Non-Labeled, Stable Labeled, or Radiolabelled Approaches for Provision of Intravenous Pharmacokinetics in Humans: A Discussion Piece

A review of the use of microdoses and isotopic microtracers for clinical intravenous pharmacokinetic (i.v. PK) data provision is presented. The extent of application of the varied approaches available and the relative merits of each are highlighted with the aim of assisting practitioners in making informed decisions on the most scientifically appropriate design to adopt for any given new drug in development. It is envisaged that significant efficiencies will be realized as i.v. PK data in humans becomes more routinely available for suitable assets in early development, than has been the case prior to the last decade.

Recommendations on the Use of Multiple Labels in Human Mass Balance Studies

The administration of radiolabeled drug candidates is considered the gold standard in absorption, distribution, metabolism, and excretion studies for small-molecule drugs since it allows facile and accurate quantification of parent drug, metabolites, and total drug-related material independent of the compound structure. The choice of the position of the radiolabel, typically 14C or 3H, is critical to obtain relevant information. Sometimes, a biotransformation reaction may lead to cleavage of a part of the molecule. As a result, only the radiolabeled portion can be followed, and information on the fate of the nonlabeled metabolite may be lost. Synthesis and administration of two or more radiolabeled versions of the parent drug as a mixture or in separate studies may resolve this issue but comes with additional challenges. In this paper, we address the questions that may be considered to help make the right choice whether to use a single or multiple radiolabel approach and discuss the pros and cons of different multiple-labeling strategies that can be taken as well as alternative methods that allow the nonlabeled part of the molecule to be followed. SIGNIFICANCE STATEMENT: Radiolabeled studies are the gold standard in drug metabolism research, but molecules can undergo cleavage with loss of the label. This often results in discussions around potential use of multiple labels, which seem to be occurring with increased frequency since an increasing proportion of the small-molecule drugs are tending towards larger molecular weights. This review provides insight and decision criteria in considering a multiple-label approach as well as pros and cons of different strategies that can be followed.

Considerations for Human ADME Strategy and Design Paradigm Shift(s) - An Industry White Paper

The human absorption, distribution, metabolism, and excretion (hADME) study is the cornerstone of the clinical pharmacology package for small molecule drugs, providing comprehensive information on the rates and routes of disposition and elimination of drug-related material in humans through the use of 14 C-labeled drug. Significant changes have already been made in the design of the hADME study for many companies, but opportunity exists to continue to re-think both the design and timing of the hADME study in light of the potential offered by newer technologies, that enable flexibility in particular to reducing the magnitude of the radioactive dose used. This paper provides considerations on the variety of current strategies that exist across a number of pharmaceutical companies and on some of the ongoing debates around a potential move to the so called "human first/human only" approach, already adopted by at least one company. The paper also provides a framework for continuing the discussion in the application of further shifts in the paradigm.

Insights into the Chemistry of Iodine New Particle Formation: The Role of Iodine Oxides and the Source of Iodic Acid

Iodine chemistry is an important driver of new particle formation in the marine and polar boundary layers. There are, however, conflicting views about how iodine gas-to-particle conversion proceeds. Laboratory studies indicate that the photooxidation of iodine produces iodine oxides (I_xO_y), which are well-known particle precursors. By contrast, nitrate anion chemical ionization mass spectrometry (CIMS) observations in field and environmental chamber studies have been interpreted as evidence of a dominant role of iodic acid (HIO₃) in iodine-driven particle formation. Here, we report flow tube laboratory experiments that solve these discrepancies by showing that both I_xO_y and HIO₃ are involved in atmospheric new particle formation. I₂O_y molecules (y = 2, 3, and 4) react with nitrate core ions to generate mass spectra similar to those obtained by CIMS, including the iodate anion. Iodine pentoxide (I₂O₅) produced by photolysis of higher-order I_xO_y is hydrolyzed, likely by the water dimer, to yield HIO₃, which also contributes to the iodate anion signal. We estimate that ∼50% of the iodate anion signals observed by nitrate CIMS under atmospheric water vapor concentrations originate from I₂O_y. Under such conditions, iodine-containing clusters and particles are formed by aggregation of I₂O_y and HIO₃, while under dry laboratory conditions, particle formation is driven exclusively by I₂O_y. An updated mechanism for iodine gas-to-particle conversion is provided. Furthermore, we propose that a key iodine reservoir species such as iodine nitrate, which we observe as a product of the reaction between iodine oxides and the nitrate anion, can also be detected by CIMS in the atmosphere.

An integrated assessment of the ADME properties of the CDK4/6 Inhibitor ribociclib utilizing preclinical in vitro, in vivo, and human ADME data

Ribociclib (LEE011, Kisqali ®) is a highly selective small molecule inhibitor of cyclin-dependent kinases 4 and 6 (CDK4/6), which has been approved for the treatment of advanced or metastatic breast cancer. A human ADME study was conducted in healthy male volunteers following a single oral dose of 600 mg [¹⁴ C]-ribociclib. Mass balance, blood and plasma radioactivity, and plasma ribociclib concentrations were measured. Metabolite profiling and identification was conducted in plasma, urine, and feces. An assessment integrating the human ADME results with relevant in vitro and in vivo non-clinical data was conducted to provide an estimate of the relative contributions of various clearance pathways of the compound. Ribociclib is moderately to highly absorbed across species (approx. 59% in human), and is extensively metabolized in vivo, predominantly by oxidative pathways mediated by CYP3A4 (ultimately forming N-demethylated metabolite M4) and, to a lesser extent, by FMO3 (N-hydroxylated metabolite M13). It is extensively distributed in rats, based on QWBA data, and is eliminated rapidly from most tissues with the exception of melanin-containing structures. Ribociclib passed the placental barrier in rats and rabbits and into milk of lactating rats. In human, 69.1% and 22.6% of the radiolabeled dose were excreted in feces and urine, respectively, with 17.3% and 6.75% of the ¹⁴ C dose attributable to ribociclib, respectively. The remainder was attributed to numerous metabolites. Taking into account all available data, ribociclib is estimated to be eliminated by hepatic metabolism (approx. 84% of total), renal excretion (7%), intestinal excretion (8%), and biliary elimination (1%).

Metabolism and Disposition of Siponimod, a Novel Selective S1P1/S1P5 Agonist, in Healthy Volunteers and In Vitro Identification of Human Cytochrome P450 Enzymes Involved in Its Oxidative Metabolism

Siponimod, a next-generation selective sphingosine-1-phosphate receptor modulator, is currently being investigated for the treatment of secondary progressive multiple sclerosis. We investigated the absorption, distribution, metabolism, and excretion (ADME) of a single 10-mg oral dose of [¹⁴C]siponimod in four healthy men. Mass balance, blood and plasma radioactivity, and plasma siponimod concentrations were measured. Metabolite profiles were determined in plasma, urine, and feces. Metabolite structures were elucidated using mass spectrometry and comparison with reference compounds. Unchanged siponimod accounted for 57% of the total plasma radioactivity (area under the concentration-time curve), indicating substantial exposure to metabolites. Siponimod showed medium to slow absorption (median T_max: 4 hours) and moderate distribution (Vz/F: 291 l). Siponimod was mainly cleared through biotransformation, predominantly by oxidative metabolism. The mean apparent elimination half-life of siponimod in plasma was 56.6 hours. Siponimod was excreted mostly in feces in the form of oxidative metabolites. The excretion of radioactivity was close to complete after 13 days. Based on the metabolite patterns, a phase II metabolite (M3) formed by glucuronidation of hydroxylated siponimod was the main circulating metabolite in plasma. However, in subsequent mouse ADME and clinical pharmacokinetic studies, a long-lived nonpolar metabolite (M17, cholesterol ester of siponimod) was identified as the most prominent systemic metabolite. We further conducted in vitro experiments to investigate the enzymes responsible for the oxidative metabolism of siponimod. The selective inhibitor and recombinant enzyme results identified cytochrome P450 2C9 (CYP2C9) as the predominant contributor to the human liver microsomal biotransformation of siponimod, with minor contributions from CYP3A4 and other cytochrome P450 enzymes.

A novel instrument to measure differential ablation of meteorite samples and proxies: The Meteoric Ablation Simulator (MASI)

On entering the Earth's atmosphere, micrometeoroids partially or completely ablate, leaving behind layers of metallic atoms and ions. The relative concentration of the various metal layers is not well explained by current models of ablation. Furthermore, estimates of the total flux of cosmic dust and meteoroids entering the Earth's atmosphere vary over two orders of magnitude. To better constrain these estimates and to better model the metal layers in the mesosphere, an experimental Meteoric Ablation Simulator (MASI) has been developed. Interplanetary Dust Particle (IDP) analogs are subjected to temperature profiles simulating realistic entry heating, to ascertain the differential ablation of relevant metal species. MASI is the first ablation experiment capable of simulating detailed mass, velocity, and entry angle-specific temperature profiles whilst simultaneously tracking the resulting gas-phase ablation products in a time resolved manner. This enables the determination of elemental atmospheric entry yields which consider the mass and size distribution of IDPs. The instrument has also enabled the first direct measurements of differential ablation in a laboratory setting.

Pancreatitis as a complication of endovascular aneurysm repair

INTRODUCTION

We report a case of acute pancreatitis complicating an endovascular abdominal aortic aneurysm repair (EVAR).

REPORT

A seventy three year old man underwent an EVAR and developed acute onset epigastric pain, followed by mottling of the upper abdominal wall. A raised amylase confirmed the diagnosis of acute pancreatitis.

DISCUSSION

To our knowledge this is the first report of this complication of EVAR.

Ultra-performance liquid chromatography coupled to linear ion trap mass spectrometry for the identification of drug metabolites in biological samples

The coupling of ultra-performance liquid chromatography, operating at elevated pressures, to a linear ion trap mass spectrometer provides a high-performance system suitable for drug metabolite characterisation. This system demonstrates improved chromatographic efficiency and sensitivity and at the same time provides diagnostic MSn data often critical for metabolite structural assignment. The linear ion trap was capable of dealing with the high chromatographic efficiencies and hence narrow peak widths associated with 1.7 microm particle-packed column separations. Polarity switching and data-dependent MSn data were generated with ease, and applied to the identification of metabolites found in human plasma.

Case report: myoepithelial carcinoma of the breast: a case report with imaging and pathological findings

We present a case of myoepithelial carcinoma of the breast together with illustrations of the imaging and pathological appearances as well as discussion on the management of this condition.

The economics of foot and mouth disease

The economic effects of foot and mouth disease (FMD) are summarised. Losses arise from the direct effects of the disease on production, costs of disease control and restriction of trade. Direct effects are of greatest importance in dairy and pig production systems. Costs of disease control, whether by stamping-out or vaccination are high. Even countries that are free of the disease incur prevention and emergency preparedness costs. The published studies indicate that where FMD eradication is feasible, this is the least-cost policy option, even allowing for the costs of prevention, emergency preparedness and the risk of outbreaks. Where eradication is not feasible, it is economically beneficial to protect high-producing livestock by vaccination. Vaccination of lower-producing animals may also be justified, especially where these animals produce milk or traction power, or where this would serve to protect high-producing livestock from disease challenge.

Financial analysis of East Coast fever control strategies in traditionally managed Sanga cattle in Central Province of Zambia

Five different East Coast fever (ECF)-control strategies (involving ECF immunisation by the infection-and-treatment method) were tested in groups of traditionally managed Sanga cattle in the Central Province of Zambia over a period of 2.5 years. Two groups were under intensive tick control (weekly spraying with acaricide)--one group immunised and the other non-immunised. Two groups were under no tick control--one group immunised and the other non-immunised. The fifth group was under seasonal tick control (18 sprays/year) and was immunised against ECF. The input and output data were used to construct discounted cash flows for each group. The seasonally sprayed and immunised group gave the highest net present value, and the non-immunised group with no tick control, the lowest. A break-even analysis showed that the immunisation costs could rise to US$25.9 per animal before profitability was affected. For herds under intensive tick control, immunisation was of no financial benefit. The results demonstrate the value of immunisation, and indicate the importance of its combination with seasonal tick-control measures.

Guide to epidemiological surveillance for rinderpest. Office International des Epizooties

The practical implementation of epidemiological surveillance programmes for rinderpest prescribed by the standards of the Office International des Epizooties (OIE) is described. The rationale of surveillance is discussed in relation to the stages of disease control, discontinuation of vaccination, clinical surveillance and serological surveillance. These stages lead to provisional and confirmed declarations of freedom from disease, and the confirmed declaration of freedom from infection. Practical methods of stratification of livestock populations, and selection of samples of herds and animals within selected herds are explained. The actions to follow any discovery of disease, or any clinical or serological signs of disease, are discussed. In the serological surveillance stage, balancing the number of herds and the number of animals within selected herds tested can result in considerable reduction in the overall number of serum samples to be tested. The methods used in rinderpest surveillance can readily be adapted to surveillance programmes for other diseases.

Epidemiology and control of east coast fever in Zambia. A field trial with traditionally managed Sanga cattle

The main objective of the reported field trial was to compare different East Coast Fever (ECF) control strategies for their efficacy, effect on cattle productivity and cost-effectiveness. Five strategies were tested in groups of traditionally managed Sanga cattle over a period of 2.5 years. Two groups were under intensive tick control, one group immunized by the infection and treatment method and the other non-immunized. Two groups were under no tick control, one group immunized and the other non-immunized (the control group). The fifth group was under strategic tick control and was immunized against ECF. All ECF control methods tested significantly reduced mortality, but no marked differences to the control group were seen in other production parameters. No difference in mortality was observed between animals protected from ECF by immunization or by tick control. The most cost-effective method of controlling the disease was by immunization. A financial analysis showed that under the prevailing conditions the break-even price for immunization ranged from US$21.5 to US$25.7 depending of the proportion of reactors. The carrier state induced by immunization did not lead to a persistent high incidence of ECF in non-immunized animals using the same grazing area.

An outbreak of East Coast fever in a herd of Sanga cattle in Lutale, Central Province of Zambia

An outbreak of East Coast fever (ECF) occurred in an experimental herd of Sanga cattle maintained under a traditional rangeland grazing system at Lutale, Central Province of Zambia. Two groups of cattle had been kept under different tick-control regimens for several years prior to the introduction of the disease and epidemiological information on the outbreak were recorded. Weekly tick control was no sufficient to achieve full protection against Theileria parva infection. Systematic body temperature monitoring seems to be a good method for early detection of infection resulting in an important reduction of the case fatality rate after treatment with anti-theilerial drugs.

Effect of different East Coast fever control strategies on disease incidence in traditionally managed Sanga cattle in Central Province of Zambia

A clinical trial, including five East Coast fever (ECF) control strategies (involving tick control and/or immunisation by infection-and-treatment) in five different groups of traditionally managed Sanga cattle, was conducted in Central Province of Zambia over 2.5 years between 1992 and 1995. Two groups were kept under intensive tick control by weekly acaricide treatment by hand spray; (one immunised and one non-immunised), two groups were under no tick control (one immunised and one non-immunised), and a fifth, immunised group was maintained under strategic tick control (18 sprays yr-1). ECF-specific mortality was highest in the non-immunised and non-treated group, while no difference in ECF-specific mortality could be observed between animals treated for ECF by immunisation or by tick control. Acaricide treatment and/or immunisation reduced the risk of clinical ECF by 92%. The results of an artificial challenge experiment at the end of the field trial indicated that about 60% of the animals in the control group had become infected with Theileria parva without showing clinical signs. ECF incidence in non-vaccinated cattle markedly declined six months after immunisation--suggesting that the carrier state induced by immunisation did not lead to a persistent high incidence, and might accelerate the progress to endemicity.

Effect of different East Coast Fever control strategies on fertility, milk production and weight gain of Sanga cattle in the Central Province of Zambia

Five different East Coast Fever (ECF) (Theileria parva infection) control strategies, based on tick control and/or ECF immunization, were tested in groups of traditionally managed Sanga cattle in the Central Province of Zambia over a period of 2.5 years. Two groups were kept under intensive tick control (sprayed weekly), one group immunized and one non-immunized. Two further groups were under no tick control, one group immunized and one non-immunized, while a fifth group was immunized against ECF and maintained under strategic tick control (18 sprays per year). Tick control increased milk production and weight gain but not fertility. Immunization had neither marked detrimental nor beneficial effects on the cattle productivity. The combination of strategic tick control and immunization resulted in the highest level of production and at the same time reduced the potential risk from other tick-borne diseases.

Long-term studies on the economic impact of ticks on Sanga cattle in Zambia

Three different tick control policies were tested in groups of traditionally managed Sanga cattle in the Central Province of Zambia over a period of 3 years. One group was given strategic tick control using 12 pyrethroid acaricide spray applications between the onset and the end of the wet season (October to March). The productivity of this herd was compared with that of a group with no tick control and a group under an intensive tick control regimen of spraying every week in the wet season and every 2 weeks in the dry season (36 applications per year). The highest output was associated with intensive tick control, followed by strategic control and then no tick control policies. However, when the costs of tick control were taken into account, the strategic tick control policy produced the best economic result, followed by the intensive and then the no tick control policies. Neither the strategic nor the intensive tick control policy was sufficient to prevent the transmission of East Coast fever (ECF) infection when this disease was introduced to the area.

Effects of immunisation against Theileria parva on beef cattle productivity and economics of control options

Over 500 cattle of all age groups on 2 farms in Zimbabwe were immunised against theileriosis using the "infection and treatment" method and disease prevalence and their productivity assessed during a period of 18 months. The immunising stock, Theileria parva (Boleni) was isolated in Zimbabwe. None of the immunised cattle suffered from theileriosis upon natural exposure whereas 22 unimmunised cattle died of theileriosis and a further 48 required treatment for theileriosis. In the first year, some immunised cattle were maintained with minimal threshold dipping (once or twice during the rainy season). During periods of very high tick challenge of 100 to 1,000 Rhipicephalus appendiculatus per animal from January to March, a transient decrease in liveweight gain was observed particularly in cows. However, by the end of the period of observation, the weights had recovered so that intensively dipped and immunised and threshold or strategically dipped groups of cattle showed no significant differences. From the results it was estimated that each engorging female R. appendiculatus caused a temporary depression in weight gain of 8 grams. In young stock the weight loss was exacerbated by the presence of screw worm (Chrysomya bezziana) infestation. It was then possible to define an economically attractive integrated tick and theileriosis control strategy based on these findings, whereby immunised cattle were dipped 6 times between mid-December and mid-March. In this regimen, no weight loss occurred and no cases of screw worm were observed. For each of 3 herd sizes of 250, 500 and 1,000 cattle, comparisons were made of the costs of 4 different control options: (i) Intensive dipping (40 times/year) (ii) Intensive pour-on acaricide treatments (18 times/year) (iii) Theileria immunisation with strategic dipping (6 times/year) (iv) Theileria immunisation with pour-on treatment (4 times/year) It is concluded from these studies that, on farms where theileriosis is a serious problem, immunisation coupled with a strategic dipping programme is economically very attractive. In the year in which immunisation is carried out, costs will be higher than for intensive dipping, but from the second year on, the costs are decreased to approximately 50% of those for intensive dipping.

DIAG, a laboratory information management system developed for regional animal disease diagnostic laboratories in Indonesia

The DIAG Laboratory Information Management System is a micro-computerised program designed for the use of regional and national animal disease diagnostic laboratories in Indonesia. It facilitates the day to day management of diagnostic data by monitoring the progress and turn round times of samples sent to laboratory sections and by printing outputs detailing the tests undertaken and results obtained. Notifiable disease reports are generated routinely as part of a national disease surveillance programme. Detailed analyses of specific diagnoses allow investigations of diseases over location and time. The database is easily accessed to allow additional analyses. Data entry is facilitated through the use of entry screens which reduce associated errors. The system is flexible and can readily be adapted to meet the demands of different countries, veterinary services and types of laboratory.

An epidemiological model of rinderpest. II. Simulations of the behaviour of rinderpest virus in populations

Fixed parameters for different hypothetical strains of rinderpest virus (RV) and different susceptible populations are described together with details of their derivation. Simulations were then carried out in a computer model to determine the effects that varying these parameters would have on the behaviour of RV in the different populations. The results indicated that virulent strains of RV are more likely to behave in epidemic fashion whereas milder strains tend towards persistence and the establishment of endemicity. High herd immunity levels prevent virus transmission and low herd immunity levels encourage epidemic transmission. Intermediate levels of immunity assist the establishment of endemicity. The virus is able to persist in large populations for longer than in small populations. Different vaccination strategies were also investigated. In areas where vaccination is inefficient annual vaccination of all stock may be the best policy for inducing high levels of herd immunity. In endemic areas and in herds recovering from epidemics the prevalence of clinically affected animals may be very low. In these situations veterinary officers are more likely to find clinical cases by examining cattle for mouth lesions rather than by checking for diarrhoea or high mortalities.

An epidemiological model of rinderpest. I. Description of the model

The development of an epidemiological model of rinderpest in cattle and wildlife populations is described. The model uses a state-transition structure, incorporating a stochastic element through the use of Monte-Carlo methods modified to allow large populations to be simulated. The potential applications include the estimation of "safe" host population immunity rates and the design of cost-effective rinderpest vaccination programmes.

Clinical trial of halofuginone lactate for the treatment of East Coast fever in Kenya

A field trial was undertaken to test the efficacy of halofuginone lactate in the treatment of East Coast fever under farming conditions in Kenya. The drug was administered orally at a dose of 1.2 mg/kg bodyweight and treatment was repeated after 48 hours. Of 293 cases treated 236 (80.5 per cent) recovered and 49 (16.7 per cent) died. Five animals were disposed of by the owners and three became chronically infected. No differences were recorded in recovery rate between uncomplicated cases and cases with concurrent anaplasmosis or babesiosis, nor were there any significant differences in recovery rates between animals of different types. However, zebu cattle (Bos indicus) tended to respond more rapidly to treatment than exotic cattle (Bos taurus). Younger animals had a poorer recovery rate than adults. Early treatments were more successful than those administered late. It was concluded that with early detection and treatment, coupled with efficient tick control, halofuginone lactate is effective in the treatment of clinical East Coast fever under field conditions.

Rainfall and epizootic Rift Valley fever

Epizootic Rift Valley fever (RVF) has occurred in Kenya four times over the last 30 years. Widespread, frequent, and persistent rainfall has been a feature of these epizootic periods. A composite statistic, based upon measurements of these rainfall characteristics, is positive during periods of epizootic Rift Valley fever. The heavy rainfall raises the level of the water table in certain areas, flooding the grassland depressions (dambos) that are the habitat of the immature forms of certain ground-pool-breeding mosquitos of the genus Aedes. RVF virus is probably transmitted transovarially in these species, very large numbers of which emerge under these damp conditions. This is when clinical signs of the disease are first seen.

Preoperative reductive chemotherapy for locally advanced carcinoma of the oral cavity, oropharynx, and hypopharynx

Recent reports have documented that five year survivals have not really improved as a result of combined therapy programs utilizing surgery and radiation therapy. The pattern of treatment failure seems to have changed in that such combined programs offer improved local and regional control but only to have patients develop distant metastases. The need for some form of systemic treatment was obvious. In 1977, a pilot study was initiated at the Ohio State University to evaluate a particular four drug combination and its effectiveness against squamous cell carcinoma of the head and neck. The initial results revealed an acceptable risk-benefit ratio to evaluate this regimen in a group of patients who had previously received no treatment. This report details the final results of the pilot study designed to evaluate response rates in previously untreated locally advanced squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx. During the 15 month duration of this study there were 58 patients who were evaluable. The overall response to a combination of cis-platinum, vincrinstine, methotrexate, and bleomycin was 66%. All toxicities occurred in less than 10% of the patients except for nausea and vomiting, which occurred to a mild to moderate degree in three quarters of the patient population. There was no increase in surgical or radiotherapeutic complications as a result of utilizing initial chemotherapy. This four-drug combination is now being evaluated to test its impact on survival as a Southwest Oncology Group study.

Combination therapy protocol for stage III or IV carcinoma of the oral cavity, oropharynx and hypopharynx

Combined therapy programs have improved recurrent and nodal metastatic rates but have not controlled distant metastases. A pilot study undertaken at Ohio State University evaluated the feasibility of adding chemotherapy to a combined modality regimen. The first phase determined that the toxicity of a four-drug combination chemotherapy yielded a favorable risk/benefit ratio and justified its inclusion in a protocol for untreated cancers. The second phase evaluated chemotherapy followed by surgery and postoperative irradiaation for untreated Stage III and IV epidermoid carcinoma of the oral cavity, oropharynx or hypopharynx. The overall chemotherapy response rate is 88% (22/25) with 6 complete and 16 partial responses. Evaluation of pathology specimens revealed 7 of 14 primary sites and 4 of 15 neck specimens had no histologic evidence of carcinoma. In the 10 patients who received all 3 modalities, 9 are free of disease (6 to 17 mo. follow-up).