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Inducible overexpression of c-Jun in MCF7 cells causes resistance to vinblastine via inhibition of drug-induced apoptosis and senescence at a step subsequent to mitotic arrest.

c-Jun is a major component of the AP-1 transcription factor and plays a key role in regulation of diverse biological processes including proliferation and apoptosis. Treatment of a wide variety of cells with the microtubule inhibitor vinblastine leads to a robust increase in c-Jun expression, JNK-mediated c-Jun phosphorylation, and activation of AP-1-dependent transcription. However, the role of c-Jun induction in the response of cells to vinblastine remains obscure. In this study we used MCF7 breast cancer cell lines that express the dominant-negative form of c-Jun, TAM-67, as well as cells that overexpress c-Jun, under the control of an inducible promoter. Vinblastine induced c-Jun protein expression, c-Jun phosphorylation, and AP-1 activation in MCF7 cells, and these parameters were strongly inhibited by inducible TAM-67 expression and strongly enhanced by inducible c-Jun expression. Vinblastine-induced cell death was not affected by TAM-67 expression whereas cells were protected by c-Jun overexpression. Further investigation revealed that apoptotic and senescent cells were observed after vinblastine treatment and that both outcomes were strongly inhibited by c-Jun overexpression. Although c-Jun expression inhibited cell death, it did not affect the ability of vinblastine to induce mitotic arrest. These results indicate that c-Jun expression plays a protective role in the cellular response to vinblastine and operates post-mitotic block to inhibit drug-induced apoptosis and senescence.

Antineoplastic Agents, Phytogenic↗

Primer unblocking by HIV-1 reverse transcriptase and resistance to nucleoside RT inhibitors (NRTIs).

During zidovudine and stavudine treatment, HIV-1 selects several mutations (thymidine-associated mutations, TAMs) in the reverse transcriptase gene that confer high- and moderate-levels of resistance, respectively, to these nucleoside reverse transcriptase inhibitors (NRTIs). The mechanism of the resistance provided by these mutations has long remained elusive. However, recent data showed that ATP-phosphorolysis, a reaction analogous to pyrophosphorolysis (the reverse of the nucleotide incorporation reaction) in which ATP is the pyrophosphate donor, is central to this mechanism by allowing repair of the chain-terminated primer. A detailed structural and mechanistic model accounting for the specificity of the ATP-phosphorolysis and its inhibition by the next complementary nucleotide is now available. In the context of multiresistant viruses, the TAMs are also associated with resistance to abacavir, and to a lesser extent to didanisone, zalcitabine and tenofovir. When associated with the TAMs, a dipeptide insertion in the fingers of reverse transcriptase increases the ATP-phosphorolysis of most chain terminators, stressing the increasing importance of this mechanism. However, some non-nucleoside reverse transcriptase inhibitors (NNRTIs) inhibit this process. In addition, point mutations conferring resistance to NNRTIs (Y181C and L100I) or NRTIs (K65R, L74V, and M184V) partially resensitize the resistant viruses to AZT by inhibiting ATP-phosphorolysis. These findings allow rationalizing the beneficial effects of some drug combinations and should contribute to improve drug cocktails. The development of NRTIs that would not allow the ATP-mediated excision to take place should prove beneficial for future treatments, even though high-level resistance to multiple NRTIs can ultimately develop in the absence of any significant primer unblocking.

Adenosine Triphosphate↗

Synthesis of oligodeoxynucleotides containing a single diastereoisomer of alpha-(N2-2'-deoxyguanosinyl)-N-desmethyltamoxifen.

A phosphoramidite chemical synthesis of oligodeoxynucleotides containing a diastereoisomer of (E)-alpha-(N(2)-deoxyguanosinyl)-N-desmethyltamoxifen, a major tamoxifen (TAM)-derived DNA adduct in animal and women treated with TAM, was described. The site-specifically modified oligodeoxynucleotide can be used for mutagenesis, DNA repair, and 3D structural studies and also as standard for quantitative analysis of TAM-DNA adducts in animal and human.

Animals↗

When to recommend and to pay for first-line adjuvant breast cancer treatment? A structured review of the literature.

A structured review of studies on the health-economic evaluation of systemic adjuvant therapy for early-stage breast cancer was carried out. Of the eight articles that have been identified four were related to the cost-effectiveness of chemotherapy, three compared chemotherapy with combined chemotherapy and hormonal therapy and one compared tamoxifen (TAM) with third-generation aromatase inhibitors (ATIs). Results of the review indicate that the cost-utility of adjuvant breast cancer therapy is within the range of other oncological interventions. Adjuvant chemotherapy is most cost-effective in pre-menopausal women with node-positive breast cancer while cost-effectiveness decreases considerably with increasing age. Endocrine therapy with TAM is most cost-effective in ER-positive tumours with no significant age effect. The cost-utility of using the ATI anastrozole instead of TAM in adjuvant therapy cannot be conclusively assessed on the basis of the existing evidence.

Aromatase Inhibitors↗

Augmented efficacy of tamoxifen in rat breast tumorigenesis when gavaged along with riboflavin, niacin, and CoQ10: effects on lipid peroxidation and antioxidants in mitochondria.

Reactive oxygen species (ROS) play a major role in causing mitochondrial changes linked to cancer and metastasis. Uptake of antioxidants by tissue to reduce the ROS production could be instrumental in controlling cancer. Tamoxifen (TAM), a nonsteroidal anti-estrogen drug most used in the chemotherapy and chemoprevention of breast cancer. Riboflavin, niacin and coenzyme Q10 (CoQ10) are proved to be potent antioxidants and protective agents against many diseases including cancer. The objective of this research is to determine the therapeutic efficacy of combinatorial therapy on mammary carcinoma bearing rats in terms of the mitochondrial lipid peroxidation and antioxidant status especially MnSOD. Female albino rats of Sprague-Dawley strain were selected for the investigation. Mammary carcinoma was induced with 7,12-dimethyl benz(a)anthracene (DMBA: 25 mg), and the treatment was started by the oral administration of TAM (10 mg/kg body weight/day) along with riboflavin (45 mg/kg body weight/day), niacin (100 mg/kg body weight/day) and CoQ10 (40 mg/kg body weight/day) for 28 days. The levels of lipid peroxides, activities of enzymic and non-enzymic antioxidants were measured in the mitochondria isolated from the mammary gland and liver of control and experimental rats. Rats treated with DMBA showed an increase in mitochondrial lipid peroxidation (mammary gland 52.3%; liver 25.1%) accompanied by high malondialdehyde levels along with lowered activities of mitochondrial enzymic antioxidants [superoxide dismutase (mammary gland 19.9%; liver 24.8%), catalase (mammary gland 50%; liver 19.7%), glutathione peroxidase (mammary gland 47.8%; liver 31.1%)] and non-enzymic antioxidants [reduced glutathione (mammary gland 14.3%; liver 13.3%), Vitamin C (mammary gland 6.49%; liver 21.4%) and E (mammary gland 20.3%; liver 22.2%)]. Administration of combinatorial therapy restored lipid peroxide level and the activities of enzymic and non-enzymic antioxidants to near normalcy. In addition, antitumour activity was also found to be enhanced which is evident from the increased expression of tumour suppressor gene MnSOD thereby preventing cancer cell proliferation. These results suggested that TAM treatment is the most effective during co-administration of riboflavin, niacin and CoQ10 in terms of mitochondrial antioxidant and antitumour activity.

9,10-Dimethyl-1,2-benzanthracene↗

Disruption of estrogen receptor DNA-binding domain and related intramolecular communication restores tamoxifen sensitivity in resistant breast cancer.

A serious obstacle to successful treatment of estrogen receptor (ER)-positive human breast cancer is cell resistance to tamoxifen (TAM) therapy. Here we show that the electrophile disulfide benzamide (DIBA), an ER zinc finger inhibitor, blocks ligand-dependent and -independent cell growth of TAM-resistant breast cancer in vitro and in vivo. Such inhibition depends on targeting disruption of the ER DNA-binding domain and its communication with neighboring functional domains, facilitating ERalpha dissociation from its coactivator AIB1 and concomitant association with its corepressor NCoR bound to chromatin. DIBA does not affect phosphorylation of HER2, MAPK, AKT, and AIB1, suggesting that DIBA-modified ERalpha may induce a switch from agonistic to antagonistic effects of TAM on resistant breast cancer cells.

Animals↗

Medroxyprogesterone and tamoxifen augment anti-proliferative efficacy and reduce mitochondria-toxicity of epirubicin in FM3A tumor cells in vitro.

We have shown that low doses of medroxyprogesterone acetate (MPA- 2.6 microM) and tamoxifen (TAM- 270 nM) could augment the effectiveness of epirubicin in breast tumor cells. In this study, we monitored early cell kinetics (24-96 h plating and S-phase) and mitochondrial morphology during chemo-endocrine treatments to delineate the epirubicin sensitizing mechanism. S-phase fractions with radioactive thymidine uptake, plating efficacy, and transmission electron microscopic analysis were taken for 24-h periods until the 7th day after drug treatments. Despite strongly enhancing the clonogenic killing, both MPA and TAM did not affect epirubicin induced early cytotoxicity. Instead, they augmented the S-phase inhibition, which was even more pronounced for TAM. Epirubicin induced prominent swelling and crista damage of mitochondria and fragmentation of nuclei. Mitochondria were a normal size during a combination of epirubicin with either MPA- or tamoxifen treatment, despite the persistence of chromatin fragmentation and strong synergism on the clonogenic killing of breast tumor cells. Low dosage endocrine agent-induced anthracycline sensitization may be independent of mitochondrial toxicity. Further studies would be worthwhile, since the uncoupling of mitochondrial toxicity from the anti-neoplastic effect may also mean obviated cardiac toxicity in clinic.

Antibiotics, Antineoplastic↗

Identification and quantification of tamoxifen and four metabolites in serum by liquid chromatography-tandem mass spectrometry.

We have developed a method for the determination of tamoxifen (tam) and its metabolites 4-hydroxytamoxifen (4OHtam), N-demethyltamoxifen (NDtam), N-dedimethyltamoxifen (NDDtam), tamoxifen-N-oxide (tamNox), and 4-hydroxy-N-demethyltamoxifen (4OHNDtam) in 50 microl human serum. Serum proteins were precipitated with acetonitrile. Deuterated-tamoxifen (D5 tam) was added as internal standard. Sample supernatant was injected into an on-line reversed-phase extraction column coupled with a C18 analytical column and analytes were detected by tandem mass spectrometry. The lower limits of quantification were 0.25 ng/mL for 4OHtam, NDtam and tam, 1.0 ng/mL for NDDtam and tamNox. Ranges of within- and between-day variation were 2.9-15.4% and 4.4-12.9%, respectively.

Breast Neoplasms↗

Key functional characteristics in designing and operating health information websites for user satisfaction: an application of the extended technology acceptance model.

OBJECTIVE: With growing demand for health information and rapid development of information technology, health information websites are emerging as the most effective media to meet the public's needs for health information. This article is intended to offer a technical view on the design and operations of health information websites. Along this line, employed here is the Technology Acceptance Model (TAM), which has been widely used to predict user acceptance based on Perceived Ease-of-Use (PEOU) and Perceived Usefulness (PU). METHODS: We extend the original TAM by including some exogenous variables since it is necessary to understand the role of the antecedents of acceptance constructs when designing an effective health information website for improving user satisfaction. This study focuses on identifying the core functional factors in designing and operating health information websites. Conducted are some multivariate statistical analyses based on data from an extensive survey. RESULTS: The results from the structural equation analysis suggest that functional characteristics should be categorized into three groups: one affecting PU and PEOU, another affecting only PEOU, and the other having no direct effect on either PU or PEOU. In particular, 'usage support' and 'customization' are two key functional characteristics in the extended TAM framework for health information websites. CONCLUSION: Contrary to expectations, however, the direct effect of PEOU on usage support is hardly observed, which differentiates health information websites from other commercial websites like online shopping malls. As a result, understanding the antecedents of PU takes on more significance.

Access to Information↗

The combination of tamoxifen and 9cis retinoic acid exerts overadditive anti-tumoral efficacy in rat hepatocellular carcinoma.

BACKGROUND/AIMS: Medical treatment for hepatocellular carcinoma (HCC) remains elusive. While an acyclic retinoid improved tumor-free survival after hepatoma resection, tamoxifen finally proved ineffective. Combination therapy of both agents has not been investigated in vitro and in vivo. METHODS: MH7777A hepatoma cells were incubated with tamoxifen (TAM) and 9-cis retinoic acid (CRA) alone or in combination. Proliferation rate and apoptosis were assessed by BrdU incorporation and flow cytometry. In vivo efficacy was studied using the Morris hepatoma model in immunocompetent rats. End points were macroscopic tumor growth, metastasis and immunohistochemistry for proliferative and apoptotic tumor cells (PCNA and TUNEL staining). RESULTS: In vitro, CRA and TAM monotherapy was effective only in the highest concentration. Combination therapy significantly enhanced apoptosis rate and growth inhibition in hepatoma cells. While in vivo monotherapy did not reduce tumor growth or metastasis, their combination reduced tumor size after 28 days by 64.5+/-28%. This was paralleled by an increase in TUNEL positive and a decrease in PCNA positive cells. CONCLUSIONS: The combination of TAM and CRA enhances their anti-tumoral efficacy in vitro as well as in vivo, while monotherapy is ineffective. This combination could be a promising adjunctive therapy of HCC.

Alitretinoin↗

Macrophage responses to hypoxia: implications for tumor progression and anti-cancer therapies.

The presence of multiple areas of hypoxia (low oxygen tension) is a hallmark feature of human and experimental tumors. Monocytes are continually recruited into tumors, differentiate into tumor-associated macrophages (TAMs), and then accumulate in these hypoxic areas. A number of recent studies have shown that macrophages respond to the levels of hypoxia found in tumors by up-regulating such transcription factors as hypoxia-inducible factors 1 and 2, which in turn activate a broad array of mitogenic, pro-invasive, pro-angiogenic, and pro-metastatic genes. This could explain why high numbers of TAMs correlate with poor prognosis in various forms of cancer. In this review, we assess the evidence for hypoxia activating a distinct, pro-tumor phenotype in macrophages and the possible effect of this on the growth, invasion, angiogenesis, and immune evasion of tumors. We also discuss current attempts to selectively target TAMs for destruction or to use them to deliver gene therapy specifically to hypoxic tumor sites.

Animals↗

The acute effects of estradiol benzoate on amygdala-kindled seizures in male rats.

Using amygdaloid-kindling model of epilepsy, effects of acute estradiol treatment on seizure parameters were investigated in male rats. Fully kindled male rats were treated with various doses of estradiol benzoate (EB, 10, 30 and 50 microg/kg, i.p.) and kindling parameters such as seizure stage (SS), afterdischarge duration (ADD) and stage 5 duration (S5D) were elicited at various times (0.25, 1.5, 3 h and every 24 h for 96 h) post-drug administration. While the 10-microg/kg dose of EB failed to change seizure parameters, administration of the 30- and 50-microg/kg doses caused significant prolongation of ADD and S5D (was not changed significantly by the latter dose) at various time intervals post-drug administration. Pretreatment with the 3 mg/kg dose of tamoxifen citrate (TAM) inhibited the EB (30 microg/kg) effect, while pretreatment with the 10-mg/kg dose produced significant prolongation of ADD and S5D. These results suggest that in male amygdaloid kindled rats, acute estradiol treatment leads to an intensification of seizure that is manifested by increases in ADD and S5D. As the effect is evident 0.25 h post-EB administration and duel action of TAM in opposing the EB effect at low doses and potentiating it at the higher doses, the possibility of a genomic effect may be ruled out. The variable effects of TAM might be explained by its partial agonistic property on estrogen receptors

Amygdala↗

The discovery of a new potential anticancer drug: a case history.

DNA minor groove binders (MGB) represent a class of anticancer agents whose DNA sequence specificity was hypothesized to lead to high selectivity of action. Tallimustine (TAM), a benzoyl nitrogen mustard derivative of distamycin A (DST), showed excellent antitumor activity in preclinical tests, but also a severe myelotoxicity. Novel nitrogen mustard, nitrogen half-mustard and sulfur mustard derivatives of DST showing excellent activity were recently identified and SAR reported. In particular nitrogen half-mustard and sulfur mustard derivatives, as one-arm alkylating agents, represent interesting structural novelties. A further new class of cytotoxic anticancer agents is that of alpha-halogenoacrylamido derivatives of DST-like oligopeptides, which show an activity profile substantially improved in comparison to TAM. In particular brostallicin (PNU-166196), alpha-bromo-acrylamido tetra-pyrrole derivative ending with a guanidino moiety, showed high cytotoxic potency and myelotoxicity dramatically reduced in comparison to TAM and other MGB. Brostallicin binds to the minor groove but appears unreactive in classical in vitro DNA alkylation assays. About the apparent lack of DNA alkylation we speculated that an intracellular nucleophile, e.g. glutathione (GSH), could activate the reactivity of the compound leading to alkylation of DNA in vivo. Evidence of both covalent interaction of brostallicin with plasmidic DNA in the presence of GSH and of enhanced cytotoxicity in cancer cells characterized by high levels of GSH were obtained. Brostallicin was selected for clinical development and is now undergoing Phase II studies.

Animals↗

Evidence of an estrogen receptor form devoid of estrogen binding ability in MCF-7 cells.

In MCF-7 breast cancer cells, hydroxytamoxifen (OH-Tam) up-regulates the estrogen receptor (ER) in a form unable to bind [(3)H]estradiol (E(2)). We show here that this property is not restricted to this antiestrogen. [(3)H]E(2) binding assays (whole cell assays, DCC assays on cell extracts) and enzyme immunoassays (Abbott) performed in parallel, establish the permanent presence of such unusual ERs in the absence of any exposure of the cells to a ligand. E(2) and the pure antiestrogen RU 58 668, which down-regulate ER, also decrease [(3)H]E(2) binding. In control cells, these ERs represent about the half of the whole receptor population; they also display a tendency to stabilize within the cell nucleus. Loss of E(2) binding ability appears irreversible, since we failed to label receptor accumulated under OH-Tam with [(3)H]E(2) or [(3)H]tamoxifen aziridine (TAZ). Cycloheximide (CHX), which blocks E(2)-induced down regulation of ER, failed to stabilize [(3)H]E(2) binding (whole cell assay) after an [(3)H]E(2) pulse (1 h), confirming that regulation of E(2) binding and peptide level are related to different regulatory mechanisms. Loss of binding ability could not be ascribed to any ER cleavage as demonstrated by Western blotting with a panel of ER antibodies raised against its various domains (67 kDa ER solely detected). We propose that loss of E(2) binding ability is related to the aging process of the receptor, i.e. it is progressively converted to a form devoted to degradation after it has accomplished its physiological role. Ligands may favor (E(2), RU 58 668) or impede (OH-Tam) this elimination process.

Antineoplastic Agents, Hormonal↗

[Clinical use of HIV-1 resistance genotyping. Predictive factors of poor virological evolution in salvage treatments].

OBJECTIVES: To describe the use of genotype resistance testing (GRT) for virological failure in clinical practice, and the long-term clinical and virological evolution in patients for whom it is requested. To identify the predictive factors of virological failure in patients with antiretroviral (ARV) salvage therapy. METHODS: Observational study in HIV-infected patients for whom GRT was requested for virological failure (VF) in the period of 1 October 1999 to 31 December 2001. Logistic regression analysis was used to determine the predictive factors of virological progression. RESULTS: Over the period studied, 196 patients required GRT for VF (15%) among those monitored in specific units. GRT was mainly requested for patients who had been extensively pretreated for a mean of 5 years and with a median of 5 ARV combinations. Half the patients presented 3 or more mutations associated with thymidine analogs (TAMs), mutations associated with non-nucleoside analogs (NNRTIs), and 5 or more mutations associated with protease inhibitors (PIs). In 143 (74%) patients, the RTV regimen was changed on the basis of GRT results. In the intent-to-treat analysis, the percentage of patients with plasma VL < 400 cop/mL at 6, 12 and 18 months was 41%, 29% and 17%, respectively. In the on-treatment analysis, the results were 50%, 48% and 46%, respectively. Mean CD4 lymphocyte increase was 59.74 and 94 cells/mm 3. The variables predicting virological failure (plasma VL > 400 cop/mL) at 12 months were plasma VL > 30,000 cop/mL (OR 6, 1.8-19.5) and accumulation of 3 or more TAMs (OR 4.4, 1.3-15) at the start of ARV salvage therapy. CONCLUSION: Even though in clinical practice GRT is requested for patients with various treatment failures, when ART salvage treatment was started, plasma VL was undetectable and immunological response persisted in 40% of patients followed-up for 18 months. The factors best predicting virological evolution were VL and the number of baseline TAMs.

Adult↗

Functional results of dynamic splinting after transmetacarpal, wrist, and distal forearm replantation.

The results of replantation at the wrist and distal forearm are reported to be better than at the metacarpal level, in part because the latter involve direct injury to the intrinsic muscles. This study evaluates a new post-operative protocol for replantation at the metacarpal, wrist and distal forearm levels. 3 days after replantation, the patient was placed in a dynamic crane outrigger splint with MP joint control, compensating for intrinsic muscle function loss. From 4 to 12 weeks, an anticlaw splint alternated with the outrigger splint. After 12 weeks, a dynamic wrist extension orthosis was added to the anti-claw splint. 11 patients (four replantations at the transmetacarpal level, three at the wrist and four in the distal forearm) had this protocol between 1988 and 1993. For distal forearm replantation, TAM of fingers averaged 216 degrees, grip strength 42 lb, and pinch strength 7.2 lb with 75% good or excellent results. For wrist replantations, TAM of fingers averaged 243 degrees, grip strength 37 lb and pinch strength 10.6 lb with 100% good or excellent results. For transmetacarpal replantations, TAM of fingers averaged 189 degrees, grip strength 37 lb and pinch strength 5.6 lb, with 75% good and excellent results. Early protected mobilization, as described here, preserves tendon gliding, muscle strength and excursion. Our results support this protocol for wrist and distal forearm replantation and especially for transmetacarpal replantation, the results of which tend to be poor according to the medical literature.

Adult↗

Adjuvant systemic treatment and the pattern of recurrences in patients with breast cancer.

The aim was to analyze the impact of adjuvant systemic treatment (AST) on the anatomical distribution, the number, and the temporal relationship of the first metastases in 635 patients (pts) with breast cancer. These patients participated in the prospective studies of AST of the Danish Breast Cancer Cooperative Group (DBCG) 77-program. All patients had primary high-risk breast cancer (i.e. node positive or local invasion or tumor size greater than 5 cm). The initial treatment was mastectomy with axillary sampling, followed by postoperative radiotherapy. The types of AST and the number of patients with recurrence were: chemotherapy (CT), 134 pts; levamisole (LEV), 96 pts; tamoxifen (TAM), 154 pts. The pattern of recurrence in these patients was compared with the pattern of recurrence in 251 pts who did not receive AST (controls). Although CT reduced the total number of metastatic sites (P = 0.04), the incidence of liver metastases was increased compared to untreated controls (P = 0.02). The median number of metastatic sites was equal in TAM- and LEV-treated pts compared to controls. The incidence of lung metastases was increased in TAM-treated pts (P = 0.03), and LEV-treated pts had a decreased incidence of lymph node (P = 0.01) and pleural recurrences (P = 0.01) compared to controls. The results may suggest that mechanisms of clonal selection during the metastatic process involve differences in sensitivity to antineoplastic treatments of metastases at various anatomical locations.

Antineoplastic Agents↗

Combination of melatonin and tamoxifen as a chemoprophylaxis against N-nitroso-N-methylurea-induced rat mammary tumors.

The effect of melatonin (Mel) and or tamoxifen (Tam) was evaluated on a mammary tumor model induced in 50 day old female Sprague-Dawley rats by a single intraperitoneal (i.p.) injection of a direct carcinogen, N-nitroso-N-methylurea (NMU) (50 mg/kg b.wt./rat). These animals were treated with either Mel 200 microg/rat per day, orally in drinking water and/or Tam (s.c.) 60 microg/rat per week or 180 microg/rat per week. The total observation period was 300 days post-NMU administration in all the animals. The mean latency period of tumor appearance and tumor incidence was recorded. The mean latency period was significantly lengthened in all the treated groups as compared to that in the only NMU-administered rats (P < 0.001). Highly significant suppression of tumor incidence was observed in Mel + Tam180 group (P < 0.001). The other two groups i.e. Mel + Tam60, and Tam180 also showed significant suppression of tumor incidence (P < 0.01). Eight weeks after the initiation of treatment regimen, we observed marked reduction in [3H]thymidine incorporation into mammary gland DNA of Mel- and/or Tam-treated groups of animals as compared to the age-matched controls and NMU-administered rats, which correlated positively with the sparse mammary gland development seen in the whole mount preparations. The result of the combined therapy is highly promising and warrants clinical evaluation in the prophylaxis of breast carcinogenesis in humans.

Animals↗