Superfund Research Program

Clement E. Furlong

University of Washington
Department of Medicine and Genome Sciences
Division of Medical Genetics
Seattle, Washington 98195
Phone: 206-543-1193
Fax: 206-543-3050
Email: clem@u.washington.edu

Projects

• University of Washington: Research Translation (2006-2023)
• University of Washington: Role of Paraoxonases (PONs) in Modulating Cadmium and Manganese Neurotoxicity (2009-2023)

Research Briefs

• 190 - Determining Susceptibility to Environmentally-induced Neurotoxicity
• 165 - PON1 as a Potential Treatment for Organophosphate Poisoning

Patents

• Engineered Recombinant Human Paraoxonase 1 (rHuPON1) Purified from E. coli Protects against Organophosphate Poisoning
• Methods of Determining Paraoxonase 1 (PON1) Status in a Mammalian Subject
• Methods of Determining the Activity of Paraoxonase 1 (PON1) and Use Of Pon1 Status as a Biomarker for Parkinsons Disease

Publications

2023

• Burdon J, Budnik LT, Baur X, Hageman G, Howard CV, Roig J, Coxon L, Furlong CE, Gee D, Loraine T, Terry AV, Midavaine J, Petersen H, Bron D, Soskolne CL, Michaelis S. 2023. Health consequences of exposure to aircraft contaminated air and fume events: a narrative review and medical protocol for the investigation of exposed aircrew and passengers. Environmental Health 22(1):43. doi:10.1186/s12940-023-00987-8 PMID:37194087 PMCID:PMC10186727

2022

• Garrick JM, Dao K, Costa LG, Marsillach J, Furlong CE. 2022. Examining the role of paraoxonase 2 in the dopaminergic system of the mouse brain. BMC Neurosci 23(1):52. doi:10.1186/s12868-022-00738-4 PMID:36056313 PMCID:PMC9438175

2021

• Garrick JM, Cole TB, Bammler TK, MacDonald JW, Marsillach J, Furlong CE, Costa LG. 2021. Paraoxonase 2 deficiency in mice alters motor behavior and causes region-specific transcript changes in the brain. Neurotoxicol Teratol 87(14):doi:10.1016/j.ntt.2021.107010 PMID:34216730 PMCID:PMC8440460
• Marsillach J, Richter RJ, Costa LG, Furlong CE. 2021. Paraoxonase-1 (PON1) status analysis using non organophosphate substrates. Curr Protoc 1:e25. doi:10.1002/cpz1.25 PMID:33484495 PMCID:PMC7924808

2020

• Kahng S, Soelberg SD, Fondjo F, Kim J, Furlong CE, Chung J. 2020. Carbon nanotube-based thin-film resistive sensor for point-of-care screening of tuberculosis. Biomed Microdevices 22(3):50. doi:10.1007/s10544-020-00506-3 PMID:32725281

2017

• Costa LG, Cole TB, Garrick JM, Marsillach J, Furlong CE. 2017. Metals and paraoxonases. Adv Neurobiol 18:85-111. doi:10.1007/978-3-319-60189-2_5 PMID:28889264

2016

• Furlong CE, Marsillach J, Jarvik GP, Costa LG. 2016. Paraoxonases-1, -2 and -3: what are their functions?. Chem Biol Interact 259(PtB):51-62. doi:10.1016/j.cbi.2016.05.036 PMID:27238723
• Garrick JM, Dao K, de Laat R, Elsworth J, Cole TB, Marsillach J, Furlong CE, Costa LG. 2016. Developmental expression of paraoxonase 2. Chem Biol Interact 259(PtB):168-174. doi:10.1016/j.cbi.2016.04.001 PMID:27062895 PMCID:PMC5055469
• Marsillach J, Costa LG, Furlong CE. 2016. Paraoxonase-1 and early life environmental exposures. Ann Glob Health 82(1):100-110. doi:10.1016/j.aogh.2016.01.009 PMID:27325068 PMCID:PMC4916371

2015

• Costa LG, Cole TB, Furlong CE. 2015. Paraoxonase (PON1) and Detoxication of Nerve Agents. Chapter 73 in: Handbook of Toxicology of Chemical Warfare Agents, 2nd edition. Academic Press,
• Kim D, Burt AA, Ranchalis J, Vuletic S, Vaisar T, Li WF, Rosenthal EA, Dong W, Eintracht JF, Motulsky AG, Brunzell J, Albers JJ, Furlong CE, Jarvik GP. 2015. PLTP activity inversely correlates with CAAD: effects of PON1 enzyme activity and genetic variants on PLTP activity. J Lipid Res 56(7):1351-1362. doi:10.1194/jlr.P058032 PMID:26009633 PMCID:PMC4479339
• Marsillach J, Becker J, Vaisar T, Hahn B, Brunzell J, Furlong CE, de Boer I, McMahon M, Hoofnagle A. 2015. Paraoxonase-3 is depleted from the high-density lipoproteins of autoimmune disease patients with subclinical atherosclerosis. J Proteome Res 14(5):2046-2054. doi:10.1021/pr5011586 PMID:25723336 PMCID:PMC4434596

2014

• Cole TB, Li WF, Co AL, Hay AM, MacDonald JW, Bammler TK, Farin FM, Costa LG, Furlong CE. 2014. Repeated gestational exposure of mice to chlorpyrifos oxon is associated with paraoxonase 1 (PON1) modulated effects in maternal and fetal tissues. Toxicol Sci 141(2):409-422. doi:10.1093/toxsci/kfu144 PMID:25070982 PMCID:PMC4271046
• Costa LG, de Laat R, Dao K, Pellacani C, Cole TB, Furlong CE. 2014. Paraoxonase-2 (PON2) in brain and its potential role in neuroprotection. Neurotoxicology 43:3-9. doi:10.1016/j.neuro.2013.08.011 PMID:24012887 PMCID:PMC3942372
• Inoue S, Becker AL, Kim J, Shu Z, Soelberg SD, Weigel KM, Hiraiwa M, Cairns A, Lee H, Furlong CE, Oh K, Lee K, Gao D, Chung J, Cangelosi GA. 2014. Semi-automated, occupationally safe immunofluorescence microtip sensor for rapid detection of Mycobacterium cells in sputum. PLoS One 9(1):e86018. doi:10.1371/journal.pone.0086018 PMID:24465845 PMCID:PMC3899086
• Kim D, Burt AA, Rosenthal EA, Ranchalis J, Eintracht JF, Hatsukami TS, Furlong CE, Marcovina S, Albers JJ, Jarvik GP. 2014. HDL-3 is a superior predictor of carotid artery disease in a case-control cohort of 1725 participants. J Am Heart Assoc 3(3):e000902. doi:10.1161/JAHA.114.000902 PMID:24965026 PMCID:PMC4309059
• Kim D, Crosslin DR, Auer PL, Suzuki SM, Marsillach J, Burt AA, Gordon AS, Meschia JF, Nalls MA, Worrall BB, Longstreth WT, Gottesman RF, Furlong CE, Peters U, Rich SS, Nickerson DA, Jarvik GP. 2014. Rare coding variation in paraoxonase-1 is associated with ischemic stroke in the NHLBI Exome Sequencing Project. J Lipid Res 55(6):1173-1178. doi:10.1194/jlr.P049247 PMID:24711634 PMCID:PMC4031948
• Marsillach J, Suzuki SM, Richter RJ, McDonald MG, Rademacher PM, MacCoss MJ, Hsieh EJ, Rettie AE, Furlong CE. 2014. Human valacyclovir hydrolase/biphenyl hydrolase-like protein is a highly efficient homocysteine thiolactonase. PLoS One 9(10):e110054. doi:10.1371/journal.pone.0110054 PMID:25333274 PMCID:PMC4198189

2013

• Baker PE, Cole TB, Cartwright M, Suzuki SM, Thummel KE, Lin YS, Co AL, Rettie AE, Kim JH, Furlong CE. 2013. Identifying safer anti-wear triaryl phosphate additives for jet engine lubricants. Chem Biol Interact 203(1):257-264. doi:10.1016/j.cbi.2012.10.005 PMID:23085349 PMCID:PMC3618534
• Costa LG, Giordano G, Cole TB, Marsillach J, Furlong CE. 2013. Paraoxonase 1 (PON1) as a genetic determinant of susceptibility to organophosphate toxicity. Toxicology 307:115-122. doi:10.1016/j.tox.2012.07.011 PMID:22884923 PMCID:PMC3516631
• Costa LG, Tait L, de Laat R, Dao K, Giordano G, Pellacani C, Cole TB, Furlong CE. 2013. Modulation of paraoxonase 2 (PON2) in mouse brain by the polyphenol quercetin: a mechanism of neuroprotection?. Neurochem Res 38(9):1809-1818. doi:10.1007/s11064-013-1085-1 PMID:23743621 PMCID:PMC3735620
• Giordano G, Tait L, Furlong CE, Cole TB, Kavanagh TJ, Costa LG. 2013. Gender differences in brain susceptibility to oxidative stress are mediated by levels of paraoxonase-2 expression. Free Radic Biol Med 58:98-108. doi:10.1016/j.freeradbiomed.2013.01.019 PMID:23376469 PMCID:PMC3622778
• Kim D, Marsillach J, Furlong CE, Jarvik GP. 2013. Pharmacogenetics of paraoxonase activity: elucidating the role of high-density lipoprotein in disease. Pharmacogenomics 14:1495-1515. doi:10.2217/pgs.13.147 PMID:24024900 PMCID:PMC3888096
• Marsillach J, Costa LG, Furlong CE. 2013. Protein adducts as biomarkers of exposure to organophosphorus compounds. Toxicology 307:46-54. doi:10.1016/j.tox.2012.12.007 PMID:23261756 PMCID:PMC3747771
• Marsillach J, Hsieh EJ, Richter RJ, MacCoss MJ, Furlong CE. 2013. Proteomic analysis of adducted butyrylcholinesterase for biomonitoring organophosphorus exposures. Chem Biol Interact 203(1):85-90. doi:10.1016/j.cbi.2012.10.019 PMID:23123252 PMCID:PMC4108156

2012

• Cole TB, Fisher JC, Burbacher T, Costa LG, Furlong CE. 2012. Neurobehavioral assessment of mice following repeated postnatal exposure to chlorpyrifos-oxon. Neurotoxicol Teratol 34(3):311-322. doi:10.1016/j.ntt.2012.02.003 PMID:22425525 PMCID:PMC3367041
• Furlong CE, Richter RJ, Costa LG, Jarvik GP. 2012. Paraoxonase 1 (PON1) Status in Risk Assessment for Organophosphate Exposure and Pharmacokinetics. Chapter 9 in: Parameters for pesticide QSAR and PBPK/PD models for human risk assessment. American Chemical Society, Washington, DC. pp.133-147.

2011

• Cole TB, Beyer RP, Bammler TK, Park SS, Farin FM, Costa LG, Furlong CE. 2011. Repeated developmental exposure of mice to chlorpyrifos oxon is associated with paraoxonase 1 (PON1)-modulated effects on cerebellar gene expression. Toxicol Sci 123:155-169. doi:10.1093/toxsci/kfr157 PMID:21673326 PMCID:PMC3164442
• Costa LG, Furlong CE. 2011. Paraoxonase 1: Structure, Function and Polymorphisms. Chapter 7 in: Anticholinesterase Pesticides: Metabolism, Neurotoxicity, and Epidemiology. Wiley, Hoboken, NJ. pp.85-96.
• Costa LG, Giordano G, Furlong CE. 2011. Pharmacological and dietary modulators of paraoxonase 1 (PON1) activity and expression: the hunt goes on. Biochem Pharmacol 81(3):337-344. doi:10.1016/j.bcp.2010.11.008 PMID:21093416 PMCID:PMC3077125
• Giordano G, Cole TB, Furlong CE, Costa LG. 2011. Paraoxonase 2 (PON2) in the mouse central nervous system: a neuroprotective role?. Toxicol Appl Pharmacol 256:369-378. doi:10.1016/j.taap.2011.02.014 PMID:21354197 PMCID:PMC3155737
• Kim JH, Stevens RC, MacCoss MJ, Goodlett DR, Scherl A, Richter RJ, Suzuki SM, Furlong CE, Marsillach J, Tomazela D, Schopfer LM, Lockridge O. 2011. Biomarkers of organophosphorus (OP) exposures in humans. Neurotoxicology 32:656-660. doi:10.1016/j.neuro.2011.06.005 PMID:21767566 PMCID:PMC3279568
• Liyasova M, Li B, Schopfer LM, Nachon F, Masson P, Furlong CE, Lockridge O. 2011. Exposure to tri-o-cresyl phosphate detected in jet airplant passengers. Toxicol Appl Pharmacol 256:337-347. doi:10.1016/j.taap.2011.06.016 PMID:21723309 PMCID:PMC3205265

2010

• Cole TB, Park SS, Li WF, Furlong CE, Costa LG, Jansen KL. 2010. The toxicity of mixtures of specific organophosphorus (OP) compounds is modulated by paraoxonase 1 status. Advances in Experimental Medicine and Biology 660:47-60. doi:10.1007/978-1-60761-350-3_6 PMID:20221870 PMCID:PMC3035621
• Furlong CE, Suzuki SM, Stevens RC, Marsillach J, Richter RJ, Jarvik GP, Checkoway H, Samii A, Costa LG, Griffith A, Roberts JW, Yearout D, Zabetian CP. 2010. Human PON1, a biomarker of risk of disease and exposure. Chem Biol Interact 187(1-3):355-361. doi:10.1016/j.cbi.2010.03.033 PMID:20338154 PMCID:PMC3035622
• Hofmann JN, Keifer M, Checkoway H, De Roos AJ, Farin FM, Fenske RA, Richter RJ, van Belle G, Furlong CE. 2010. Biomarkers of sensitivity and exposure in Washington state pesticide handlers. Advances in Experimental Medicine and Biology 660:19-27. doi:10.1007/978-1-60761-350-3_3 PMID:20221867 PMCID:PMC3041670
• Hofmann JN, Keifer M, De Roos AJ, Fenske RA, Furlong CE, van Belle G, Checkoway H. 2010. Occupational determinants of serum cholinesterase inhibition among organophosphate-exposed agricultural pesticide handlers in Washington State. Occup Environ Med 67(6):375-386. doi:10.1136/oem.2009.046391 PMID:19819864 PMCID:PMC2908529
• Kim JH, Stevens RC, MacCoss MJ, Goodlett DR, Scherl A, Richter RJ, Suzuki SM, Furlong CE. 2010. Identification and characterization of biomarkers of organophosphorus (OP) exposures in humans. Advances in Experimental Medicine and Biology 660:61-71. doi:10.1007/978-1-60761-350-3_7 PMID:20221871 PMCID:PMC2878371
• Richter RJ, Cole TB, Park SS, Otto TC, Cerasoli DM, Lenz DE, Furlong CE, Suzuki SM, Stevens RC. 2010. Engineering Human P0N1 in an E. coli Expression System. In: Paraoxonases in Inflammation, Infection and Toxicology. Humana Press, pp.37-46.
• Richter RJ, Jarvik GP, Furlong CE. 2010. Paraoxonase 1 status as a risk factor for disease or exposure. Advances in Experimental Medicine and Biology 660:29-35. doi:10.1007/978-1-60761-350-3_4 PMID:20221868 PMCID:PMC2868909
• Ross S, Brewin C, Curran H, Furlong CE, Abraham-Smith K, Harrison V. 2010. Neuropsychological and psychiatric functioning in sheep farmers exposed to low levels of organophosphate pesticides. Neurotoxicol Teratol 32(4):452-459. doi:10.1016/j.ntt.2010.03.004 PMID:20227490 PMCID:PMC3042861
• Schopfer L, Furlong CE, Lockridge O. 2010. Development of diagnostics in the search for an explanation of aerotoxic syndrome. Anal Biochem 404(1):64-74. doi:10.1016/j.ab.2010.04.032 PMID:20447373 PMCID:PMC2900449
• Suzuki SM, Stevens RC, Richter RJ, Cole TB, Park SS, Otto TC, Cerasoli DM, Lenz DE, Furlong CE. 2010. Engineering human PON1 in an E. coli expression system. Advances in Experimental Medicine and Biology 660:37-45. doi:10.1007/978-1-60761-350-3_5 PMID:20221869 PMCID:PMC3056878
• Ticozzi N, LeClerc AL, Keagle PJ, Glass JD, Wills AM, van Blitterswijk M, Bosco DA, Rodriguez-Leyva I, Gellera C, Ratti A, Taroni F, McKenna-Yasek D, Sapp PC, Silvani V, Furlong CE, Brown RH, Landers JE. 2010. Paraoxonase gene mutations in amyotrophic lateral sclerosis. Ann Neurol 68(1):102-107. doi:10.1002/ana.21993 PMID:20582942 PMCID:PMC2945725

2009

• Hofmann JN, Keifer M, Furlong CE, De Roos AJ, Farin FM, Fenske RA, van Belle G, Checkoway H. 2009. Serum cholinesterase inhibition in relation to paraoxonase-1 (PON1) status among organophosphate-exposed agricultural pesticide handlers. Environ Health Perspect 117:1402-1408. PMID:19750105
• Huen K, Richter RJ, Furlong CE, Eskenazi B, Holland NT. 2009. Validation of PON1 enzyme activity assays for longitudinal studies. Clin Chim Acta 402(1-2):67-74. doi:10.1016/j.cca.2008.12.019 PMID:19146843 PMCID:PMC2683673
• Jansen KL, Cole TB, Park SS, Furlong CE, Costa LG. 2009. Paraoxonase 1 (PON1) modulates the toxicity of mixed organophosphorus compounds. Toxicol Appl Pharmacol 236(2):142-153. doi:10.1016/j.taap.2009.02.001 PMID:19371602 PMCID:PMC2717945
• Richter RJ, Jarvik GP, Furlong CE. 2009. Paraoxonase 1 (PON1) status and substrate hydrolysis. Toxicol Appl Pharmacol 235(1):1-9. doi:10.1016/j.taap.2008.11.001 PMID:19071155 PMCID:PMC3045428

2008

• Richter RJ, Jarvik GP, Furlong CE. 2008. Determination of paraoxonase 1 status without the use of toxic organophosphate substrates. Circ Cardiovasc Genet 1(2):147-152. doi:10.1161/CIRCGENETICS.108.811638 PMID:20031556 PMCID:PMC3035628
• Stevens RC, Suzuki SM, Cole TB, Park SS, Richter RJ, Furlong CE. 2008. Engineered recombinant human paraoxonase 1 (rHuPON1) purified from Escherichia coli protects against organophosphate poisoning. Proc Natl Acad Sci U S A 105(35):12780-12784. doi:10.1073/pnas.0805865105 PMID:18711144 PMCID:PMC2529096

2007

• Furlong CE. 2007. Genetic variability in the cytochrome P450-paraoxonase 1 (PON1) pathway for detoxication of organophosphorus compounds. J Biochem Mol Toxicol 21(4):197-205. PMID:17936934

2006

• Costa LG, Cole TB, Furlong CE. 2006. Gene-environment interactions: paraoxonase (PON1) and sensitivity to organophosphate toxicity. LabMedicine 37(2):109-113.
• Costa LG, Cole TB, Furlong CE. 2006. Genetic ponymorphisms of human paraoxonase (PON1) and susceptibility to organophosphorous insecticide toxicity. In: 28^th International Congress on Occupational Health (ICOH); May 11-16. Milan, Italy.
• Costa LG, Cole TB, Furlong CE. 2006. PON1 and organophosphate toxicity. In: 2^nd International Conference on paraoxonases; September 7-10. Debrecen, Hungary.
• Costa LG, Cole TB, Vitalone A, Furlong CE. 2006. Paraoxonase polymorphisms and toxicity of organophosphates. Toxicology of Organophosphate and Carbamate Pesticides
• Furlong CE. 2006. A surface plasmon resonance (SPR)-based sensor system for near real-time monitoring of analytes. In: Center for Process Analytical Chemistry Fall Sponser Meeting, November 7-10. Seattle, WA.
• Furlong CE, Cole TB, Richter RJ, Brophy V, Carlson CS, Rieder R, Nickerson DA, Costa LG, Ranchalis J, Jarvik GP, Lusis AJ, Shih DM, Tward A. 2006. The functional consequences of polymorphisms in the human PON1 gene. In: 2^nd International Conference on paraoxonases; September 7-10. Debrecen, Hungary.

2005

• Cole TB, Walter BJ, Shih DM, Tward A, Lusis AJ, Timchalk C, Richter RJ, Costa LG, Furlong CE. 2005. Toxicity of chlorpyrifos and chlorpyrifos oxon in a transgenic mouse model of the human paraoxonase (PON1) Q192R polymorphism. Pharmacogenet Genomics 15(8):589-598. PMID:16007003
• Costa LG, Cole TB, Furlong CE. 2005. Paraoxonase (PON1): from toxicology to cardiovascular medicine. Acta Biomed 76Suppl2:50-57. PMID:16353344
• Costa LG, Cole TB, Vitalone A, Furlong CE. 2005. Measurement of paraoxonase (PON1) status as a potential biomarker of susceptibility to organophosphate toxicity. Clin Chim Acta 352(1-2):37-47. PMID:15653099
• Costa LG, Vitalone A, Cole TB, Furlong CE. 2005. Modulation of paraoxonase (PON1) activity. Biochem Pharmacol 69(4):541-550. PMID:15670573
• Furlong CE, Cole TB, Jarvik GP, Pettan-Brewer C, Geiss GK, Richter RJ, Shih DM, Tward A, Lusis AJ, Costa LG. 2005. Role of paraoxonase (PON1) status in pesticide sensitivity: genetic and temporal determinants. Neurotoxicology 26(4):651-659. PMID:16112327
• Furlong CE, Cole TB, Walter BJ, Shih DM, Tward A, Lusis AJ, Timchalk C, Richter RJ, Costa LG. 2005. Paraoxonase 1 (PON1) status and risk of insecticide exposure. J Biochem Mol Toxicol 19(3):182-183. PMID:15977192

2004

• Costa LG, Kelada SN, Costa-Mallen P, Farin FM, Viernes HA, Smith-Weller T, Franklin GM, Longstreth WT, Swanson PD, Checkoway H, Furlong CE. 2004. Paraoxonase 2 (PON2) polymorphisms and Parkinson's disease. Neurosci Res Commun 34(3):130-135.

2003

• Cole TB, Jampsa RL, Walter BJ, Arndt TL, Richter RJ, Shih DM, Tward A, Lusis AJ, Jack RM, Costa LG, Furlong CE. 2003. Expression of human paraoxonase (PON1) during development. Pharmacogenet Genomics 13(6):357-364. PMID:12777966
• Costa LG, Cole TB, Furlong CE. 2003. Polymorphisms of paraoxonse (PONl)and their significance in clinical toxicology of organophosphates. Toxicology 41(1):37-45. PMID:12645966
• Costa LG, Cole TB, Jarvik GP, Furlong CE. 2003. Functional genomic of the paraoxonase (PON1) polymorphisms: effects on pesticide sensitivity, cardiovascular disease, and drug metabolism. Annu Rev Med 54:371-392. doi:10.1146/annurev.med.54.101601.152421 PMID:12525679
• Costa LG, Richter RJ, Li WE, Cole TB, Guizzetti M, Furlong CE. 2003. Paraoxonase (PON 1) as a biomarker of susceptibility for organophosphate toxicity. Biomarkers 8(1):1-12. doi:10.1080/13547500210148315 PMID:12519632
• Kelada SN, Costa-Mallen P, Checkoway H, Viernes HA, Farin FM, Costa LG, Longstreth WT, Furlong CE, Jarvik GP, Swanson PD. 2003. Paraoxonase 1 promoter and coding region polymorphisms in Parkinson's disease. Journal of Neurology, Neurosurgery & Psychiatry 74(4):546-547. PMID:12640090

2002

• Costa LG, Furlong CE. 2002. Perspectives in PONI research. Chapter 10. In: Paraoxonase (PON1) in Health and Disease: Basic and Clinical Aspects. Kluwer Academic Publishers, pp.197-210.
• Costa LG, Li WF, Richter RJ, Shih DM, Lusis AJ, Furlong CE. 2002. PONl and organophosphate toxicity. Chapter 8. In: Paraoxonase (PON1) in Health and Disease: Basic and Clinical Aspects. Kluwer Academic Publishers, pp.165-183.
• Furlong CE, Cole TB, Jarvik GP, Costa LG. 2002. Pharmacogenomic considerations of the paraoxonase polymorphisms. Pharmacogenet Genomics 3(3):341-348. PMID:12052142

1993

• Furlong CE, Costa LG, Hassett C, Richter RJ, Sundstrom JA, Adler DA, Disteche CM, Omiecinski CJ, Chapline CM, Crabb JW, Humbert R. 1993. Human and rabbit paraoxonases: purification, cloning, sequencing, mapping and role of polymorphism in organophosphate detoxification. Chem Biol Interact 87(1-3):35-48. PMID:8393745