 120 ppm groups. The incidences of uterine stromal polyp and endometrium hyperplasia were significantly increased in 120 ppm females. Incidences of interstitial cell adenoma and germinal epithelium atrophy of the testis in 30 and 120 ppm males were significantly greater than those in the chamber controls. The incidences of olfactory epithelium degeneration, metaplasia, basal cell hyperplasia, suppurative inflammation, and mineralization (except 30 ppm females) in the nose were significantly increased in all exposed groups of rats. The incidences of glandular dilatation were significantly increased in 120 ppm males and all exposed groups of females. The incidences of respiratory epithelium chronic inflammation were significantly increased in males exposed to 60 or 120 ppm and all exposed groups of females. The incidences of lens cataract in 120 ppm females were significantly increased. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice were exposed to tetralin at air concentrations of 0, 30, 60, or 120 ppm, 6 hours plus T90 (12 minutes) per day, 5 days per week for 105 weeks. Additional groups of five male and five female mice were exposed to the same concentrations for 12 months. Survival of 60 and 120 ppm female mice was significantly greater than that of the chamber controls. The mean body weights of all exposed groups of male and female mice were similar to those of the chamber controls by the end of the study. Dark-stained urine was observed in all exposed groups of male mice and in females exposed to 60 or 120 ppm. Creatinine-adjusted levels of all urinary metabolites increased with increasing exposure concentration in males and females. The incidence of hemangiosarcoma of the spleen was increased in 120 ppm females and exceeded the historical control range for inhalation studies. The incidences of olfactory epithelium atrophy, respiratory metaplasia, glandular hyperplasia, and suppurative inflammation in exposed groups of mice were significantly greater than those in the chamber controls. Transitional epithelium cytoplasmic eosinophilic granules were present in the urinary bladder of all exposed mice. (ABSTRACT TRUNCATED)

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5,5-Diphenylhydantoin and its sodium salt are primarily used in the treatment of grand mal and psychomotor seizures, often in combination with other anticonvulsants, including phenobarbital. 5,5-Diphenylhydantoin is a suspected human carcinogen and was one of three compounds selected by the NTP to investigate the potential value of perinatal exposures in assessing chemical carcinogenicity. Chronic toxicity and carcinogenicity studies of 5,5-diphenylhydantoin were conducted in male and female F344/N rats and B6C3F1 mice. The studies were designed to determine the following: a) the effects of 5,5-diphenylhydantoin in the diet given to rats and mice during the adult (F1) period only (a typical carcinogenicity study), b) the toxic and carcinogenic effects of 5,5-diphenylhydantoin in rats and mice receiving perinatal (F0) exposure only (dietary exposure of dams prior to breeding and throughout gestation and lactation), and c) the effects of combined perinatal and adult exposure to 5,5-diphenylhydantoin. Genetic toxicology studies were conducted in Salmonella typhimurium, mouse Iymphoma cells, cultured Chinese hamster ovary cells, Drosophila melanogaster, and mouse bone marrow cells. STUDIES IN F344/N RATS: A 13-week toxicity study was conducted to select the exposure levels for adults in the 2-year study. The exposure levels for the 13-week study ranged from 300 to 4,800 ppm 5,5-diphenylhydantoin in the diet. The final mean body weights of males and females exposed to 2,400 or 4,800 ppm were significantly decreased. All groups showed a net weight gain over the study period, although the mean body weight gain of females in the 4,800 ppm group was only one-half that of the controls. Feed consumption also decreased with increasing exposure level. No chemical-related gross lesions were present in the tissues of exposed rats. Microscopically, centrilobular hypertrophy of hepatocytes was observed in the liver of rats in the 4,800 ppm groups. Based on these results, 2,400 ppm was selected as the highest exposure for the adult-only portion of the 2-year carcinogenicity study. A gestational study was performed to select the exposure levels for the perinatal portion of the 2-year study. The exposure levels ranged from 80 to 2,400 ppm 5,5-diphenylhydantoin in the diet of the dams. The 2,400 ppm exposure level was found to have reproductive and embryotoxic effects, as none of the sperm-positive females delivered litters. In the 800 ppm group, a greater number of pups died between postnatal day 1 and day 28 than in the control group. No gross external malformations were observed among fetuses or pups surviving to term in any exposure group, and no gross or histopathologic lesions were observed in the animals exposed to 800 ppm for 4 weeks following weaning. Based on these results, 630 ppm was selected as the highest exposure level for the perinatal portion of the 2-year carcinogenicity study. The eight F0:F1 exposure combinations selected for the 2-year study are listed in the table (contained in full report - page 6). In the 2-year study, male and female rats in the 630:2,400 ppm groups evaluated at 9 months had increased relative liver weights. Hematologic evaluations indicated mild but consistent chemical-related increases in erythrocyte and platelet counts in male and female rats. Mild decreases in triglyceride concentrations and alanine aminotransferase enzyme activity were seen generally in the high-exposure groups. In the 2-year study, the survival of exposed rats was similar to that of the controls. However, body weights of exposed rats were lower than those of the controls, and body weights were 11% to 35~ lower in rats receiving adult exposure of 2,400 ppm 5,5-diphenylhydantoin. Feed consumption was similar for exposed and control groups. Hepatocellular neoplasms, primarily adenomas, occurred with a positive trend in male rats fed 5,5-diphenylhydantoin only as adults (0:0 ppm, 0/50; 0:800 ppm, 2/50; 0:2,400 ppm, 4/50). There were no increased neoplasm incidences at other sites in exposed males or at any site in exposed females.emales. Perinatal-only or combined perinatal and adult exposure to 5,5-diphenylhydantoin did not enhance the overall incidences of liver neoplasms in male or female rats. However, the finding of 5/49 hepatocellular adenomas in the 630:2,400 male rat group was consistent with the marginally elevated liver neoplasm rate observed in the 0:2,400 group. Decreased incidences of a number of different neoplasms in exposed groups were most likely related to the lower body weights. STUDIES IN B6C3F1 MICE: A 13-week toxicity study was conducted to select the exposure levels for adults in the 2-year study. The exposure levels for the 13-week study ranged from 75 to 1,200 ppm 5,5-diphenylhydantoin in the diet. With the exception of one male, all mice exposed to 1,200 ppm died before the end of the study. No other chemical-related deaths occurred. All groups of mice except the 1,200 ppm groups gained weight over the 13-week period; however, an exposure related decrease in body weight gain was seen in males and females. Feed consumption by exposed and control groups was generally similar. Chemical related histomorphologic lesions were present in the liver of exposed mice, particularly 600 ppm males, and consisted of centrilobular hypertrophy of hepatocytes. Females appeared to be less sensitive than males to the effects of 5,5-diphenylhydantoin on growth and on histomorphologic liver lesions. Based on these results, 300 ppm (males) and 600 ppm (females) were selected as the highest exposure levels for the adult-only portion of the 2-year carcinogenicity study. A gestational study was performed to select the exposure levels for the perinatal portion of the 2-year study. The exposure levels for males and females ranged from 20 to 600 ppm 5,5-diphenylhydantoin in the diet. In general, reproductive performance and maternal care were poor in all groups, including the controls, thus restricting the sample size and sensitivity of this evaluation. There were no litters in the 600 ppm group, and maternal weight gain was depressed. There were no gross external malformations among pups surviving to term, and no gross or histopathologic lesions were observed in any mice exposed for 4 weeks following weaning. Based on these results, 210 ppm was selected as the highest exposure level for the perinatal portion of the 2-year carcinogenicity study. The F0:F1 exposure combinations selected for the 2-year study are listed in the following table (contained in full report - page 7). For mice evaluated at 9 months, males and females receiving the highest F0:F1 exposure levels had increased relative liver weights. In the 2-year study, the survival of exposed animals was similar to that of the controls; however, body weights were lower for exposed groups, and decreased body weights were most severe in adult females receiving 600 ppm 5,5-diphenylhydantoin. Feed consumption was similar for exposed and control groups. The incidences of hepatocellular neoplasms were increased in female mice receiving adult-only exposure (0:0 ppm, 5/48; 0:200 ppm, 14/49; 0:600 ppm, 30/50) or combined perinatal and adult exposure (210:200 ppm, 16/50; 210:600 ppm, 34/50). A marginally increased incidence of liver neoplasms (12/49) occurred in females in the perinatal-only (210:0) exposure group. There were no chemical-related increased incidences of liver neoplasms in males receiving adult-only or perinatal-only exposure. However, males receiving the high-exposure combined perinatal and adult exposure regimen (210:300 ppm) had an increased incidence of liver neoplasms (41/50) compared to the 0:0 (29/50), 0:300 (26/49), and 210:0 (33/50) groups. As a result, there was a significant enhancement (interaction) associated with combined perinatal and adult exposure. Such enhancement of neoplasia did not occur in female mice. Decreased incidences of malignant neoplasms in exposed groups were most likely related to the lower body weights. GENETIC TOXICOLOGY: In general, tests for genotoxic activity of 5,5-diphenylhydantoin were negative. All in vitro testing was performed in the presence and the absence of exogenous metabolic activation (S9). 5,5-Diphenylhydantoin did not induce mutations in Salmonella typhimurium, in L5178Y mouse Iymphoma cells, or in germ cells of male Drosophila melanogaster, nor did it induce chromosomal aberrations in cultured Chinese hamster ovary cells. A small but statistically significant increase was obtained in the cultured Chinese hamster ovary cell test for induction of sister chromatid exchanges in the presence of S9; without S9, no increase in sister chromatid exchanges was observed. In vivo, 5,5-diphenylhydantoin did not induce micronuclei polychromatic erythrocytes or chromosomal aberrations in bone marrow cells of male mice; equivocal results were obtained in an in vivo test for induction of sister chromatid exchanges in mouse bone marrow cells. CONCLUSIONS: Adult-Only Exposure: Under the conditions of these 2-year, adult-only, dietary exposure studies, there was equivocal evidence of carcinogenic activity of 5,5-diphenylhydantoin in male F344/N rats based on marginally increased incidences of hepatocellular neoplasms. There was no evidence of carcinogenic activity of 5,5-diphenylhydantoin in female F344/N rats given 240, 800, or 2,400 ppm. There was no evidence of carcinogenic activity of 5,5-diphenylhydantoin in male B6C3F1 mice given 30,100, or 300 ppm. There was clear evidence of carcinogenic activity of 5,5-diphenylhydantoin in female B6C3F1 mice based on increased incidences of hepatocellular neoplasms. Perinatal-Only Exposure: Perinatal exposure alone (through dietary administration of 210 ppm 5,5-diphenylhydantoin during the perinatal period) caused a marginal increase in the incidences of hepatocellular neoplasms in female B6C3F1 mice evaluated 2 years after cessation of exposure. In male and female F344/N rats, exposure to 630 ppm during the perinatal period did not influence the incidences of hepatocellular or other neoplasms. Similarly, exposure of male B6C3F1 mice to dietary levels of 210 ppm 5,5-diphenylhydantoin during the perinatal period did not affect neoplasm incidences. No teratologic effects were observed. Combined Perinatal and Adult Exposure: Combined perinatal and adult dietary exposure to 5,5-diphenylhydantoin confirmed the findings of the increased incidences of hepatocellular neoplasms for adult-only exposures in male F344/N rats and female B6C3F1 mice, although combined exposure did not enhance these neoplastic effects. However, in male B6C3F1 mice, combined perinatal and adult exposure resulted in increased incidences of hepatocellular neoplasms (hepatocellular carcinomas and multiple adenomas) that were not seen when dietary exposure was limited to the adult exposure period only. Synonyms: Diphenylhydantoin; 5,5-diphenyl-2,4-imidazolidinedione Trade names: Difhydan; Dihycon; Di-Hydan; Di-Lan; Dilabid; Dilantin; Ekko; Hydantol; Lehydan; Zentropil

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Kava beverages, made from dried roots of the shrub Piper methysticum, have been used ceremonially and socially in the South Pacific and in Europe since the 1700s. The drink is reported to have pleasant mild psychoactive effects, similar to alcoholic beverages. In the United States, kava kava is an herbal product used extensively as an alternative to anti-anxiety drugs such as Xanax and Valium. It has also been reported as being used to help children with hyperactivity and as a skin-conditioning agent in cosmetics. Kava kava was nominated by the National Cancer Institute for study because of its increasing use as a dietary supplement in the mainstream United States market and reports of liver toxicity among humans. Male and female F344/N rats and B6C3F1 mice received kava kava extract in corn oil by gavage for 2 weeks, 3 months, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, Escherichia coli, and mouse peripheral blood erythrocytes. 2-WEEK STUDY IN RATS: Groups of five male and five female rats were administered kava kava extract in corn oil by gavage at doses of 0, 0.125, 0.25, 0.5, 1.0, or 2.0 g/kg body weight, 5 days per week for 16 days. One female rat administered 2.0 g/kg kava kava extract died on day 3 of the study. Mean body weights of all dosed groups of rats were similar to those of the vehicle controls. Clinical findings included abnormal breathing, ataxia, and lethargy in the 2.0 g/kg groups of males and females and ataxia and lethargy in the 1.0 g/kg group of females. Liver weights were significantly increased in 1.0 and 2.0 g/kg males and in 0.5 g/kg or greater females compared to the vehicle controls. Minimal hepatocellular hypertrophy occurred in all 2.0 g/kg males and in all females administered 0.25 g/kg or greater. 2-WEEK STUDY IN MICE: Groups of five male and five female mice were administered kava kava extract in corn oil by gavage at doses of 0, 0.125, 0.25, 0.5, 1.0, or 2.0 g/kg body weight, 5 days per week for 17 days. In the 2.0 g/kg group of males, one died on day 2 and one died on day 3. Mean body weights of all dosed groups of mice were similar to those of the vehicle controls. Clinical findings included abnormal breathing, ataxia, and lethargy in males and females in the 1.0 and 2.0 g/kg groups. Liver weights of 2.0 g/kg males and females were significantly increased. The incidence of hepatocellular hypertrophy in 2.0 g/kg female mice was significantly greater than that in the vehicle control group. 3-MONTH STUDY IN RATS: Groups of 10 male and 10 female rats were administered kava kava extract in corn oil by gavage at doses of 0, 0.125, 0.25, 0.5, 1.0, or 2.0 g/kg, 5 days per week for 14 weeks. Deaths attributed to kava kava extract administration included three males and four females in the 2.0 g/kg groups and one female in the 1.0 g/kg group. One 0.25 g/kg male and one vehicle control female also died before the end of the study. The mean body weights of males in the 1.0 and 2.0 g/kg groups and females in the 2.0 g/kg group were significantly less than those of the vehicle controls. Ataxia and lethargy were observed in males and females in the 1.0 g/kg groups during week 1 and in the 2.0 g/kg groups throughout the study. Increased -glutamyltransferase activity in 1.0 g/kg females and 2.0 g/kg males and females may represent enzyme induction. However, the hepatocellular hypertrophy observed in the 2.0 g/kg females may have contributed to the increased -glutamyltransferase activity. The liver weights of 0.25 g/kg or greater males and 0.5 g/kg or greater females were significantly increased compared to the vehicle controls. The kidney weights of 0.5 g/kg or greater males and females were significantly increased compared to the vehicle controls. The incidence of hepatocellular hypertrophy in 2.0 g/kg females was significantly greater than that in the vehicle controls. 3-MONTH STUDY IN MICE: Groups of 10 male and 10 female mice were administered kava kava extract in corn oil by gavage at doses of 0, 0.125, 0.25, 0.5, 1.0, or 2.0 g/kg, 5 days per week for 14 weeks. Four male and three female 2.0 g/kg mice died during week 1; these deaths were attributed to kava kava extract administration. One additional 2.0 g/kg female died during week 6 due to a gavage accident. The mean body weights of dosed males and females were similar to those of the vehicle controls. Ataxia and lethargy occurred in males and females in the 1.0 and 2.0 g/kg groups during week 1. The liver weights of 2.0 g/kg males and 1.0 and 2.0 g/kg females were significantly increased compared to those of the vehicle control groups. The incidences of centrilobular hypertrophy in the liver of 0.5 g/kg or greater males and 1.0 and 2.0 g/kg females were significantly greater than those in the vehicle controls. 2-YEAR STUDY IN RATS: Groups of 49 or 50 male and 50 female rats were administered kava kava extract in corn oil by gavage at doses of 0, 0.1, 0.3, or 1.0 g/kg, 5 days per week for 104 (males) or 105 (females) weeks. Survival of dosed groups of males and females was similar to that of the vehicle controls. Mean body weights of males administered 1.0 g/kg were less than those of the vehicle controls after week 65, and those of the 1.0 g/kg females were less than those of the vehicle controls after week 41. Clinical findings included ataxia and lethargy that occurred in 21 males and 14 females in the 1.0 g/kg groups during the first 4 weeks of the study. After week 5, ataxia and lethargy were noted in 10 males and eight females in the 1.0 g/kg groups and these findings were observed randomly and intermittently throughout the study. At approximately 1 year into the study, twitching and seizures were observed in males and females in all dosed groups but mainly in the 1.0 g/kg groups. There was a dose-related increase in the incidences of interstitial cell adenoma in the testis with increased incidences of bilateral neoplasms. The incidences of hepatocellular hypertrophy in 1.0 g/kg males and females were significantly greater than those in the vehicle controls. Increased -glutamyltransferase activity and/or bile salt concentrations in males and females may represent a cholestatic event related to the hepatocellular hypertrophy observed in rats. Enzyme induction may have played a role in the increased -glutamyltransferase activity. Significantly increased incidences of centrilobular fatty change occurred in 0.1 and 1.0 g/kg males. The incidences of inflammation, ulcer, and epithelial hyperplasia in the forestomach were significantly increased in 1.0 g/kg males and females. The severity of nephropathy was increased in 1.0 g/kg male rats, and the incidence of nephropathy was significantly increased in 1.0 g/kg females. Incidences of transitional epithelial hyperplasia of the pelvis of the kidney were significantly increased in 1.0 g/kg males and 0.3 and 1.0 g/kg females. The incidences of retinal degeneration in the eye were significantly increased in 1.0 g/kg males and females. The incidences of metaplasia of pancreatic acinar cells to a hepatocytic morphology increased in 1.0 g/kg males and females, and the increase in males was significant. Significantly decreased incidences of pars distalis adenoma in the pituitary gland occurred in 1.0 g/kg males and in 0.1 and 1.0 g/kg females. The incidence of fibroadenoma of the mammary gland in 1.0 g/kg females was significantly less than that in the vehicle control group. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice received kava kava extract in corn oil by gavage at doses of 0, 0.25, 0.5, or 1.0 g/kg, 5 days per week for 105 weeks. Survival of dosed groups of males and females was similar to that of the vehicle controls. Mean body weights of males administered 1.0 g/kg were generally similar to those of the vehicle controls until the end of the study; however, those of 1.0 g/kg females were less than those of the vehicle controls after week 21. Clinical findings included ataxia and lethargy that occurred in 13 males and 31 females in the 1.0 g/kg groups during the first week of the study. Decreasing numbers of animals exhibited ataxia or lethargy during the remainder of the study, but these findings were observed in 1.0 g/kg females as late as week 101. The incidences of hepatoblastoma in 0.5 and 1.0 g/kg males were significantly increased compared to the vehicle controls. The incidences of hepatocellular carcinoma or hepatoblastoma (combined) were significantly increased in 0.5 g/kg males. Incidences of hepatocellular carcinoma were increased in all dosed groups of females, and the increase was significant in the 0.25 g/kg group. The incidences of hepatocellular adenoma or carcinoma (combined) were significantly increased in 0.25 and 0.5 g/kg females. In the liver, the incidences of centrilobular hypertrophy in all dosed groups of males and females were significantly greater than those in the vehicle control groups. Significantly increased incidences of eosinophilic foci occurred in 0.5 g/kg males and in 1.0 g/kg males and females, and the incidence of angiectasis was significantly increased in the 1.0 g/kg males. The incidences of hepatocellular necrosis were significantly increased in 0.25 and 1.0 g/kg males. In the forestomach, the incidences of chronic inflammation, epithelial hyperplasia, and erosion were significantly increased in 0.5 and 1.0 g/kg females, and the incidence of ulceration was significantly increased in 1.0 g/kg females. Kava kava extract was tested for bacterial mutagenicity over a broad range of concentrations in two independent assays using several strains of bacteria (S. typhimurium tester strains TA97, TA98, TA100, and TA1535 and E. coli strain WP2 uvrA/pKM101), with and without exogenous metabolic activation. No increase in mutant colonies was seen in any of the tester strains, under any activation condition. (ABSTRACT TRUNCATED)

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The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared-decision making for adult patients and health care providers in all health care settings.The specific questions to be answered are: BACKGROUND: Patient-centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients' Organizations (IAOP) who describe patient-centered healthcare as care that is aimed at addressing the needs and preferences of patients. The IAOP presents five principles which are foundational to the achievement of patient-centered healthcare: respect, choice, policy, access and support, as well as information. These five principles are further described as:Within the description of these five principles the idea of shared decision-making is clearly evident.The concept of shared decision-making began to appear in the literature in the 1990s. It is defined as a "process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient-centered care." The details of the shared decision-making process are complex and consist of a series of steps including:Three overall representative decision-making models are noted in contemporary literature. These three models include: paternalistic, informed decision-making, and shared decision-making. The paternalistic model is an autocratic style of decision-making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision-making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement. Finally, the shared decision-making model is representative of a sharing and a negotiation towards treatment decisions. Thus, these models represent a range with patient non-participation at one end of the continuum to informed decision making or a high level of patient power at the other end. Several shared decision-making models focus on the process of shared decision-making previously noted. A discussion of several process models follows below.Charles et al. depicts a process model of shared decision-making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included:This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker. This model also depicts the need to take steps to participate in the shared decision-making process. To take steps means that there is an agreement between and among all involved that shared decision-making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision-making and the actuality of shared decision-making in practice is not strong. Research concerning patients and patient preferences on shared decision-making points to variations depending on age, education, socio-economic status, culture, and diagnosis. Healthcare providers may also hold preferences for shared decision-making; however, research in this area is not as comprehensive as is patient focused research. Elwyn et al. explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision-making process. An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines. This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.The notion of information sharing as a prerequisite to shared decision-making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision-making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision-making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al. portrays shared decision-making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the "test of a shared decision (as distinct from the decision-making process) is if both parties agree on the treatment option."Towle and Godolphin developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision-making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision-making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include:Patient competencies include:This model illustrates the shared decision-making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model. This model, however, gives greater emphasis to the process of the co-participation of the healthcare provider and the patient. The co-participation depicts a mutual partnership with mutual responsibilities that can be seen as "reciprocal relationships of dialogue." For this to take place the relationship between and among the participants of the shared decision-making process is important along with other internal and external influences such as communication, trust, mutual respect, honesty, time, continuity, and commitment. Cultural, social, and age group differences; evidence; and team and family are considered within this model.Elwyn et al. presents yet another model that depicts the shared decision-making process; however, this model offers a view where the healthcare provider holds greater responsibility in this process. In this particular model the process focuses on the healthcare provider and the essential skills needed to engage the patient in shard decisions. The competencies outlined in this model include:The healthcare provider must demonstrate knowledge, competencies, and skills as a communicator. The skills for communication competency require the healthcare provider to be able to elicit the patient's thoughts and input regarding treatment management throughout the consultation. The healthcare provider must also demonstrate competencies in assessment skills beyond physical assessment that includes the ability to assess the patient's perceptions and readiness to participate. In addition, the healthcare provider must be able to assess the patient's readiness to learn the information that the patient needs to know in order to fully engage in the shared decision-making process, assess what the patient already knows, what the patient does not know, and whether or not the information that the patient knows is accurate. Once this assessment is completed the healthcare provider then must draw on his/her knowledge, competencies, and skills necessary to teach the patient what the patient needs to know to be informed. This facilitates the notion of the tailor-made information noted previously. The healthcare provider also requires competencies in how to check and evaluate the entire process to ensure that the patient does understand and accept with comfort not only the plan being negotiated but the entire process of sharing in decision-making. In addition to the above, there are further competencies such as competence in working with groups and teams, competencies in terms of cultural knowledge, competencies with regard to negotiation skills, as well as, competencies when faced with ethical challenges.Shared decision-making has been associated with autonomy, empowerment, and effectiveness and efficiency. Both patients and health care providers have noted improvement in relationships and improved interactions when shared decision-making is in evidence. Along with this improved relationship and interaction enhanced compliance is noted. Additional research points to patient satisfaction and enhanced quality of life. There is some evidence to suggest that shared decision-making does facilitate positive health outcomes.In today's healthcare environment there is greater emphasis on patient-centered care that exemplifies patient engagement, participation, partnership, and shared decision-making. Given the shift from the more autocratic delivery of care to the shared approach there is a need to more fully understand the what of shared decision-making as well as how shared decision-making takes place along with what internal and external influences may encourage, support, and facilitate the shared decision-making process. These influences are intervening variables that may be of significance for the successful development of practice-based strategies that may foster shared decision-making in practice. The purpose of this qualitative systematic review is to identify internal and external influences on shared decision-making in all health care settings.A preliminary search of the Joanna Briggs Library of Systematic Reviews, MEDLINE, CINAHL, and PROSPERO did not identify any previously conducted qualitative systematic reviews on the meaningfulness of internal and external influences on shared decision-making.

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Gallium arsenide is used primarily to make light- emitting diodes, lasers, laser windows, and photodetectors and in the photoelectronic transmission of data through optical fibers. Gallium arsenide was nominated for study because of its widespread use in the microelectronics industry, the potential for worker exposure, and the absence of chronic toxicity data. Male and female F344/N rats and B6C3F1 mice were exposed to gallium arsenide particles (greater than 98% pure; mass median aerodynamic diameter = 0.8 to 1.0 &amp;mgr;m) by inhalation for 16 days, 14 weeks, or 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, and the frequency of micronuclei was determined in the peripheral blood of mice exposed to gallium arsenide for 14 weeks. 16-DAY STUDY IN RATS: Groups of five male and five female rats were exposed to particulate aerosols of gallium arsenide with a mass median aerodynamic diameter of approximately 1 &amp;mgr;m at concentrations of 0, 1, 10, 37, 75, or 150 mg/m(3) by inhalation, 6 hours per day, 5 days per week, for 16 days. All rats survived to the end of the study. The final mean body weights of all exposed groups of males and females were similar to those of the chamber controls. Compared to chamber controls, the liver and lung weights of males exposed to 1 mg/m(3) or greater and females exposed to 10 mg/m(3) or greater were increased; the thymus weights of all exposed groups of males were decreased. Gallium arsenide particles were visible in the alveolar spaces and, to a lesser extent, within alveolar macrophages of exposed rats. Moderate proteinosis (surfactant mixed with small amounts of fibrin) and minimal histiocytic cellular infiltrate were observed in the alveoli of exposed males and females. Epithelial hyperplasia and squamous metaplasia of the larynx were observed primarily in males exposed to 150 mg/m(3). 16-DAY STUDY IN MICE: Groups of five male and four or five female mice were exposed to particulate aerosols of gallium arsenide with a mass median aerodynamic diameter of approximately 1 &amp;mgr;m at concentrations of 0, 1, 10, 37, 75, or 150 mg/m(3) by inhalation, 6 hours per day, 5 days per week, for 16 days. The final mean body weights were similar among exposed and chamber control groups. Compared to chamber controls, the lung weights of males and females exposed to 10 mg/m(3) or greater were increased. Gallium ar senide particles were visible in alveolar spaces and macrophages in some mice exposed to 150 mg/m(3). Moderate proteinosis, mild epithelial hyperplasia, and histiocytic infiltration of the lung were observed in males and females exposed to 10 mg/m(3) or greater. In the larynx, mild squamous metaplasia was seen in mice exposed to 10 mg/m(3) or greater, and mild chronic inflammation occurred in mice exposed to 75 or 150 mg/m(3). 14-WEEK STUDY IN RATS: Groups of 10 male and 10 female rats were exposed by inhalation to gallium arsenide particulate at concentrations of 0, 0.1, 1, 10, 37, or 75 mg/m(3), 6 hours per day, 5 days per week, for 14 weeks. All rats survived until the end of the study. The final mean body weight and body weight gain of males exposed to 75 mg/m(3) were significantly less than those of the chamber controls. Hematology and clinical chemistry results indicated that exposure to gallium arsenide induced a microcytic responsive anemia with an erythrocytosis and increased zinc protoporphyrin/heme ratios in exposed groups of rats. There were also increases in platelet and neutrophil counts, a transient decrease in leukocyte counts, and increases in the serum activities of alanine aminotransferase and sorbitol dehydrogenase. These changes were of greater magnitude in male rats. The lung weights of all exposed groups of rats were increased, while testis, cauda epididymis, and epididymis weights of males exposed to 37 or 75 mg/m(3) were generally less than those of chamber controls. Total spermatid heads and spermatid counts were significantly decreased in males exposed to 75 mg/m(3), while epididymal spermatozoa motility was significantly reduced in males ees exposed to 10 mg/m(3) or greater. Gallium arsenide particles were visible in alveolar spaces and macrophages in the lungs of exposed rats. Minimal to marked proteinosis and minimal histiocytic cellular infiltration of the alveoli were observed in all exposed groups; minimal squamous metaplasia in the larynx and lymphoid cell hyperplasia of the mediastinal lymph node were observed in some males and females exposed to 37 or 75 mg/m(3). Exposure-related increases in the incidences of plasma cell hyperplasia of the mandibular lymph node, testicular atrophy, epididymal hypospermia, bone marrow hyperplasia (males), and hemosiderosis in the liver were observed in the 37 and 75 mg/m(3) groups. 14-WEEK STUDY IN MICE: Groups of 10 male and 10 female mice were exposed by inhalation to gallium arsenide particulate at concentrations of 0, 0.1, 1, 10, 37, or 75 mg/m(3), 6 hours per day, 5 days per week, for 14 weeks. One female mouse exposed to 75 mg/m(3) died before the end of the study. Final mean body weights and body weight gains of males in the 75 mg/m(3) group were signifi cantly less than the chamber controls. Hematology and clinical chemistry results indicated that exposure to gallium arsenide affected the circulating erythroid mass and induced a microcytic responsive anemia with an erythrocytosis and increased zinc protoporphyrin/heme ratios in male and female mice. There were also increases in platelet and neutrophil counts. Compared to the chamber controls, the lung weights of males exposed to 1 mg/m(3) or greater and females exposed to 10 mg/m(3) or greater were increased. Testis, cauda epididymis, and epididymis weights, total spermatid heads, spermatid counts, and concentration and motility of epididymal spermatozoa were generally decreased. Gallium arsenide particles were visible in alveolar spaces and macrophages in the lungs of mice exposed to 1 mg/m(3) or greater. Mild to marked proteinosis, histiocytic infiltration, and epithelial hyperplasia were observed in the alveoli of males and females exposed to 1 mg/m(3) or greater. Minimal to mild suppurative inflammation and granuloma in the lung and squamous metaplasia in the larynx were present in males and females exposed to 10 mg/m(3) or greater. Min imal hyperplasia was observed in the tracheobronchial lymph node of males exposed to 10 mg/m(3) or greater and females exposed to 37 or 75 mg/m(3). Exposure- related increases in the incidences of testicular atrophy, epididymal hypospermia, hematopoietic cell proliferation of the spleen, and hemosiderosis of the liver and spleen were observed in groups of male and female mice exposed to 10 mg/m(3) or greater. 2-YEAR STUDY IN RATS: Groups of 50 male and 50 female rats were exposed by inhalation to gallium arsenide particulate at concentrations of 0, 0.01, 0.1, or 1.0 mg/m(3), 6 hours per day, 5 days per week, for 105 weeks. Survival and Body Weights: Survival of exposed male and female rats was similar to the chamber controls. Mean body weights of males exposed to 1.0 mg/m(3) were generally less than those of the chamber controls throughout the study; females exposed to 1.0 mg/m(3) had slightly lower mean body weights during the second year. Pathology Findings: Compared to the chamber controls, the incidences of alveolar/bronchiolar neoplasms were significantly increased in females exposed to 1.0 mg/m(3) and exceeded the historical control ranges. Exposure-related nonneoplastic lesions in the lungs of male and female rats included atypical hyperplasia, alveolar epithelial hyperplasia, chronic active inflammation, proteinosis, and alveolar epithelial metaplasia. In the larynx of males exposed to 1.0 mg/m(3), the incidences of hyperplasia, chronic active inflammation, squamous metaplasia, and hyperplasia of the epiglottis were significantly increased. The incidences of benign pheochromocytoma of the adrenal medulla occurred with a positive trend in female rats, and the incidence was significantly increased in the 1.0 mg/m(3) group and exceeded the historical control range. The incidence of mononuclear cell leukemia was significantly increased in females exposed to 1.0 mg/m(3) and exceeded the historical control range. 2-YEAR STUDY IN MICE: Groups of 50 male and 50 female mice were exposed by inhalation to gallium arsenide particulate at concentrations of 0, 0.1, 0.5, or 1.0 mg/m(3), 6 hours per day, 5 days per week, for 105 (males) or 106 (females) weeks. Survival and Body Weights: Survival of male and female mice was similar to the chamber controls. Mean body weights of exposed groups of males were similar to those of the chamber controls throughout the study; mean body weights of exposed groups of females were greater than those of the chamber controls from week 13 until the end of the study. Pathology Findings: Exposure-related nonneoplastic lesions in the lung of all groups of exposed mice included suppurative focal inflammation, chronic focal inflammation, histiocyte cellular infiltration, alveolar epithelial hyperplasia, and proteinosis. Increased incidences of minimal lymphoid hyperplasia of the tracheobronchial lymph node occurred in mice exposed to 1.0 mg/m(3) and in 0.5 mg/m(3)mg/m(3) males. GENETIC TOXICOLOGY: Gallium arsenide was not mutagenic in several strains of Salmonella typhimurium, with or without S9 metabolic activation enzymes, and no increase in the frequency of micronucleated erythrocytes was observed in peripheral blood of male or female mice exposed to gallium arsenide by inhalation for 14 weeks. CONCLUSIONS: Under the conditions of these 2-year inhalation studies, there was no evidence of carcinogenic activity of gallium arsenide in male F344/N rats exposed to 0.01, 0.1, or 1.0 mg/m(3). There was clear evidence of carcinogenic activity in female F344/N rats based on increased incidences of benign and malignant neoplasms in the lung. Increased incidences of benign neoplasms of the adrenal medulla and increased incidences of mononuclear cell leukemia were also considered to be exposure related. There was no evidence of carcinogenic activity in male or female B6C3F1 mice exposed to 0.1, 0.5, or 1.0 mg/m(3). Exposure to gallium arsenide caused a spectrum of nonneoplastic lesions in the lung of rats and mice, the larynx of male rats and hyperplasia of the tracheobronchial lymph node in mice. Synonym: Gallium monoarsenide.

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CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. Rapid review of articles published between January 2000 and May 2020. We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km<sup2</sup . We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

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We are writing in regards to Armstrong et al`s recent discussion paper (1), which addresses the scientific basis of ISO standards on biomechanical risk factors and more specifically the OCRA methodology. The paper comments on the ISO's working methods, but it will be up to the ISO to respond if it sees fit to do so. As the authors of the OCRA method, we wish to respond in a individual capacity. For several years, we have belonged to an ISO working group (ISO TC 159/SC3/WG4) advocating methods for the assessment of biomechanical overload risk; the members of the working group come from various countries and represent public authorities, social partners and researchers with particular expertise in this field. Our decision to send this letter to the editor was motivated by the following position put forth in Armstrong et al`s paper concerning the rigor of development of the ISO ergonomics standards: "The production of the ISO ergonomics standards differed substantially from the writing of evidence-based practical guidelines. According to the limited information provided in the published documents, the ISO ergonomics standards were not based on a systematic search and appraisal of available literature. It is not clear why the ISO subcommittee preferred one method of risk assessment over others. For instance, the ISO 11228-3 identified three detailed risk assessment methods for repetitive hand exertions at high frequency: OCRA (a concise index for the assessment of exposure to repetitive movements of the upper limbs) (20), ACGIH hand activity level (HAL) (21), and the Strain Index (22), but preferred the OCRA methods without providing a scientific basis or comparison (eg, intra- and inter-observer reliability, strength of association with musculoskeletal disorders (MSD), etc.) even though such comparisons are available in the literature (13, 23). As a result, some statements in ISO 11228-3 appear to be based on personal opinions and are in contrast with scientific evidence from the literature. For instance, the ISO standard includes a statement "in many epidemiological surveys it (OCRA) has shown itself to be well related with health effects (such as the occurrence of UL-WMSD [upper limb-work related MSD)]" (13). This statement was not supported by a well-designed epidemiological study in 2007 when the ISO standard was published (19). Indeed, in 2010, Takala and colleagues noted the absence of longitudinal studies on the association between the OCRA index and the risk of MSD. They also pointed out the absence of studies on the repeatability of the OCRA method (13)". (Note: the references in italic relate to the original paper). We would like to point out that the ISO standards in question (2) were actually developed by the working group, as mandated by ISO, over the period 2000‒2004.The years leading up to the publication of the standard (2005‒2007) were dedicated to the challenging task of democratically seeking the endorsement of the ISO member countries. During this time, no significant changes could be made to the basic text other than those arising from specific observations or comments from the countries. This needs to be taken into account, especially when debating the references underpinning the standard. More specifically, the standard in question (ISO 11228-3) (2) in Annex A, clearly states that the general reference model for assessing "repetitive, high frequency, low load movements of the upper limbs" is a Consensus Document, drafted and published in 2001 by the IEA-Technical Committee on Musculoskeletal Disorders, with the endorsement of the International Commission on Occupational Health (ICOH) (3). The study considered at least 14 different methods that have over time been suggested in the literature as briefly summarized in the same ISO standard (2). The recommendations set forth in this vital Consensus Document went on to become the basis for choosing the most appropriate methods to suggest to future users through the standard (OCRA; ACGIH Hand Activity Level (HAL); Strain Index), each with their respective merits and limits in compliance with the criteria set out in the Consensus Document and taking into account their applicability in the field and ability to interpret the results of the risk assessment. It is against this background, and in light of the rationale described in Annex A, that the entire group agreed that the OCRA method was to be considered as the "preferred" method, insofar as it was deemed to best match the recommendations laid out in the aforementioned Consensus Document. Furthermore the OCRA method was, at the time, the only risk assessment method supported by the results of several epidemiological, albeit cross-sectional studies, uniquely available in literature. The study was based on a very large number of cases (&gt;5000 cases) with results both of risk evaluation of upper-limb biomechanical overload (using the OCRA method) and of musculo-skeletal clinical examination (assessing the corresponding diseases). Such studies were reported in a special issue of Ergonomics (4), in an updated paper ‒ first published in Italian (5) ‒ also in Ergonomics (6), in the books edited by Elsevier (7), and CRC Taylor &amp; Francis (8). This risk/damage database enabled an estimation (within defined limits) of the risk of upper-limb work-related musculoskeletal disorders at a given OCRA index level. Starting from the established relation among risk indexes and percent of pathological subjects, it was possible to determine the risk limit values provided by the ISO standard (2). With reference to the alleged absence of studies on the repeatability of the OCRA method, we prefer to mention the most recent results obtained by other researchers, rather than our findings, acknowledging the good "inter-rater reliability" of the OCRA Checklist, and stating that "the OCRA Checklist inter-rater reliability scores were among the highest reported in the literature for semi-quantitative physical exposure assessment tools of the upper extremity" (9) As for the scientific base, we suggest Armstrong et al (1) could get more valuable information about the OCRA methodology looking not only to the 1996 special issue in Italian language (10) ‒ the only publication they mention dealing specifically with OCRA ‒ but to the many updated publications. Some of the most relevant publications in English (as suggested by the publisher) are mentioned in the references here below. Many other publications and manuals in English, Italian, Spanish and Portuguese are available but not reported here due to limitation of space. A complete list of our publications can be found on our website: www.epmresearch.org, where some of the articles are available for download. Simple tools (Excel spreadsheets) for carrying out risk assessments by OCRA can also be freely downloaded from the same website. The validity and usability of OCRA methodology can also be indirectly confirmed by its extensive use around the world. For example, a recent search on ScienceDirect (www.sciencedirect.com/science/journals/all/full-text-access) has recently shown that more than 477 works dealing with OCRA hae been published by different authors in indexed journals to date. In conclusion, we recommend the authors of the discussion paper (1) deepen their analysis of the OCRA methodology [beyond the only cited old 1996 paper (10)] before expressing definite conclusions about the scientific value of the OCRA methodology and about the entire ISO standard-setting system. Our team is always happy to engage with the scientific community and end users of studies on biomechanical overload, as we have also done within the ISO for many years now. ISO working groups arguably offer valuable opportunities to come together at the international level and table discussions between researchers and users. We are researchers who have devoted our life's work to prevention, and intend to continue striving towards that goal, with everyone's help and without bickering, bias, vested interests, or professional rivalry. The health and well-being of workers is all we have ever cared about. We have always been ready to cooperate with those who share this vital objective. References 1. Armstrong T J, Burdorf I A, Descatha A, Farioli A, Graf M, Horie S, Marras W S, Potvin J R, Rempel D, Spatari G, Takala E P, Verbeek J, Violante FS. Scientific basis of ISO standards on biomechanical risk factors. Scand J Work Environ Health ‒ online first. https://doi.org/10.5271/sjweh.3718 2. ISO. ISO 11228-3. Ergonomics - Manual handling - Handling of low loads at high frequency. ISO, 2007. Geneva, Switzerland. 3. Colombini D, Occhipinti E, Delleman D, Fallentin N, Kilbom A, Grieco A. Exposure assessment of upper limb repetitive movements: a consensus document in W. Karwowski International Encyclopaedia of Ergonomics and Human Factors, New York: Taylor &amp; Francis, 2001. 4. Colombini D, Grieco A, Occhipinti E. Occupational musculoskeletal disorders of the upper limbs due to mechanical overload. Ergonomics. Special issue;1998:41(9). 5. Occhipinti, E., Colombini, D. Metodo OCRA: aggiornamento dei valori di riferimento e dei modelli di previsione dell'occorrenza di UL-WMSDs nelle popolazioni lavorative esposte a movimenti e sforzi ripetuti degli arti superiori. [The OCRA method: update of UL-WMSDs reference values and prediction models of occurrence in working populations exposed to repetitive movements and strains of the upper limbs]. La Medicina del Lavoro, 2004. 95;4:305-319 6. Occhipinti E, Colombini D. Updating reference values and predictive models of the OCRA method in the risk assessment of work-related musculoskeletal disorders of the upper limbs. Ergonomics; 2007,50(11):1727-1739. https://doi.org/10.1080/00140130701674331 7. Colombini D, Occhipinti E, Grieco A. Risk assessment and management of repetitive movements and exertions of upper limbs. Amsterdam: Elsevier Science, 2002. 8. Colombini D, Occhipinti E. Risk analysis and management of repetitive actions: a guide for applying the OCRA system (occupational repetitive actions). New York: CRC press, 2016. 9. Paulsen R, Gallu T, Gilkey D, Reiser R, Murgia L, Rosecrance J. The inter-rater reliability of Strain Index and OCRA Checklist task assessments in cheese processing. Applied Ergonomics. 2015;51,199-204. https://doi.org/10.1016/j.apergo.2015.04.019 10. Occhipinti E, Colombini D. Proposal of a concise index for the evaluation of the exposure to repetitive movements of the upper extremity (OCRA index)]. Med Lav. Special issue, 1996 Nov-Dec; 87(6): 526-548.

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A fully annotated catalog of genus- and species-group names of Neotropical Lauxaniidae (Diptera: Lauxanioidea) is presented, providing details of references to these names in literature, and providing additional details such as distributions, generic combinations, synonymies, misspellings and emendations, information on types, notes on unusual situations, etc. As this catalog is meant to supplement the older Catalog of the Diptera of America North of Mexico, to complete the cataloging of the New World Lauxaniidae, "Neotropical" is herein inclusive of everything south of the United States, and the Nearctic parts of Mexico are not separately distinguished. The catalog is organized alphabetically within each of the three lauxaniid subfamilies, Eurychoromyiinae, Homoneurinae and Lauxaniinae, treating 91 available genus-group names, of which 77 represent valid genera. In the species-group, the catalog treats 441 available species-group names, of which 391 represent valid Neotropical lauxaniid species, 39 are invalid, three are valid but extralimital lauxaniids, five are valid but removed from Lauxaniidae, and two are new replacement names for two homonyms outside Lauxaniidae. The following nine new genera are described, based on previously described species: Elipolambda Gaimari Silva (type species, Sapromyza lopesi Shewell, 1989), Griphoneuromima Silva Gaimari (type species, Sapromyza frontalis Macquart, 1844b), Meraina Silva Gaimari (type species, Lauxania ferdinandi Frey, 1919), Myzaprosa Gaimari Silva (type species, Myzaprosa mallochi Gaimari Silva), Paradeceia Silva Gaimari (type species, Sapromyza sororia Williston, 1896b), Pseudodeceia Silva Gaimari (type species, Lauxania leptoptera Frey, 1919), Sericominettia Gaimari Silva (type species, Minettia argentiventris Malloch, 1928), Zamyprosa Gaimari Silva (type species, Sapromyza semiatra Malloch, 1933), and Zargopsinettia Gaimari Silva (type species, Minettia verticalis Malloch, 1928). The following four new replacement names in the species-group replace junior homonyms: Myzaprosa mallochi Gaimari Silva (for Sapromyza spinigera Malloch, 1933, nec Malloch, 1925), Pseudogriphoneura mallochi Silva Gaimari (for Minettia infuscata Malloch, 1928, nec Sciomyza infuscata Wulp, 1897), Xenochaetina hendeli Silva Gaimari (for Allogriphoneura robusta Hendel, 1936, nec Helomyza robusta Walker, 1858), Zamyprosa macquarti Gaimari Silva (for Sciomyza nigripes Blanchard, 1854, nec Sapromyza nigripes Macquart, 1844). The following six genus-group names are new synonyms: Allogriphoneura Hendel, 1925 (= Xenochaetina Malloch, 1923), Bacilloflagellomera Papp Silva, 1995 (= Stenolauxania Malloch, 1926), Haakonia Curran, 1942 (= Xenochaetina Malloch, 1923), Homoeominettia Broadhead, 1989 (= Allominettia Hendel, 1925), Paraphysoclypeus Papp Silva, 1995 (= Physoclypeus Hendel, 1907), Tibiominettia Hendel, 1936 (= Allominettia Hendel, 1925). The following 12 species-group names are new synonyms: Chaetocoelia banksi Curran, 1942 (= Chaetocoelia excepta (Walker, 1853)), Chaetocoelia tripunctata Malloch, 1926 (= Chaetocoelia excepta (Walker, 1853)), Minettia semifulva Malloch, 1933 (= Zamyprosa nigriventris (Blanchard, 1854)), Pseudogriphoneura scutellata Curran, 1934a (= Xenochaetina porcaria (Fabricius, 1805)), Sapromyza apta Walker, 1861 (= Chaetominettia mactans (Fabricius, 1787)), Sapromyza brasiliensis Walker, 1853 (= Chaetominettia corollae (Fabricius, 1805)), Sapromyza semiatra subsp. remissa Malloch, 1933 (= Zamyprosa semiatra (Malloch, 1933)), Sapromyza sordida Williston, 1896b (= Neogriphoneura sordida (Wiedemann, 1830)), Setulina geminata subsp. quadripunctata Malloch, 1941, subsp. tripunctata Malloch, 1941 subsp. verticalis Malloch, 1941 (= Setulina geminata (Fabricius, 1805)), Tibiominettia setitibia Hendel, 1932 (= Allominettia assimilis (Malloch, 1926)). The following 96 lauxaniid species-group names are in new combinations: Allominettia approximata (Malloch, 1928; Deutominettia Hendel, 1925), Allominettia assimilis (Malloch, 1926; Minettia Robineau-Desvoidy, 1830), Allominettia rubescens (Macquart, 1844b; Sapromyza Fallén, 1810), Allominettia woldae (Broadhead, 1989; Homoeominettia Broadhead, 1989), Camptoprosopella sigma (Hendel, 1910; Procrita Hendel, 1908), Camptoprosopella verena (Becker, 1919; Sapromyza Fallén, 1810), Dryosapromyza pirioni (Malloch, 1933; Minettia Robineau-Desvoidy, 1830), Elipolambda duodecimvittata (Frey, 1919; Lauxania Latreille, 1804), Elipolambda lopesi (Shewell, 1989; Sapromyza Fallén, 1810), Elipolambda picrula (Williston, 1897; Sapromyza Fallén, 1810), Griphoneuromima frontalis (Macquart, 1844b; Sapromyza Fallén, 1810), Homoneura maculipennis (Loew, 1847; Sapromyza Fallén, 1810), Lauxanostegana albispina (Albuquerque, 1959; Steganopsis Meijere 1910), Marmarodeceia claripennis (Curran, 1934a; Pseudogriphoneura Hendel, 1907), Melanomyza nigerrima (Becker, 1919; Sapromyza Fallén, 1810), Meraina ferdinandi (Frey, 1919; Lauxania Latreille, 1804), Minettia altera (Curran, 1942; Pseudogriphoneura Hendel, 1907), Minettia duplicata (Lynch Arribálzaga, 1893; Sapromyza Fallén, 1810), Minettia lateritia (Rondani, 1863; Sapromyza Fallén, 1810), Minettia lupulinoides (Williston, 1897; Sapromyza Fallén, 1810), Minettia pallens (Blanchard, 1854; Sapromyza Fallén, 1810), Minettia remota (Thomson, 1869; Sapromyza Fallén, 1810), Minettia setosa (Thomson, 1869; Sapromyza Fallén, 1810), Myzaprosa chiloensis (Malloch, 1933; Sapromyza Fallén, 1810), Myzaprosa emmesa (Malloch, 1933; Sapromyza Fallén, 1810), Myzaprosa triloba (Malloch, 1933; Sapromyza Fallén, 1810), Neodecia albovittata (Loew, 1862; Lauxania Latreille, 1804), Neodecia bivittata (Curran, 1928b; Pseudogriphoneura Hendel, 1907), Neodecia flavipennis (Curran, 1928b; Pseudogriphoneura Hendel, 1907), Neodecia vittifacies (Curran, 1931; Pseudogriphoneura Hendel, 1907), Neominettia eronis (Curran, 1934a; Sapromyza Fallén, 1810), Neominettia lebasii (Macquart, 1844b; Sapromyza Fallén, 1810), Neominettia melanaspis (Wiedemann, 1830; Sciomyza Fallén, 1820d), Neoxangelina congruens (Hendel, 1910; Physegenua Macquart, 1848a/b), Neoxangelina facialis (Wiedemann, 1830; Sciomyza Fallén, 1820d), Neoxangelina flavipes (Hendel, 1926; Physegenua Macquart, 1848a/b), Paracestrotus albipes (Fabricius, 1805; Scatophaga Fabricius, 1805), Paradeceia incidens (Curran, 1934a; Sapromyza Fallén, 1810), Paradeceia shannoni (Malloch, 1933; Sapromyza Fallén, 1810), Paradeceia sororia (Williston, 1896b; Sapromyza Fallén, 1810), Physegenua annulata (Macquart, 1844b; Ephydra Fallén, 1810), Physoclypeus nigropleura (Papp Silva, 1995; Paraphysoclypeus Papp Silva, 1995), Poecilohetaerus suavis (Loew, 1847; Sapromyza Fallén, 1810), Poecilolycia blanchardi (Malloch, 1933; Sapromyza Fallén, 1810), Poecilolycia lineatocollis (Blanchard, 1854; Sapromyza Fallén, 1810), Poecilominettia aibonito (Curran, 1926; Minettia Robineau-Desvoidy, 1830), Poecilominettia bipunctata (Say, 1829; Sapromyza Fallén, 1810), Poecilominettia evittata (Malloch, 1926; Minettia Robineau-Desvoidy, 1830), Poecilominettia mona (Curran, 1926; Minettia Robineau-Desvoidy, 1830), Poecilominettia nigropunctata (Malloch, 1928; Minettia Robineau-Desvoidy, 1830), Poecilominettia plantaris (Thomson, 1869; Sapromyza Fallén, 1810), Poecilominettia quichuana (Brèthes, 1922; Sapromyza Fallén, 1810), Poecilominettia schwarzi (Malloch, 1928; Sapromyza Fallén, 1810), Poecilominettia sonax (Giglio-Tos, 1893; Sapromyza Fallén, 1810), Poecilominettia thomsonii (Lynch-Arribálzaga, 1893; Sapromyza Fallén, 1810), Poecilominettia triseriata (Coquillett, 1904a; Sapromyza Fallén, 1810), Pseudocalliope albomarginata (Malloch, 1933; Minettia Robineau-Desvoidy, 1830), Pseudodeceia leptoptera (Frey, 1919; Lauxania Latreille, 1804), Pseudogriphoneura albipes (Wiedemann, 1830; Lauxania Latreille, 1804), Pseudominettia argyrostoma (Wiedemann, 1830; Lauxania Latreille, 1804), Ritaemyia unifasciata (Macquart, 1835; Tephritis Latreille, 1804), Sciosapromyza fuscinervis (Malloch, 1926; Minettia Robineau-Desvoidy, 1830), Sciosapromyza limbinerva (Rondani, 1848; Sapromyza Fallén, 1810), Sciosapromyza scropharia (Fabricius, 1805; Scatophaga Fabricius, 1805), Scutominettia guyanensis (Macquart, 1844b; Sapromyza Fallén, 1810), Sericominettia argentiventris (Malloch, 1928; Minettia Robineau-Desvoidy, 1830), Sericominettia aries (Curran, 1942; Pseudogriphoneura Hendel, 1907), Sericominettia holosericea (Fabricius, 1805; Scatophaga Fabricius, 1805), Sericominettia nigra (Curran, 1934a; Pseudogriphoneura Hendel, 1907), Sericominettia velutina (Walker, 1853; Helomyza Fallén, 1820a), Stenolauxania flava (Silva, 1999a; Bacilloflagellomera Papp Silva, 1995), Stenolauxania fusca (Silva, 1999a; Bacilloflagellomera Papp Silva, 1995), Stenolauxania longicornus (Silva, 1999a; Bacilloflagellomera Papp Silva, 1995), Stenolauxania nigrifemuris (Silva, 1999a; Bacilloflagellomera Papp Silva, 1995), Stenolauxania pectinicornis (Papp Silva, 1995; Bacilloflagellomera Papp Silva, 1995), Trivialia nigrifrontata (Becker, 1919; Sapromyza Fallén, 1810), Trivialia scutellaris (Williston, 1896b; Phortica Schiner, 1862), Trivialia venusta (Williston, 1896b; Sapromyza Fallén, 1810), Xenochaetina annuliventris (Hendel, 1926; Allogriphoneura Hendel, 1925), Xenochaetina glabella (Becker, 1895; Lauxania Latreille, 1804), Xenochaetina nigra (Williston, 1896b; Physegenua Macquart, 1848a/b), Xenochaetina phacosoma (Hendel, 1926; Allogriphoneura Hendel, 1925), Xenochaetina porcaria (Fabricius, 1805; Scatophaga Fabricius, 1805), Xenochaetina robusta (Walker, 1858; Helomyza Fallén, 1820a), Zamyprosa dichroa (Malloch, 1933; Minettia Robineau-Desvoidy, 1830), Zamyprosa edwardsi (Malloch, 1933; Sapromyza Fallén, 1810), Zamyprosa ferruginea (Macquart, 1844b; Opomyza Fallén, 1820b), Zamyprosa fulvescens (Blanchard, 1854; Sciomyza Fallén, 1820d), Zamyprosa fulvicornis (Malloch, 1933; Sapromyza Fallén, 1810), Zamyprosa micropyga (Malloch, 1933; Sapromyza Fallén, 1810), Zamyprosa nigripes (Macquart, 1844b; Sapromyza Fallén, 1810), Zamyprosa nigriventris (Blanchard, 1854; Sapromyza Fallén, 1810), Zamyprosa parvula (Blanchard, 1854; Sapromyza Fallén, 1810), Zamyprosa semiatra (Malloch, 1933; Sapromyza Fallén, 1810), Zamyprosa seminigra (Malloch, 1933; Minettia Robineau-Desvoidy, 1830), Zargopsinettia verticalis (Malloch, 1928; Minettia Robineau-Desvoidy, 1830). The following 42 species have lectotype designations herein: Allogriphoneura nigromaculata Hendel, 1925 (synonym of Xenochaetina porcaria (Fabricius, 1805)), Allogriphoneura robusta Hendel, 1936 (= Xenochaetina hendeli Silva Gaimari), Allominettia maculifrons Hendel, 1925 (synonym of Allominettia xanthiceps (Williston, 1897)), Blepharolauxania trichocera Hendel, 1925, Chaetocoelia palans Giglio-Tos, 1893, Euminettia zuercheri Hendel, 1933b (Minettia Robineau-Desvoidy, 1830), Griphoneura triangulata Hendel, 1926, Lauxania albovittata Loew, 1862 (Neodecia Malloch, in Malloch McAtee, 1924), Lauxania imbuta Wiedemann, 1830 (Griphoneura Schiner, 1868), Lauxania lutea Wiedemann, 1830 (Neominettia Hendel, 1925), Lauxania ruficornis Macquart, 1851a (synonym of Xenochaetina flavipennis (Fabricius, 1805)), Neominettia fumosa Hendel, 1926 (synonym of Neominettia costalis (Fabricius, 1805)), Physegenua ferruginea Schiner, 1868, Physegenua vittata Macquart, 1848a/b, Pseudogriphoneura cormoptera Hendel, 1907, Sapromyza angustipennis Williston, 1896b (Chaetocoelia Giglio-Tos, 1893), Sapromyza distinctissima Schiner, 1868 (Chaetocoelia Giglio-Tos, 1893), Sapromyza exul Williston, 1896b (Neodecia Malloch, in Malloch McAtee, 1924), Sapromyza gigas Schiner, 1868 (Dryosapromyza Hendel, 1933a), Sapromyza ingrata Williston, 1896b (Poecilominettia Hendel, 1932), Sapromyza latelimbata Macquart, 1855a (synonym of Chaetominettia corollae (Fabricius, 1805)), Sapromyza lineatocollis Blanchard, 1854 (Poecilolycia Shewell, 1986), Sapromyza longipennis Blanchard, 1854 (= Minettia duplicata (Lynch Arribálzaga, 1893)), Sapromyza nigerrima Becker, 1919 (Melanomyza Malloch, 1923), Sapromyza nigriventris Blanchard, 1854 (Zamyprosa Gaimari Silva), Sapromyza octovittata Williston, 1896b (Poecilominettia Hendel, 1932), Sapromyza ornata Schiner, 1868 (Neoxangelina Hendel, 1933a), Sapromyza pallens Blanchard, 1854 (Minettia Robineau-Desvoidy, 1830), Sapromyza parvula Blanchard, 1854 (Zamyprosa Gaimari Silva), Sapromyza picrula Williston, 1897 (Elipolambda), Sapromyza puella Williston, 1896b (Trivialia Malloch, 1923), Sapromyza sororia Williston, 1896b (Paradeceia Silva Gaimari), Sapromyza venusta Williston, 1896b (Trivialia Malloch, 1923), Sapromyza xanthiceps Williston, 1897 (Allominettia Hendel, 1925), Scatophaga scropharia Fabricius, 1805 (Sciosapromyza Hendel, 1933a), Sciomyza fulvescens Blanchard, 1854 (Zamyprosa Gaimari Silva), Sciomyza melanaspis Wiedemann, 1830 (Neominettia Hendel, 1925), Sciomyza nigripes Blanchard, 1854 (= Zamyprosa macquarti Gaimari Silva), Sciomyza obscuripennis Bigot, 1857 (Physegenua Macquart, 1848a/b), Scutolauxania piloscutellaris Hendel, 1925, Trigonometopus albifrons Knab, 1914, Trigonometopus rotundicornis Williston, 1896b. The following three species are removed from being recognized as part of the Neotropical fauna: Homoneura americana (Wiedemann, 1830; Sapromyza Fallén, 1810), Homoneura maculipennis (Loew, 1847; Sapromyza Fallén, 1810), Poecilohetaerus suavis (Loew, 1847; Sapromyza Fallén, 1810). The following four species are removed from the family, three of which are put into the following new combinations: Senopterina cyanea (Fabricius, 1805; Lauxania Latreille, 1804) (Platystomatidae), Dihoplopyga delicatula (Blanchard, 1854; Sapromyza Fallén, 1810) (Heleomyzidae), Pherbellia geniculata (Macquart, 1844b; Sapromyza Fallén, 1810) (Sciomyzidae). The remaining species, Sapromyza fuscipes Macquart, 1844b, is of uncertain family placement within the Muscoidea. The following new replacement names for species of Platystomatidae were necessary due to homonymy: Senopterina gigliotosi Gaimari Silva (for Bricinniella cyanea Giglio-Tos, 1893, nec Lauxania cyanea Fabricius, 1805), and Rivellia macquarti Gaimari Silva (for Tephritis unifasciata Macquart, 1843: 381, nec Macquart, 1835: 465).

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This review asks "What is the experience and effectiveness of nurse practitioners in orthopaedic settings"?The objective of the quantitative component of this review is to synthesise the best available evidence on effectiveness of orthopaedic nurse practitioner specific care on patient outcomes and process indicators.The objective of the qualitative component of this review is to synthesise the best available evidence on the experience of becoming or being an orthopaedic nurse practitioner in relation to role development, role implementation and (ongoing) role evaluation.The objective of the text and opinion component of this review is to synthesise the best available evidence of the contemporary discourse on the effectiveness and experience of nurse practitioners in orthopaedic settings. Nurse practitioner roles have emerged in response to areas of unmet healthcare needs in a variety of settings. Nurse practitioners first evolved in the United States 40 years ago in response to a shortage of primary health care physicians. Nurse practitioners filled the void by providing access to primary health care services where otherwise there was none. Nurse practitioners comprise one branch of advanced nursing practice in the US along with Nurse Anaesthetists (NA), Clinical Nurse Specialists (CNS) and Nurse Midwives (NM). Canada soon followed America's lead by establishing the nurse practitioner role in 1967. Canada has two areas of advanced nursing practice, namely nurse practitioner and clinical nurse specialist; they are moving towards introducing nurse anaesthetists currently. The nurse practitioner role was introduced into the United Kingdom 20 years ago.There is commonality amongst the definition and characteristics of Nurse Practitioner (NP)/Advanced Practice Nurse (APN) role and practice internationally in terms of education, practice standards and regulation; operationally there is variability however. Australia's progress with nurse practitioners is very much informed by the experiences of the United States and United Kingdom and for the most part there exists a parallel between the international experience and the Australian experience of nurse practitioners.This review will focus on orthopaedic nurse practitioners in an international context. However the local context of the primary reviewer which informs this review is Australian. Australia has mirrored the trends around nurse practitioner practice found elsewhere. In the last 20 years (post implementation of the 1986 Australian nursing career structure), the debate around advanced nursing practice and nurse practitioners, in an Australian context, has developed. The inaugural 'legal &amp; policy' nurse practitioner framework was developed in New South Wales (NSW) in 1998, with the first Australian nurse practitioner authorised to practise in NSW in 2000. It is posited that evaluation of emerging roles began to be seen in the research literature from 1990 onwards. In response to a need for creative workforce re-engineering and against a context of limited health resources, nurse practitioners in Australia over the last 20 years have emerged as an alternative model of health care delivery. For the last 10 years there has been a proliferation of influential 'reports' written by nurse researchers, generated to review the progress of Australia's nurse practitioners, commissioned by the health departments of respective state governments and other service planners to guide health workforce planning.In a national context the Australian Nursing &amp; Midwifery Council (ANMC) as the peak national nursing body, defines a nurse practitioner as a Registered Nurse (RN) who is educated and authorised to practice autonomously and collaboratively in an advanced and extended clinical role. The ANMC Competency Standards for the Nurse Practitioner encompass three generic standards which are further defined by nine competencies. The competency standards provide a framework for practice and licensure of nurse practitioners in Australia. In order for the nurse practitioner to be endorsed by the Australian Health Practitioner Regulation Agency (AHPRA) to practise as a nurse practitioner they must have met the competency standards and be endorsed to practise by the Nursing and Midwifery Board of Australia (NMBA) as a nurse practitioner under section 95 of the National Law. The nurse practitioner's endorsement in Australia is contextualised by their scope of practice, as is the case internationally.At September 2011, 450 endorsed nurse practitioners were nationally registered with AHPRA; 54 of these were endorsed to practise in South Australia. The first orthopaedic nurse practitioner was authorised in South Australia in 2005. To date there are eight endorsed orthopaedic nurse practitioners in Australia authorised to practise in a diverse range of orthopaedic settings that include acute care, community care, outpatient settings, rehabilitation, private practice and rural settings. The current scope of practice for Australian orthopaedic nurse practitioners spans the clinical range of trauma, arthroplasty, fragility fracture and ortho-geriatric care, surgical care: spinal/neurology and paediatric care. Orthopaedic nurse practitioners work within contemporary orthopaedic/musculoskeletal client disease models. These clinical models of care articulate the health care needs of populations living with musculoskeletal conditions, disorders and disease. Osteoarthritis and osteoporosis are 'highly prevalent long term [musculoskeletal] conditions known to predominantly affect the elderly and comprise the most common cause of disability in Australia'. Musculoskeletal trauma or injury as a result of an 'external force' such as vehicle accident, a fall, industrial or home environment accident or assault comprises a leading cause of hospital admission that requires orthopaedic management and care.There is some evidence to suggest that orthopaedic nursing is a 'specialty under threat' as orthopaedic-specific hospital wards are increasingly being absorbed into general surgical units; a trend observed in the United States in the mid 1990's in response to the American experience of 'downsizing' orthopaedic nursing services. Despite a limited evidence base, early citations with specific reference to orthopaedic nurses in the American context in particular started to populate the literature on or around this time. Several proponents of the specialty began to refer to a core nursing skill set that was 'highly orthopaedic' when describing 'specialist' orthopaedic nursing practice. More recently commentators point to differences in certain variables when patients are 'outlied' or managed in a non-orthopaedic ward environment by non-orthopaedic nurses.Despite 'in-principle' support for expanded scopes of practice for various health practitioner roles, the observation exists from within the specialty of orthopaedic nursing that progress in establishing the orthopaedic nurse practitioner role for this group of specialist clinicians has been slow and their journey has not been without challenge. The majority of orthopaedic nurse practitioners in Australia at least have emerged from extended practice roles similar to the generally well established experience of other nurse practitioners emerging from their own practice interest. The orthopaedic nurse practitioner is considered a 'pioneer' as they fill a 'gap' in clinical need and develop an orthopaedic nurse practitioner role. An emerging evidence base suggests that barriers such as a lack of role understanding, lack of 'team' support and a lack of resources at a system, organisational and practice level, constrain nurse practitioner practice and integration of the role into practice settings. Nurse practitioners function in an advanced clinical role. Some attempts have been made at quantifying the work of nurse practitioners. For example, Gardner et al in 2010 divided the work of nurse practitioners into three domains of practice: direct care, indirect care and service-related activities. Within these domains nurse practitioners perform a variety of tasks. Reporting on such activity by way of performance outcome measures is a variable practice amongst nurse practitioners however numbers seen/occasions of service, waiting times, effectiveness of interventions, referral patterns, patient/client satisfaction, clinical quality of care indicators are typical of the data maintained and reported by nurse practitioners to either justify their existence, embed their role service wide and/or contribute to workforce planning. Furthermore the orthopaedic nurse practitioner must effectively define and characterise the patient population to which they deliver care within the nurse practitioner's own scope of practice, ultimately to form an 'indicator' for the nurse practitioner role.The international literature pertaining to nurse practitioners or advanced practice nurses resonates with the many challenges faced by these nurses when it comes to role development and role implementation. Furthermore there is a body of evidence that validates the effectiveness of these roles. This becomes increasingly important in a context of building the health workforce of the future: a redefined workforce that must ensure adequate numbers of suitably qualified health workers who provide 'care the first time and every time'.A search of the Joanna Briggs Institute (JBI) Library of Systematic Reviews, Cochrane Library, PubMed and CINAHL has shown there are no existing or systematic reviews underway on this topic. The JBI undertook a systematic review commissioned by the Department of Health South Australia on Advanced Practice in Nursing and Midwifery and recommended a framework for advanced practice in a report released in early 2008. The framework defined advanced practice, levels of advanced practice, scope of practice, credentialing, education, preparation and regulation of advanced practitioners. The search identified a published systematic review protocol in the JBI Library for a qualitative systematic review by Ramis looking broadly at the experience of advanced practice nurses working in acute settings. The JBI Library of Systematic Reviews also contains a systematic review examining the effectiveness of nurse practitioners in residential aged care. Whilst these publications provide valuable context to this review neither specifically examines the clinical practice of orthopaedic nurse practitioners.Similarly a search of the Cochrane Library revealed a review on the topic of substitution of doctors by nurses in primary care. The focus of this particular intervention review was neither specific to nurse practitioners nor the acute care setting, but the topic of 'doctor substitution' complements the practice of nurse practitioners and may be a consideration in this review. Doctor substitution or care provided by a nurse other than an orthopaedic nurse practitioner is a natural comparator when examining the role and practice of orthopaedic nurse practitioners.Given the breadth of this topic a comprehensive approach has been chosen to systematically review the evidence as it relates to orthopaedic nurse practitioner role and practice.

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Benzyl acetate is used as a flavoring agent in foods, as a fragrance in soaps and perfumes, as a solvent for cellulose acetate and nitrate, and as a component of printing inks and varnish removers. The NTP previously studied the toxicology and carcinogenicity of this chemical in F344/N rats and B6C3F1 mice using the gavage route of administration and corn oil as a vehicle. Benzyl acetate increased the incidences of pancreatic acinar cell adenomas in male rats and the incidences of hepatocellular adenomas and forestomach neoplasms in male and female mice. Because of the confounding effect of corn oil on the incidences of pancreatic neoplasms and because of controversy over the use of the gavage route of administration, the NTP decided to restudy benzyl acetate using the dosed feed route of administration. In these repeat studies, male and female F344/N rats and B6C3F1 mice received benzyl acetate (at least 98% pure) in feed for 13 weeks and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium nunnery, cultured Chinese hamster ovary cells, LS178Y mouse lymphoma cells, Drosophila melanogaster, and mouse bone marrow and peripheral blood cells. 13-WEEK STUDY IN RATS: Groups of 10 male and 10 female F344/N rats were fed diets containing 0, 3,130, 6,250,12,500, 25,000, or 50,000 ppm (0, 230, 460, 900,1,750, or 3,900 mg/kg body weight for males and 0, 240, 480, 930,1,870, or 4,500 mg/kg for females) benzyl acetate for 13 weeks. Nine male and nine female rats receiving 50,000 ppm benzyl acetate died or were killed moribund between weeks 2 and 8 of the study. The mean body weight gain and the final mean body weight of 25,000 ppm males were significantly lower (P&lt;/=0.01) than those of the control group. Feed consumption by exposed rats, except the 25,000 and S0,000 ppm males and 50,000 ppm females, was similar to that by the controls. The reduced feed consumption by 25,000 and 50,000 ppm males and 50,000 ppm females may have been due to toxicity or decreased palatability. Tremors and ataxia occurred only in the 50,000 ppm rats. These findings were first observed on day 15 in nine males and six females and continued until the end of the study. Cholesterol levels in 12,500 and 25,000 ppm females and triglyceride levels in 25,000 ppm females were lower than those in the controls. Chemical-related lesions occurred in the brain, kidney, tongue, and skeletal muscles of the thigh. Necrosis of the brain involving the cerebellum and/or hippocampus, degeneration and regeneration of the renal tubule epithelium, and degeneration and sarcolemma nuclear hyperplasia of the tongue and skeletal muscles occurred in most male and female 50,000 ppm rats. This effect was observed in the 1,000 mg/kg group in the previous gavage study (NTP, 1986). 13-WEEK STUDY IN MICE: Groups of 10 male and 10 female B6C3F1 mice were fed diets containing 0, 3, 130, 6,250, 12,500, 25,000, or 50,000 ppm (0, 425, 1,000, 2,000, 3,700, or 7,900 mg/kg body weight for males and 0, 650, 1,280, 2,980, 4,300, or 9,400 mg/kg for females) benzyl acetate. One 50,000 ppm male mouse died and one 50,000 ppm female mouse was killed moribund before the end of the study. Mean body weight gains and final mean body weights of all exposed male and female mice were significantly lower than those of the controls and the mean body weight gains decreased with increased exposure level. Feed consumption by 3,130 ppm males and all exposed females was lower than that by the controls. Tremors occurred only in females and were first observed on day 16 in three females receiving 50,000 ppm, day 94 in one female receiving 25,000 ppm, and day 93 in one female receiving 12,500 ppm. The tremors continued until the end of the study. Necrosis of the brain involving the hippocampus occurred in four 50,000 ppm mice, one male and three females. Hepatocellular necrosis also occurred in the male with brain lesions. On reexamination of the previous 13-week gavage study (NTP, 1986), a similar lesion was seen in the brain of one 1,000 mg/kg female mouse; none were seen in 1,000 mg/kg male mi male mice. The lesion was less severe than that described in the present dosed feed study. The highest dose used in the gavage study was 1,000 mg/kg compared to an estimated high dose of 7,200 mg/kg for the feed study. 2-YEAR STUDY IN RATS: The doses selected for the 2-year feed study of benzyl acetate in F344/N rats were based on lower survival, mean body weights, and feed consumption, and on increased incidences of histopathologic brain lesions in 50,000 ppm male and female rats in the 13-week study. Groups of 60 male and 60 female F344/N rats were fed diets containing 0, 3,000, 6,000, or 12,000 ppm benzyl acetate for 2 years. Survival, Body Weights, Feed and Compound Consumption, and Clinical Pathology: Survival of exposed rats was similar to that of the controls. The mean body weights of the 12,000 ppm males and exposed females were approximately 5&amp;percnt; lower than those of the controls throughout most of the study. The feed consumption by 12,000 ppm males was slightly lower than that by the controls. Dietary levels of 3,000, 6,000, and 12,000 ppm benzyl acetate were estimated to result in average daily consumption levels of 130, 260, and 510 mg/kg body weight (males) and 145, 290, and 575 mg/kg (females). No biologically significant changes in hematology or clinical chemistry parameters were found that could be attributed to benzyl acetate administration. Pathology Findings: No compound-related increased incidences of neoplasms or nonneoplastic lesions occurred in male or female F344/N rats receiving benzyl acetate for as long as 2 years. 2-YEAR STUDY IN MICE: The doses selected for the 2-year feed study of benzyl acetate in B6C3F1 mice were based primarily on lower body weight gains and lower final mean body weights of exposed mice in the 13-week study. Groups of 60 male and 60 female B6C3F1 mice were fed diets containing 0, 330, 1,000, or 3,000 ppm benzyl acetate for 2 years. Survival, Body Weights, Feed and Compound Consumption, and Clinical Pathology: Survival of all exposed mice, except the 3,000 ppm females, was similar to that of the control groups. Survival of 3,000 ppm females was significantly higher than that of the control group. Throughout the 2-year study, the mean body weights of 1,000 and 3,000 ppm males and females were 2&amp;percnt; to 14&amp;percnt; lower than those of the control groups. Dietary levels of 330, 1,000, and 3,000 ppm benzyl acetate were estimated to result in average daily consumption levels of 35, 110, and 345 mg/kg (males) and 40, 130, and 375 mg/kg (females). No biologically significant changes in hematology or clinical chemistry parameters were observed in mice receiving 330,1,000, or 3,000 ppm benzyl acetate. Pathology Findings: No increase in neoplasm incidence in mice could be attributed to benzyl acetate administration in feed. This contrasts with the previous finding that administration of benzyl acetate in corn oil by gavage once daily 5 days a week for as long as 2 years was carcinogenic to mice, causing increased incidences of hepatocellular neoplasms and forestomach neoplasms. The contrast in results between the two studies may be due to differences in the dose levels used (highest dose: gavage, 1,000 mg/kg a day; feed, 360 mg/kg a day). Dose-related increased incidences or severities of nonneoplastic nasal lesions occurred in the most posterior portions of the nasal cavity in all exposed groups. The lesions occurred in the majority of the exposed mice and consisted of atrophy and degeneration, primarily of the olfactory epithelium, cystic hyperplasia of the nasal submucosal glands, pigmentation of the mucosal epithelium, and exudate accumulation. GENETIC TOXICOLOGY: Benzyl acetate was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537, with or without exogenous metabolic activation (S9). However, a positive response was observed for benzyl acetate, with and without S9, in the mouse lymphoma assay for induction of trifluorothymidine resistance in L5178Y cells. No significant increases in the frequencies of sister chromatid exchanges or chromosomal aberrations occurred in cultured Chinese hamster ovary cells treated with benzyl acetate in vitro, with or without S9, and no increases in either sister chromatid exchanges or chromosomal aberrations occurred in bone marrow cells of male mice treated in vivo by intraperitoneal injection. No increase in sex-linked recessive lethal germ cell mutations occurred in male Drosophila melanogaster administered benzyl acetate in feed or by injection. Tests of benzyl acetate for induction of micronucleated erythrocytes in bone marrow and peripheral blood of mice were also negative. CONCLUSIONS: Under the conditions of these 2-year feed studies, there was no evidence of carcinogenic activity of benzyl acetate in male or female F344/N rats receiving 3,000, 6,000, or 12,000 ppm; however, rats may have tolerated higher doses. There was no evidence of carcinogenic activity of benzyl acetate in male or female B6C3F1 mice receiving 330, 1,000, or 3,000 ppm. Nasal lesions associated with benzyl acetate exposure in male and female mice included nasal mucosa atrophy and degeneration (primarily of the olfactory epithelium), cystic hyperplasia of the nasal submucosal gland, and luminal exudate and pigmentation of the nasal mucosal epithelium. In previous 2-year gavage studies (TR-250), benzyl acetate increased the incidence of acinar cell adenomas of the exocrine pancreas in male F344/N rats; the gavage vehicle may have been a contributing factor. There was no evidence of carcinogenic activity in female F344/N rats receiving 250 or 500 mg/kg a day. There was some evidence of carcinogenic activity in male and female B6C3F1 mice, indicated by the increased incidences of hepatocellular adenomas and squamous cell neoplasms of the forestomach. Synonyms: acetic acid benzyl ester, acetic acid phenyl methyl ester, (acetoxymethyl)benzene, acetoxytoluene, benzyl ethanoate, phenylmethyl acetate

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We found that human genome coding regions annotated by computers have different kinds of many errors in public domain through homologous BLAST of our cloned genes in non-redundant (nr) database, including insertions, deletions or mutations of one base pair or a segment in sequences at the cDNA level, or different permutation and combination of these errors. Basically, we use the three means for validating and identifying some errors of the model genes appeared in NCBI GENOME ANNOTATION PROJECT REFSEQS: (I) Evaluating the support degree of human EST clustering and draft human genome BLAST. (2) Preparation of chromosomal mapping of our verified genes and analysis of genomic organization of the genes. All of the exon/intron boundaries should be consistent with the GT/AG rule, and consensuses surrounding the splice boundaries should be found as well. (3) Experimental verification by RT-PCR of the in silico cloning genes and further by cDNA sequencing. And then we use the three means as reference: (1) Web searching or in silico cloning of the genes of different species, especially mouse and rat homologous genes, and thus judging the gene existence by ontology. (2) By using the released genes in public domain as standard, which should be highly homologous to our verified genes, especially the released human genes appeared in NCBI GENOME ANNOTATION PROJECT REFSEQS, we try to clone each a highly homologous complete gene similar to the released genes in public domain according to the strategy we developed in this paper. If we can not get it, our verified gene may be correct and the released gene in public domain may be wrong. (3) To find more evidence, we verified our cloned genes by RT-PCR or hybrid technique. Here we list some errors we found from NCBI GENOME ANNOTATION PROJECT REFSEQs: (1) Insert a base in the ORF by mistake which causes the frame shift of the coding amino acid. In detail, abase in the ORF of a gene is a redundant insertion, which causes a reading frame shift in the translation of an alternative protein, such as LOC124919 is wrong form of C17 orf32 (with mouse and rat orthologs determined by us). (2) Put together by mistake (with force). This is a wrong assembly of non-relating cDNA segment, such as LOC147007 is wrong form of C17orf32. (3) Mistakenly insert a base or one section of cDNA in the ORF which causes it ending beforehand, only coding cDNA sequence of N-terminal amino acids, incomplete. For example, LOC123722 is wrong form of SPRYD1, and even the human hypothetical gene LOC126250 or PDCD5 is wrong form of our PDCD5 (TFAR19). (4) Incomplete, only coding cDNA sequence of C-terminal amino acids. For example, human LOC149076 and mouse LOC230761 are wrong form of our verified human ZNF362 and mouse Zfp362, respectively. (5) Incomplete, only coding one section of coding protein cDNA sequence of correct gene ORF, lacking N-terminal and C-terminal amino acids sequence, and at the same time, mistakenly anticipates the first non-initiation codon amino acid of the incomplete protein amino acid as the initiation codon, e.g. anticipating L as M. For example, LOC200084 is wrong form of ZNF362. (6) Mistakenly insert a base or one section of cDNA in the ORF, wrongly causing unwanted termination codon before the insertion, so the coding protein lacks the first part of the amino acids. For example, the GenBank Acc. No. AL096883 ( LOCUS No. HS323M22B) is wrong form of an experimentally verified human NM_012263 with mouse ortholog of BC010510 determined. (7) It may regard the polluted genomic sequence as complete gene cDNA sequence and anticipate the so-called single exon gene, even the real one, only a small ORF in the very long single exon mRNA, while there really exists termination code in the same phase of the upper part of the ORF initiation code, no other characters accord with the gene's condition. For example, LOC91126 is wrong form of ZNF362. (8) The anticipated genes only have ORF which has no EST proofs on both terminal sides. Depending on this ORF, a complete gene cDNA with double support of EST and human genome (there are termination codes at the same phase of the upper part of ORF) which indicates the anticipated ORF reference sequence may be incorrect. For example, LOC164395 may be wrong form of novel human gene bankit4590055. (9) A similar but smaller protein-coding gene is anticipated in the range of the human genome sequence that has the support of EST experimental proof, so other new anticipated gene may be incorrect. For example, LOC167563 may be wrong form of CMYA5. However,these errors can be corrected or avoided by using our strategy. Here we give one example in detail: Comparision of the sequence SPRYD1 with human hypothetical gene LOC123722. The TAA bases in the position of 478-480 in LOC123722 cDNA is redundant, which causes a reading frame shift in the translation of an alternative protein. The redundancy of GTAAA of LOC123722 is not supported by our experimental clone,and is almost fully rejected by human EST alignment, and is shown as the next intron sequence by genomic GT/AG organization analysis. The verification of cDNA or genomic DNA sequence of SPRYD1 implies that LOC123722 has a wrong stop codon within its ORF because of the prediction program, thus being not complete cds. To sum up, by combining bioinformatics analyses with experimental verification, we have found that there are many errors of at least nine kinds appeared in NCBI GENOME ANNOTATION PROJECT REFSEQs through BLAST of our cloned genes in non-redundant database, and our strategy is helpful in correcting them, such as LOC14907, LOC200084 and LOC91126 (all of them should be ZNF362, but are three different kinds of wrong forms of ZNF362), three model reference sequences predicted from NCBI contig NT_004511 by automated computational analysis using gene prediction method, or such as LOC124919 and LOC147007 (both should be C17orf32, but are two different kinds of wrong forms of C17orf32), two model reference sequences predicted from NCBI contig NT_010808 by automated computational analysis using gene prediction method. Therefore, the correct identification and annotation of novel human genes may be still a heavy task, which can be finished within a long period of time. So human genome coding regions annotated by computer should be used with caution. The articles published in the past did not clearly point out the existence of mistakes in the NCBI human gene mode reference sequence. At the Seventh International Human Genome Conference held in April 2002, we first published the researching result on this aspect in the communication form of Posterly insert a base or one section of cDNA in the ORF, wrongly causing unwanted termination codon before the insertion, so the coding protein lacks the first part of the amino acids. For example, the GenBank Acc. No. AL096883 ( LOCUS No. HS323M22B) is wrong form of an experimentally verified human NM_012263 with mouse ortholog of BC010510 determined. (7) It may regard the polluted genomic sequence as complete gene cDNA sequence and anticipate the so-called single exon gene, even the real one, only a small ORF in the very long single exon mRNA, while there really exists termination code in the same phase of the upper part of the ORF initiation code, no other characters accord with the gene's condition. For example, LOC91126 is wrong form of ZNF362. (8) The anticipated genes only have ORF which has no EST proofs on both terminal sides. Depending on this ORF, a complete gene cDNA with double support of EST and human genome (there are termination codes at the same phase of the upper part of ORF) which indicates the anticipated ORF reference sequence may be incorrect. For example, LOC164395 may be wrong form of novel human gene bankit4590055. (9) A similar but smaller protein-coding gene is anticipated in the range of the human genome sequence that has the support of EST experimental proof, so other new anticipated gene may be incorrect. For example, LOC167563 may be wrong form of CMYA5. However, these errors can be corrected or avoided by using our strategy. Here we give one example in detail: Comparision of the sequence SPRYD1 with human hypothetical gene LOC123722. The TAA bases in the position of 478-480 in LOC123722 cDNA is redundant, which causes a reading frame shift in the translation of an alternative protein. The redundancy of GTAAA of LOC123722 is not supported by our experimental clone, and is almost fully rejected by human EST alignment, and is shown as the next intron sequence by genomic GT/AG organization analysis. The verification of cDNA or genomic DNA sequence of SPRYD1 implies that LOC123722 has a wrong stop codon within its ORF because of the prediction program, thus being not complete cds. To sum up, by combining bioinformatics analyses with experimental verification, we have found that there are many errors of at least nine kinds appeared in NCBI GENOME ANNOTATION PROJECT REFSEQs through BLAST of our cloned genes in non-redundant database, and our strategy is helpful in correcting them, such as LOC14907, LOC200084 and LOC91126 (all of them should be ZNF362, but are three different kinds of wrong forms of ZNF362), three model reference sequences predicted from NCBI contig NT_004511 by automated computational analysis using gene prediction method, or such as LOC124919 and LOC147007 (both should be C17orf32, but are two different kinds of wrong forms of C17orf32), two model reference sequences predicted from NCBI contig NT_010808 by automated computational analysis using gene prediction method. Therefore, the correct identification and annotation of novel human genes may be still a heavy task, which can be finished within a long period of time. So human genome coding regions annotated by computer should be used with caution. (ABSTRACT TRUNCATED)

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There has been a reported rise in the number of people with chronic illness (also referred to as long-term disease) in the Western world. One hundred million people in the United States have at least one chronic condition and in the United Kingdom (UK) as many as 17.5 million adults may be living with chronic disease. New models of care have been developed which recognise the complexities of managing care where there is overlap between the wider community, the health care system and provider organisations, for example, the Chronic Care Model and the Expert Patient Programme. These new models herald a shift away from the idea of chronically ill patients as passive recipients of care towards active engagement, in partnership with health professionals, in managing their own care.Partnership, ideally, involves collaborative care and self-management education. This may support self-care alongside medical, preventative and health maintenance interventions. In this context the nature of the patient-practitioner consultation in promoting self-care takes on a new importance. The overall objective of the review was to determine the best available evidence regarding the promotion and support of self-care management for adults living in the community with chronic illness during the patient-practitioner encounter. Specifically the review sought to determine: What is the effectiveness of the patient-practitioner encounter in promoting and supporting self-care management of people with chronic illness? What are the individual and organisational factors which help or hinder recognition, promotion and support of chronic disease self-care management strategies? What are the similarities and differences between how 'effectiveness' is defined in this context by patients and different practitioners? The review focussed on self-caring adults aged nineteen years and older living in the community, with a physical chronic illness, and not currently being treated as an in-patient. For example, people with diabetes, asthma, arthritis, coronary disease, lung disease, heart failure, epilepsy, kidney disease and inflammatory bowel disease. Since patients meet various professionals in a variety of community settings regarding their care, a practitioner in this review included doctors (physicians and General Practitioners), nurses, nurse specialists, dieticians, podiatrists and community health workers.A variety of outcomes measures was used to evaluate effective self-care management. These included physiological measurements such as: HbA1c, blood pressure, body weight, lipids; lifestyle measurements, for example physical activity; and self-care determinants such as knowledge, attitude; and self-care behaviours regarding, for example, diet and physical exercise, and medication. The outcome measures used to explore the meaningfulness of the patient-practitioner encounter, concerned patients', physicians' and nurses' views and perceptions of self-care management and support.The review considered all types of quantitative and qualitative evidence regarding the patient-practitioner encounter where self-care in chronic illness was the focus. The quantitative studies reviewed included systematic reviews, randomised controlled trials (RCTs), quasi-experimental studies, and survey studies.Qualitative studies reviewed included interview designs, vignette technique, qualitative evaluation, grounded theory, and exploratory descriptive design. The search sought to find both published and unpublished studies between 1990 and 2005. The year 1990 was deemed appropriate since it precedes the development of the Chronic Care Model in which self-management support for people living with chronic illness is heralded as an important part of care-management. An initial search of CINAHL and MEDLINE databases was undertaken to identify appropriate search terms regarding self-care and chronic illness. A search strategy was then developed using all identified MeSH headings and key words and the following databases were searched: - Ovid CINAHL; Ovid MEDLINE (R); Ovid EMBASE; Ovid EBM Reviews (CDSR, ACP Journal Club, DARE, CCTR); ASSIA; SIGLE; Digital Dissertations; and British Library's Zetoc Services. Thirty-two papers were considered applicable to the review topic from the title and abstract. Two reviewers used the appropriate critical appraisal instruments designed by the Joanna Briggs Institute (JBI) to assess methodological quality of papers retrieved for review, and agreed on the papers for inclusion. A total of 18 papers reporting 16 studies were included in the review (3 papers reported from the same study): 12 quantitative studies, 5 qualitative studies and 1 study using mixed methods. These papers were heterogeneous in nature, diverse in subject matter and considered a wide range of physiological, psychological, sociological and behavioural self-care outcome measures. Data were extracted by the two independent reviewers using a variety of data extraction instruments developed by JBI. The heterogeneous nature of the quantitative studies prevented meta-analysis and so these studies are presented in narrative summary. Meta-synthesis of the qualitative data was performed for the six qualitative pieces following the process of meta-synthesis set out in the JBI-QARI software package. The process of meta-synthesis embodied in this programme involves the aggregation or synthesis of findings. Seven syntheses were produced from fifty findings. For effective patient-centeredness to be established patients should be able to discuss their own ideas about self-care actions, including lifestyle management in an unhurried fashion and with a practitioner who has the time and who is willing to listen. Patient-centred interventions aimed at providers such as patient-centred training and patient-centred materials were shown to have a positive effect on the patient-centeredness of an encounter, but their effect on self-care outcomes was not clear. Interventions directed at enhancing patient participation in the encounter were shown to effect diabetes self-care and self-behaviour.Nurses were shown to have an effective role in educating patients and facilitating adherence to treatment. Patients found nurses approachable and some studies showed that when given the choice, patients were more likely to contact a nurse (than a doctor) regarding their care.Professional interventions such as education, and organisational interventions such as management of regular review and follow up, were shown to improve process outcomes in the management of a patient-practitioner encounter. When patient-orientated interventions were added to professional and organisational interventions, in which patient education and / or the role of the nurse was enhanced, patient health outcomes were improved.The different patient-orientated interventions reviewed highlighted some of the elements that can effectively support self-care management during a patient-practitioner encounter. These are information giving, including the use of a guidebook, the use of care plans, the structure of treatment using checklists, and education and support for staff in 'collaboratives'.Comprehensive, well-paced, user-friendly information is effective in supporting and promoting self-care management in a variety of ways. It informs and reassures patients and their families. It can be used during a doctor/patient consultation to assist communication between doctors and patients, and may help patients feel more involved in their care.For information to effect self-care management, it is important that it is given at diagnosis and from then onwards so that the implications of good self-care management in relation to long term health outcomes are established.Care plans and self-management plans can be useful in facilitating patients' discussion of self-care actions and lifestyle management.Organisational factors affect opportunities for professionals to support patient self-care management. These include time, resources, the existing configuration and expectations of a consultation, the opportunity for open access to appointments, the ability to see the same doctor and early referral to other professional groups.Correlational design studies indicated that individual psychological factors, such as attachment style and autonomy support given to a patient during a patient-practitioner encounter, have a relationship to self-care behaviours and outcomes.Correlational design studies indicated that both general communication and diabetic specific communication used during a patient-practitioner encounter have a positive effect on patient self-care management and outcomes for patients with diabetes.Consultations about self-care for patients with chronic illness tend to be medically focussed and do not always include discussion of patients' views of the routines and self-care actions. This can lead to tension and unresolved issues between the patient and professional.Studies in the context of diabetes self-management reveal that professionals can effectively support patients in a number of ways. These include assisting the orientation of patients towards skills and competencies needed for self-care; sharing knowledge and information; endorsing the patient's view that he or she is the most reliable and accurate source of information about his or her physiological function; trusting the patients' interpretations of their physiological function, and modifying advice in response to patients in accordance with their bodily cues and experiences. The nature of the patient-practitioner encounter is multifaceted involving patient, professional and organisational factors. Patient-orientated interventions are the most effective in effecting positive self-care behavioural and health outcomes. Patient participation in the patient-practitioner encounter is a key factor in influencing self-care outcomes. Patients' self-care management involves social as well as medical management. Professionals need to recognise and value patients' views and experiences in order to support their self-care management. Patients need information at diagnosis and from then onwards to enable good self-care management. It is important to enable patient participation during the patient-practitioner encounter.For patients' self-care needs to be addressed opportunities for patients to talk about their diet, routines and lifestyle management need to be incorporated into the encounter. Extra time in consultations may be required. Care plans can help to facilitate this discussion.To support patients with their self-care management, both sharing of medical and nursing knowledge, and recognition of the value of patient's knowledge and experiences are vital.Nurses relate well to patients who want to discuss self-care management.Professional interventions and organisational interventions can improve the management of a patient-practitioner encounter. Patient-orientated interventions in addition to good management of the encounter can improve health care outcomes. Patient focussed interventions have a positive effect on patient self-care outcomes. Further research regarding patients' self-care and health outcomes and behaviours is needed to establish which patient focussed interventions in particular are effective.Qualitative research has proved to be important in understanding the different ways that professionals and patients approach self-care management during an encounter. More qualitative research would assist an understanding of the processes that inspire effective partnership between patients and professionals to support the establishment of self-care management of chronic illness.

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Diethylphthalate and dimethylphthalate are used as phthalate plasticizers, in an extensive array of products. The chronic dermal toxicity of diethylphthalate was evaluated in male and female F344/N rats and B6C3F1 mice in 2-year studies. In a series of special studies, the tumor initiation or promotion potential of diethylphthalate or dimethylphthalate was evaluated in male Swiss (CD-1(R)) mice by an initiation/promotion model of skin carcinogenesis. The genetic toxicity of diethylphthalate and dimethylphthalate in Salmonella typhimurium and cultured Chinese hamster ovary cells was also evaluated. 4-WEEK STUDY IN F344/N RATS: Groups of 10 male and 10 female rats were dermally administered diethylphthalate at volumes of 0, 37.5, 75, 150, or 300 &amp;mgr;L (0, 46, 92, 184, or 369 &amp;mgr;g) applied neat, 5 days per week for 4 weeks. All male and female rats survived to the end of the study. No evidence of dermatotoxicity was observed, with no adverse clinical signs observed and no effects on weight gain or feed consumption. Relative liver weights of 300 &amp;mgr;L males and females and 150 &amp;mgr;L females were greater than those of controls. Relative kidney weights of 150 and 300 &amp;mgr;L males and 150 &amp;mgr;L females were greater than those of controls. No other adverse effects were observed in this study. 4-WEEK STUDY IN B6C3F1 MICE: Groups of 10 male and 10 female mice were dermally administered diethylphthalate at volumes of 0, 12.5, 25, 50, or 100 &amp;mgr;L (0, 15, 31, 62, or 123 &amp;mgr;) applied neat, five days per week for 4 weeks. One control female died before the end of the study; all other mice survived. No evidence of dermatotoxicity or other adverse clinical signs were observed, and no clear adverse effects on weight gain or feed consumption were seen. Absolute and relative liver weights of 25 and 100 &amp;mgr;L females were greater than those of the controls. Based on these 4-week study results, doses of 0, 35, and 100 &amp;mgr;L diethylphthalate were recommended for the 2-year mouse studies. A chronic study in male and female B6C3F1 mice at 0, 35, and 100 &amp;mgr;L (applied neat, once per day, 5 days per week) was started and subsequently stopped after 32 weeks when significant body weight reductions were noted in treated animals (males and females, 100 &amp;mgr;L groups: 19% lower; males, 35 &amp;mgr;L group: 12% lower; females, 35 &amp;mgr;L group: 10% lower than controls). Based on these body weight reductions, doses of 0, 7.5, 15, and 30 &amp;mgr;L in 100 &amp;mgr;L acetone were recommended for the restart of the 2-year mouse study. 2-YEAR STUDY IN F344/N RATS: Based upon the results of the 4-week study, doses of 0, 100, or 300 &amp;mgr;L diethylphthalate (0, 123, or 369 &amp;mgr;) were chosen for the 2-year rat study. Groups of 60 male and 60 female rats received the doses applied neat 5 days per week for 103 weeks and up to 10 animals per group were evaluated after 15 months. Survival, Body Weights, and Clinical Findings: Survival of dosed rats during the first 15 months was similar to that of controls. However, 2-year survival was significantly reduced in all groups of male rats (survival probabilities, males: 0 &amp;mgr;L, 8%; 100 &amp;mgr;L, 12%; and 300 &amp;mgr;L, 12%). The mean body weights of 300 &amp;mgr;L males were slightly less than those of the controls throughout the study. No adverse clinical signs were observed, including no evidence of dermatotoxicity. Pathology Findings: No morphological evidence of dermal or systemic toxicity was observed in male or female rats. Skin neoplasms were not observed in female rats and were only rarely observed in male rats. A high incidence of anterior pituitary adenoma occurred in all groups of male and female rats. The incidence of anterior pituitary adenomas in the 0, 100, and 300 &amp;mgr;L groups were: males, 39/44, 41/49, 41/49; females, 38/50, 33/49, 33/48. The incidence of this benign tumor in control males (84%) exceeded the historical control mean incidence [feed controls, (28.7%)] and range (12% to 60%). Anterior pituitary adenomas were considered a primary contributing factor in the increased mortality observed in all grtor in the increased mortality observed in all groups, regardless of treatment. A dose-related decreasing trend in the incidence of mammary gland fibroadenomas was observed in female rats (21/50, 12/48, 7/50). The incidence of mononuclear cell leukemia in male rats in this study was lower than the historical incidence and may be attributable to the shortened life span of male rats. Similarly, the incidence of interstitial cell tumors of the testes was markedly decreased in all groups of males (4/50, 3/50, 8/50), relative to historical control rates (90.1&amp;percnt;; range 74&amp;percnt;-98&amp;percnt;). The incidence of fatty liver degeneration was notably lower in dosed rats than in controls (males: 26/50, 8/50, 4/51; females: 23/50, 11/50, 3/50). 2-YEAR STUDY IN B6C3F1 MICE: Groups of 60 male and 60 female mice received doses of 0, 7.5, 15, or 30 &amp;mu;L diethylphthalate (0, 9, 18, or 37 &amp;mu;) in 100 &amp;mu;L acetone 5 days per week for 103 weeks with a 1 week recovery period, and up to 10 animals per group were evaluated after 15 months. Survival, Body Weights, and Clinical Findings: Two-year survival of dosed mice was similar to that of controls: 43/50, 41/48, 46/50, and 43/50 (males), and 41/50, 38/51, 37/49, and 36/49 (females). Mean body weights of dosed male and female mice were similar to those of the controls throughout the study. No adverse clinical signs were observed in mice, including no gross evidence of dermatotoxicity. Feed consumption by male and female mice was similar to or up to 13% greater than that by controls. Pathology Findings: No morphological evidence of dermal toxicity was observed in male or female mice. No skin neoplasms were observed in dosed male mice. In female mice receiving 30 &amp;mu;L, one squamous cell carcinoma and one basal cell carcinoma were seen at the site of application. An increased incidence of liver neoplasms was observed in dosed male and female mice. The incidence of hepatocellular adenoma or carcinoma (combined) in B6C3F1 mice in the 0, 7.5, 15, and 30 &amp;mu;L groups were: (males) 9/50, 14/50, 14/50, and 18/50; (females) 7/50, 16/51, 19/50, and 12/50. The incidence of adenoma or carcinoma (combined) was increased in 30 &amp;mu;L male mice and the incidences of adenoma and of adenoma or carcinoma (combined) were increased in 7.5 and 15 &amp;mu;L females. A positive dose-related trend in the incidence of adenoma or carcinoma (combined) was also observed in male mice. The incidence of basophilic hepatic foci was increased in 15 &amp;mu;L male mice (0/50, 1/50, 9/50, 3/50). The increased incidence of liver neoplasms in this study was considered equivocal because the incidence of hepatocellular neoplasms in control and dosed males was within the historical range and because there was no clear dose-response relationship in females. No other treatment-related findings were observed in this study. 1-YEAR INITIATION/PROMOTION STUDY IN MALE SWISS (CD-1&amp;reg;) MICE: Groups of 50 male mice were dosed dermally with diethylphthalate or dimethylphthalate to study their effect as initiators and promoters. Diethylphthalate and dimethylphthalate were tested as initiators with and without the known skin tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA). Diethyl phthalate and dimethylphthalate were tested as promoters with and without the known skin tumor initiator 7,12-dimethylbenzanthrancene (DMBA). Comparative control groups used during the study of diethylphthalate and dimethylphthalate included: vehicle control (acetone/acetone); initiation/promotion control (DMBA/TPA); initiator control (DMBA/acetone); and promoter control (acetone/TPA). Based on the incidence of skin neoplasms diagnosed histologically and the multiplicity of skin neoplasms, there was no suggestion that either diethylphthalate or dimethylphthalate was able to initiate skin carcinogenesis when chronically promoted by TPA. Further, there was no evidence that either diethylphthalate or dimethylphthalate was able to promote skin carcinogenesis in skin previously initiated with DMBA. High incidences of both squamous cell papillomas and squamous cell carcinomas occurred among the initiation/promotion control animals initiated with DMBA and promoted with TPA. All TPA-dosed groups had significantly greater incidences of dermal acanthosis, ulceration, exudation, and hyperkeratosis than controls. GENETIC TOXICOLOGY: Neither diethylphthalate (10-10,000 &amp;mu;/plate) nor dimethylphthalate (33-6,666 &amp;mu;/plate) induced gene mutations in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537, with or without rat and hamster liver S9. In cultured Chinese hamster ovary cells, both diethylphthalate and dimethylphthalate induced sister chromatid exchanges in the presence of S9. Neither induced sister chromatid exchanges in the absence of S9. Neither chemical induced chromosomal aberrations, with or without S9, in cultured Chinese hamster ovary cells. CONCLUSIONS: Under the conditions of these 2-year dermal studies, there was no evidence of carcinogenic activity of diethylphthalate in male or female F344/N rats receiving 100 or 300 &amp;mu;L. The sensitivity of the male rat study was reduced due to low survival in all groups. There was equivocal evidence of carcinogenic activity of diethylphthalate in male and female B6C3F1 mice based on increased incidences of hepatocellular neoplasms, primarily adenomas. In an initiation/promotion model of skin carcinogenesis, there was no evidence of initiating activity of diethylphthalate or dimethylphthalate in male Swiss (CD-1&amp;reg;) mice. Further, there was no evidence of promotion activity of diethylphthalate or dimethylphthalate in male Swiss (CD-1&amp;reg;) mice. The promoting activity of TPA following DMBA initiation was confirmed in these studies. Minor dermal acanthosis was observed following dermal application of diethylphthalate in male and female F344/N rats dosed for 2 years and in male Swiss (CD-1&amp;reg;) mice dosed for 1 year. Synonyms: Diethylphthalate (CAS No. 84-66-2): 1,2-benzenedicarboxylic acid, diethyl ester; DEP; diethyl 1,2-benzenedicarboxylate; diethyl o-phthalate; diethyl phthalate; ethyl phthalate; o-benzenedicarboxylic acid diethyl ester; phthalic acid, diethyl ester; RCRA U088 Dimethylphthalate (CAS No. 131-11-3): 1,2-benzenedicarboxylic acid, dimethyl ester; dimethyl 1,2-benzenedicarboxylate; dimethyl benzene-o-dicarboxylate; dimethyl benzeneorthodicarboxylate; dimethyl o-phthalate; dimethyl phthalate; DMP; FIFRA 028002; methyl phthalate; go-dimethyl phthalate; phthalic acid, dimethyl ester; phthalic acid methyl ester; RCRA U102

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The present guideline (S2k) on allergen-specific immunotherapy (AIT) was established by the German, Austrian and Swiss professional associations for allergy in consensus with the scientific specialist societies and professional associations in the fields of otolaryngology, dermatology and venereology, pediatric and adolescent medicine, pneumology as well as a German patient organization (German Allergy and Asthma Association; Deutscher Allergie- und Asthmabund, DAAB) according to the criteria of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). AIT is a therapy with disease-modifying effects. By administering allergen extracts, specific blocking antibodies, toler-ance-inducing cells and mediators are activated. These prevent further exacerbation of the allergen-triggered immune response, block the specific immune response and attenuate the inflammatory response in tissue. Products for SCIT or SLIT cannot be compared at present due to their heterogeneous composition, nor can allergen concentrations given by different manufacturers be compared meaningfully due to the varying methods used to measure their active ingredients. Non-modified allergens are used for SCIT in the form of aqueous or physically adsorbed (depot) extracts, as well as chemically modified allergens (allergoids) as depot extracts. Allergen extracts for SLIT are used in the form of aqueous solutions or tablets. The clinical efficacy of AIT is measured using various scores as primary and secondary study endpoints. The EMA stipulates combined symptom and medication scores as primary endpoint. A harmonization of clinical endpoints, e. g., by using the combined symptom and medication scores (CSMS) recommended by the EAACI, is desirable in the future in order to permit the comparison of results from different studies. The current CONSORT recommendations from the ARIA/GA2LEN group specify standards for the evaluation, presentation and publication of study results. According to the Therapy allergen ordinance (TAV), preparations containing common allergen sources (pollen from grasses, birch, alder, hazel, house dust mites, as well as bee and wasp venom) need a marketing authorization in Germany. During the marketing authorization process, these preparations are examined regarding quality, safety and efficacy. In the opinion of the authors, authorized allergen preparations with documented efficacy and safety, or preparations tradeable under the TAV for which efficacy and safety have already been documented in clinical trials meeting WAO or EMA standards, should be preferentially used. Individual formulations (NPP) enable the prescription of rare allergen sources (e.g., pollen from ash, mugwort or ambrosia, mold Alternaria, animal allergens) for specific immunotherapy. Mixing these allergens with TAV allergens is not permitted. Allergic rhinitis and its associated co-morbidities (e. g., bronchial asthma) generate substantial direct and indirect costs. Treatment options, in particular AIT, are therefore evaluated using cost-benefit and cost-effectiveness analyses. From a long-term perspective, AIT is considered to be significantly more cost effective in allergic rhinitis and allergic asthma than pharmacotherapy, but is heavily dependent on patient compliance. Meta-analyses provide unequivocal evidence of the efficacy of SCIT and SLIT for certain allergen sources and age groups. Data from controlled studies differ in terms of scope, quality and dosing regimens and require product-specific evaluation. Therefore, evaluating individual preparations according to clearly defined criteria is recommended. A broad transfer of the efficacy of certain preparations to all preparations administered in the same way is not endorsed. The website of the German Society for Allergology and Clinical Immunology (www.dgaki.de/leitlinien/s2k-leitlinie-sit; DGAKI: Deutsche Gesellschaft für Allergologie und klinische Immunologie) provides tables with specific information on available products for AIT in Germany, Switzerland and Austria. The tables contain the number of clinical studies per product in adults and children, the year of market authorization, underlying scoring systems, number of randomized and analyzed subjects and the method of evaluation (ITT, FAS, PP), separately given for grass pollen, birch pollen and house dust mite allergens, and the status of approval for the conduct of clinical studies with these products. Strong evidence of the efficacy of SCIT in pollen allergy-induced allergic rhinoconjunctivitis in adulthood is well-documented in numerous trials and, in childhood and adolescence, in a few trials. Efficacy in house dust mite allergy is documented by a number of controlled trials in adults and few controlled trials in children. Only a few controlled trials, independent of age, are available for mold allergy (in particular Alternaria). With regard to animal dander allergies (primarily to cat allergens), only small studies, some with methodological deficiencies are available. Only a moderate and inconsistent therapeutic effect in atopic dermatitis has been observed in the quite heterogeneous studies conducted to date. SCIT has been well investigated for individual preparations in controlled bronchial asthma as defined by the Global Initiative for Asthma (GINA) 2007 and intermittent and mild persistent asthma (GINA 2005) and it is recommended as a treatment option, in addition to allergen avoidance and pharmacotherapy, provided there is a clear causal link between respiratory symptoms and the relevant allergen. The efficacy of SLIT in grass pollen-induced allergic rhinoconjunctivitis is extensively documented in adults and children, whilst its efficacy in tree pollen allergy has only been shown in adults. New controlled trials (some with high patient numbers) on house dust mite allergy provide evidence of efficacy of SLIT in adults. Compared with allergic rhinoconjunctivitis, there are only few studies on the efficacy of SLIT in allergic asthma. In this context, newer studies show an efficacy for SLIT on asthma symptoms in the subgroup of grass pollen allergic children, adolescents and adults with asthma and efficacy in primary house dust mite allergy-induced asthma in adolescents aged from 14 years and in adults. Aspects of secondary prevention, in particular the reduction of new sensitizations and reduced asthma risk, are important rationales for choosing to initiate treatment early in childhood and adolescence. In this context, those products for which the appropriate effects have been demonstrated should be considered. SCIT or SLIT with pollen or mite allergens can be performed in patients with allergic rhinoconjunctivitis using allergen extracts that have been proven to be effective in at least one double-blind placebo-controlled (DBPC) study. At present, clinical trials are underway for the indication in asthma due to house dust mite allergy, some of the results of which have already been published, whilst others are still awaited (see the DGAKI table "Approved/potentially completed studies" via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit (according to www.clinicaltrialsregister.eu)). When establishing the indication for AIT, factors that favour clinical efficacy should be taken into consideration. Differences between SCIT and SLIT are to be considered primarily in terms of contraindications. In individual cases, AIT may be justifiably indicated despite the presence of contraindications. SCIT injections and the initiation of SLIT are performed by a physician experienced in this type of treatment and who is able to administer emergency treatment in the case of an allergic reaction. Patients must be fully informed about the procedure and risks of possible adverse events, and the details of this process must be documented (see "Treatment information sheet"; available as a handout via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit). Treatment should be performed according to the manufacturer's product information leaflet. In cases where AIT is to be performed or continued by a different physician to the one who established the indication, close cooperation is required in order to ensure that treatment is implemented consistently and at low risk. In general, it is recommended that SCIT and SLIT should only be performed using preparations for which adequate proof of efficacy is available from clinical trials. Treatment adherence among AIT patients is lower than assumed by physicians, irrespective of the form of administration. Clearly, adherence is of vital importance for treatment success. Improving AIT adherence is one of the most important future goals, in order to ensure efficacy of the therapy. Severe, potentially life-threatening systemic reactions during SCIT are possible, but - providing all safety measures are adhered to - these events are very rare. Most adverse events are mild to moderate and can be treated well. Dose-dependent adverse local reactions occur frequently in the mouth and throat in SLIT. Systemic reactions have been described in SLIT, but are seen far less often than with SCIT. In terms of anaphylaxis and other severe systemic reactions, SLIT has a better safety profile than SCIT. The risk and effects of adverse systemic reactions in the setting of AIT can be effectively reduced by training of personnel, adhering to safety standards and prompt use of emergency measures, including early administration of i. m. epinephrine. Details on the acute management of anaphylactic reactions can be found in the current S2 guideline on anaphylaxis issued by the AWMF (S2-AWMF-LL Registry Number 061-025). AIT is undergoing some innovative developments in many areas (e. g., allergen characterization, new administration routes, adjuvants, faster and safer dose escalation protocols), some of which are already being investigated in clinical trials. <bCite this as</b Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases - S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). Allergo J Int 2014;23:282-319.

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