Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation

Background

It is uncertain whether skin pigmentation affects pulse oximeter accuracy at low HbO2 saturation.

Methods

The accuracy of finger pulse oximeters during stable, plateau levels of arterial oxygen saturation (Sao2) between 60 and 100% were evaluated in 11 subjects with darkly pigmented skin and in 10 with light skin pigmentation. Oximeters tested were the Nellcor N-595 with the OxiMax-A probe (Nellcor Inc., Pleasanton, CA), the Novametrix 513 (Novametrix Inc., Wallingford, CT), and the Nonin Onyx (Nonin Inc., Plymouth, MN). Semisupine subjects breathed air-nitrogen-carbon dioxide mixtures through a mouthpiece. A computer used end-tidal oxygen and carbon dioxide concentrations determined by mass spectrometry to estimate breath-by-breath Sao2, from which an operator adjusted inspired gas to rapidly achieve 2- to 3-min stable plateaus of desaturation. Comparisons of oxygen saturation measured by pulse oximetry (Spo2) with Sao2 (by Radiometer OSM3) were used in a multivariate model to determine the interrelation between saturation, skin pigmentation, and oximeter bias (Spo2 - Sao2).

Results

At 60-70% Sao2, Spo2 (mean of three oximeters) overestimated Sao2 (bias +/- SD) by 3.56 +/- 2.45% (n = 29) in darkly pigmented subjects, compared with 0.37 +/- 3.20% (n = 58) in lightly pigmented subjects (P < 0.0001). The SD of bias was not greater with dark than light skin. The dark-light skin differences at 60-70% Sao2 were 2.35% (Nonin), 3.38% (Novametrix), and 4.30% (Nellcor). Skin pigment-related differences were significant with Nonin below 70% Sao2, with Novametrix below 90%, and with Nellcor at all ranges. Pigment-related bias increased approximately in proportion to desaturation.

Conclusions

The three tested pulse oximeters overestimated arterial oxygen saturation during hypoxia in dark-skinned individuals.

Sequential application of cold and sodium lauryl sulphate decreases irritation and barrier disruption in vivo in humans

BACKGROUND

Irritant contact dermatitis (ICD) is one of the most frequent types of occupational dermatitis. Different factors are involved in the development of contact dermatitis. In the food-processing industry, the combined exposure to different irritants may be involved in the development of ICD. Few data have been published regarding the irritant potential of sodium lauryl sulphate (SLS) in combination with cold.

OBJECTIVES

The present study was intended to analyse whether cold exposure and low skin temperature influence the development of ICD.

METHODS

Twenty (part I) and 12 (part II) healthy volunteers were exposed twice daily for 4 days to SLS alone, different low temperatures alone (4 degrees C six times for 90 s with an interval of 20 s or 15 degrees C for 10 min) or a combination of cold and SLS (19.6 microL SLS 1% cm(-2), part I; or 52.6 microL SLS 0.5% cm(-2), part II) using the tandem repetitive irritation test. Irritant cutaneous reactions were measured by noninvasive biophysical methods with transepidermal water loss as a parameter for permeability barrier function and skin colour reflectance together with visual scoring as parameters for inflammatory reactions.

RESULTS

Cold alone caused no significant skin reaction compared with untreated control. Exposure to SLS alone and SLS together with cold (independent of the applied temperature of 4 or 15 degrees C) twice daily induced a clear irritant reaction and barrier disturbance. Reactions did not differ whether SLS was applied before or after cold. Furthermore, 'tandem application' of cold and SLS diminished the barrier disruption and irritant reaction compared with SLS alone.

CONCLUSIONS

We conclude that the application of cold may have a protective effect on the development of ICD, at least in our short-term model.

Erbium:YAG laser treatment of post-burn scars: potentials and limitations

Erbium:YAG lasers are successfully used to treat a variety of epidermal and dermal lesions, including rhytides, dyschromias, and certain types of scars. To date, however, no report has focused on the experiences with this laser in reconstructive burn surgery. Since 2001, the Erbium:YAG laser has become an integral part of the treatment of postburn scars at the Berlin Burn Center. This paper presents the techniques applied and clinical experiences obtained. In addition, a new stripe technique is introduced, which avoids healing disturbances in scars following deep burns. In conclusion, the Erbium:YAG laser has proven to be a valuable supplementary tool for the improvement of cosmetically disturbing mild postburn scars. It is particularly handy in areas difficult to treat, such as the eyes, nose, lips, and fingers. The individual advantages of the Erbium:YAG laser, other laser systems, and dermabrasion for the treatment of burn scars are compared in a brief survey.

Melatonin, melatonin receptors and melanophores: a moving story

Melatonin (5-methoxy N-acetyltryptamine) is a hormone synthesized and released from the pineal gland at night, which acts on specific high affinity G-protein coupled receptors to regulate various aspects of physiology and behaviour, including circadian and seasonal responses, and some retinal, cardiovascular and immunological functions. In amphibians, such as Xenopus laevis, another role of melatonin is in the control of skin coloration through an action on melanin-containing pigment granules (melanosomes) in melanophores. In these cells, very low concentrations of melatonin activate the Mel(1c) receptor subtype triggering movement of granules toward the cell centre thus lightening skin colour. Mel(1c) receptor activation reduces intracellular cAMP via a pertussis toxin-sensitive inhibitory G-protein (Gi), but how this and other intracellular signals regulate pigment movement is not yet fully understood. However, melanophores have proven an excellent model for the study of the molecular mechanisms which coordinate intracellular transport. Melanosome transport is reversible and involves both actin- (myosin V) and microtubule-dependent (kinesin II and dynein) motors. Melanosomes retain both kinesin and dynein during anterograde and retrograde transport, but the myosin V motor seems to be recruited to melanosomes during dispersion, where it assists kinesin II in dominating dynein thus driving net dispersion. Recent work suggests an important role for dynactin in coordinating the activity of the opposing microtubule motors. The melanophore pigment aggregation response has also played a vital role in the ongoing effort to devise specific melatonin receptor antagonists. Much of what has been learnt about the parts of the melatonin molecule required for receptor binding and activation has come from detailed structure-activity data using novel melatonin ligands. Work aiming to devise ligands specific for the distinct melatonin receptor subtypes stands poised to deliver selective agonists and antagonists which will be valuable tools in understanding the role of this enigmatic hormone in health and disease.

Under the skin: On the impartial treatment of genetic and environmental hypotheses of racial differences

Environmental and genetic explanations have been given for Black-White racial differences in intelligence and other traits. In science, viable, alternative hypotheses are ideally given equal Bayesian prior weights; but this has not been true in the study of racial differences. This article advocates testing environmental and genetic hypotheses of racial differences as competing hypotheses. Two methods are described: (a) fitting means within structural equation models and (b) predicting means of interracial children. These methods have limitations that call for improved research designs of racial differences. One improvement capitalizes on biotechnology. Genetic admixture estimates--the percentage of genes of European origin that a Black individual possesses (independent of genes related to skin coloration)--can represent genetic influences. The study of interracial children can be improved by increasing sample size and by choosing family members who are most informative for a research question. Eventually, individual-admixture estimates will be replaced by molecular genetic tests of alleles of those genes that influence traits.

Skin color correction for tissue spectroscopy: demonstration of a novel approach with tissue-mimicking phantoms

The application of partial least squares (PLS) regression to visible-near-infrared (VIS-NIR) spectroscopy for modeling important blood and tissue parameters is generally complicated by the variation in skin pigmentation (melanin) across the human population. An orthogonal correction method for removing the influence of skin pigmentation has been demonstrated in diffuse reflectance spectra from two-layer tissue-mimicking phantoms. The absorption properties of the phantoms were defined by lyophilized human hemoglobin (bottom layer) and synthetic melanin (top layer). Tissue-like scattering was simulated in both layers with intralipid. The approach uses principal components analysis (PCA) loading vectors from a separate set of phantom spectra that encode the unwanted melanin variation to remove the effect of melanin from the test phantoms. The preprocessing of phantom spectra using this orthogonal correction method resulted in PLS models with reduced complexity and enhanced prediction performance. Preliminary results from a separate study that evaluates the feasibility of defining skin color variation in an experiment with a single human subject are also presented.

Identification of the F1F0 mitochondrial ATPase as a target for modulating skin pigmentation by screening a tagged triazine library in zebrafish

A triazine-based combinatorial library of small molecules was screened in zebrafish to identify compounds that produced interesting phenotypes. One compound (of 1536 screened) induced a dramatic increase in the pigmentation of early stage zebrafish embryos. This compound, PPA, was also found to increase pigmentation in cultured mammalian melanocytes. The cellular target was identified as the mitochondrial F1F0-ATP synthase (ATPase) by affinity chromatography. Oligomycin, a small molecule known to inhibit the mitochondrial ATPase, competed with PPA for its cellular target in melanocytes. In addition, PPA was shown to alter the membrane potential of mitochondria, consistent with inhibition of the mitochondrial ATPase. Thus, PPA has been successfully used as a chemical probe in a forward chemical genetic approach to establish a link between the phenotype and the protein. The results attest to the power of screening small molecule libraries in zebrafish as a means of identifying mammalian targets and suggest the mitochondrial ATPase as a target for modulating pigmentation in both melanocytes and melanoma cells.

Skin segmentation using color pixel classification: analysis and comparison

This paper presents a study of three important issues of the color pixel classification approach to skin segmentation: color representation, color quantization, and classification algorithm. Our analysis of several representative color spaces using the Bayesian classifier with the histogram technique shows that skin segmentation based on color pixel classification is largely unaffected by the choice of the color space. However, segmentation performance degrades when only chrominance channels are used in classification. Furthermore, we find that color quantization can be as low as 64 bins per channel, although higher histogram sizes give better segmentation performance. The Bayesian classifier with the histogram technique and the multilayer perceptron classifier are found to perform better compared to other tested classifiers, including three piecewise linear classifiers, three unimodal Gaussian classifiers, and a Gaussian mixture classifier.

[Cutaneous photobiology]

The integration of the various cell reactions with ultraviolet light is modulated by the phototypes. It is responsible for photo-immunological processes and for photocancerogenesis.

[Skin and its ethnic shades]

Ethnic (racial) differences exist for a series of physiological skin characteristics. Colour is responsible for typology and resistance to ultraviolet irradiations. Other differences have also been reported for the transepidermal water loss, the size and cohesion of corneocytes, the vascular reactiviy, the biomechanical properties, the pH, the lipidic content, the superficial microflora and the structure of mast cell granules.

[Skin photophysics and colors]

The optical properties of skin and of chromophores orientate and absorbe light. The resulting skin colour can be assessed by visual inspection or by objective methods. Spectrophotometry, tristimulus colorimetry and computerized image analysis are well codified methods. Epidermal melanisation is detected with great sensitivity under ultraviolet light illumination.

Effects of PGF2alpha on human melanocytes and regulation of the FP receptor by ultraviolet radiation

Prostaglandins are potent lipid hormones that activate multiple signaling pathways resulting in regulation of cellular growth, differentiation, and apoptosis. In the skin, prostaglandins are rapidly released by keratinocytes following ultraviolet radiation and are chronically present in inflammatory skin lesions. We have shown previously that melanocytes, which provide photoprotection to keratinocytes through the production of melanin, express several receptors for prostaglandins, including the PGE2 receptors EP1 and EP3 and the PGF2alpha receptor FP, and that PGF2alpha stimulates melanocyte dendricity. We now show that PGF2alpha stimulates the activity and expression of tyrosinase, the rate-limiting enzyme in melanin synthesis. Analysis of FP receptor regulation showed that the FP receptor is regulated by ultraviolet radiation in melanocytes in vitro and in human skin in vivo. We also show that ultraviolet irradiation stimulates production of PGF2alpha by melanocytes. These results show that PGF2alpha binding to the FP receptor activates signals that stimulate a differentiated phenotype (dendricity and pigmentation) in melanocytes. The regulation of the FP receptor and the stimulation of production of PGF2alpha in melanocytes in response to ultraviolet radiation suggest that PGF2alpha could act as an autocrine factor for melanocyte differentiation.

Biogenesis of pigment granules: a sensitive way to regulate melanocyte function

Pigmentation not only provides a wide range of cosmetic coloration to the skin, hair and eyes, but also provides the underlying tissue significant protection from ultraviolet (UV) damage, which can lead to photoaging and photocarcinogenesis. The melanin pigment is synthesized and deposited within a unique, membrane-bound organelle termed the melanosome. Recent advances in molecular biology and biochemistry have allowed a greater appreciation of how melanocytes generate this organelle and how its biogenesis, structure and function is regulated by the environment. Melanosomes serve as ideal models for the study of organelle biogenesis, protein trafficking, organelle movement and cell-cell interactions that occur during the transfer of melanosomes to keratinocytes. Our understanding of the mechanisms behind a wide range of human pigmentary diseases have grown remarkably as melanosomes have been unraveled.

Physiological variation in the erythemal response to ultraviolet radiation and photoadaptation

We have studied the cutaneous response to ultraviolet radiation, measured objectively as erythema in a sample of 12 body sites on 15 Northern European subjects with multiple doses of ultraviolet B (UVB). Skin pigmentation and the development of photoadaptation in response to five repeated doses of irradiation at three body sites was also measured. We report striking differences of up to 5-fold at different body sites to the same challenge dose (p < 0.001) and demonstrate that for this population, site variation is just as important as between-person variation. Skin color at each body site is a strong predictor of response (p < 0.001) and that this cannot be attributed to vascular differences, but instead we believe it reflects site-specific variations in melanin pigmentation. We also observed similar but smaller within-person effects for responses to another inflammatory agent, dithranol (p < 0.01). Despite this, we did not find evidence for differences in the development of photoadaptation by body site. These results have clear clinical implications for the practice of phototesting prior to commencing phototherapy, for therapeutic failure in sites such as the legs in patients with psoriasis, and perhaps for melanoma body-site distribution.

Pigmentation in Intrinsically Aged Skin of A1 Guinea Pigs

It is known that skin often shows irregular pigmentation during aging which is frequently associated with hyperpigmentation. Many studies have utilized brownish A1 guinea pigs to investigate the pathogenesis of ultraviolet (UV)-induced skin pigmentation, however, changes associated with intrinsic aging in A1 guinea pig skin have not been documented. To characterize such changes, skin from the dorsal and neck areas of 20-week, 1-, 2-, 3- and 5-yr-old guinea pigs was examined. Skin color was measured using a colorimeter, and biopsy specimens were stained with Masson-Fontana, L-3,4-dihydroxyphenylalanine (DOPA), and antibodies against KIT (ACK-45), gp100 (HMB-45) and S-100 proteins. The L* value of skin color decreased with aging and melanin deposits increased in the epidermis. Further, DOPA+, gp100+ and S-100+ melanocytes increased, indicating that the number of melanocytes had increased with age, whereas KIT+ melanocytes did not increase in dorsal skin and actually decreased in neck skin with aging. Further, rippled pigmented areas appeared in the neck skin of the 3-yr-old animals, and in the dorsal and neck skin of 5-yr-old guinea pigs in the absence of UV irradiation. Melanocytes were distributed uniformly in younger skin, whereas they were clustered in older skin. UV irradiation caused an increase in the number of melanocytes, although they were not clustered. These results are the first to provide evidence that pigmentation is induced in the skin of intrinsically aged A1 guinea pigs in the absence of UV irradiation, a process that differs from that elicited by UV irradiation.

Low temperature stimulates alpha-melanophore-stimulating hormone secretion and inhibits background adaptation in Xenopus laevis

It is well-known that alpha-melanophore-stimulating hormone (alpha-MSH) release from the amphibian pars intermedia (PI) depends on the light condition of the animal's background, permitting the animal to adapt the colour of its skin to background light intensity. In the present study, we carried out nine experiments on the effect of low temperature on this skin adaptation process in the toad Xenopus laevis, using the skin melanophore index (MI) bioassay and a radioimmunoassay to measure skin colour adaptation and alpha-MSH secretion, respectively. We show that temperatures below 8 degrees C stimulate alpha-MSH secretion and skin darkening, with a maximum at 5 degrees C, independent of the illumination state of the background. No significant stimulatory effect of low temperature on the MI and alpha-MSH plasma contents was noted when the experiment was repeated with toads from which the neurointermediate lobe (NIL) had been surgically extirpated. This indicates that low temperature stimulates alpha-MSH release from melanotrope cells located in the PI. An in vitro superfusion study with the NIL demonstrated that low temperature does not act directly on the PI. A possible role of the central nervous system in cold-induced alpha-MSH release from the PI was tested by studying the hypothalamic expression of c-Fos (as an indicator for neuronal activity) and the coexistence of c-Fos with the regulators of melanotrope cell activity, neuropeptide Y (NPY) and thyrotrophin-releasing hormone (TRH), using double fluorescence immunocytochemistry. Upon lowering temperature from 22 degrees C to 5 degrees C, in white-adapted animals c-Fos expression decreased in NPY-producing suprachiasmatic-melanotrope-inhibiting neurones (SMIN) in the ventrolateral area of the suprachiasmatic nucleus (SC) but increased in TRH-containing neurones of the magnocellular nucleus. TRH is known to stimulate melanotrope alpha-MSH release. We conclude that temperatures around 5 degrees C inactivate the SMIN in the SC and activate TRH-neurones in the magnocellular nucleus, resulting in enhanced alpha-MSH secretion from the PI, darkening the skin of white-adapted X. laevis.

Unsupervised learning of a finite mixture model based on the Dirichlet distribution and its application

This paper presents an unsupervised algorithm for learning a finite mixture model from multivariate data. This mixture model is based on the Dirichlet distribution, which offers high flexibility for modeling data. The proposed approach for estimating the parameters of a Dirichlet mixture is based on the maximum likelihood (ML) and Fisher scoring methods. Experimental results are presented for the following applications: estimation of artificial histograms, summarization of image databases for efficient retrieval, and human skin color modeling and its application to skin detection in multimedia databases.

Evaluation of sun-protective practices of organ transplant recipients

The incidence, morbidity and mortality of skin cancer are markedly increased in organ transplant recipients. Efforts aimed at reducing sun exposure through sun avoidance, sunscreens and sun-protective clothing are the most effective means to reduce the risk of skin cancer. We evaluated the sun-protective behaviors of 205 transplant recipients. Twenty-three percent of transplant patients continued to seek a tan. Thirty percent of patients did not use sunscreens, and of those patients who did, less than 5% were committed to using them daily. Thirty-seven percent of patients frequently wore hats and 39% of patients frequently wore additional clothing to block the sun. When data were stratified according to patient age, gender or skin phototype, we identified preferences for specific sun-protective methods. These data strongly suggest that many transplant recipients do not use adequate sun protection. Further study of strategies to encourage the use of sun protection among transplant patients is needed to reduce the incidence of skin cancer.

The Time Course of Photoadaptation and Pigmentation Studied Using a Novel Method to Distinguish Pigmentation from Erythema

The dynamics of human pigmentation in response to ultraviolet radiation (UVR) remain poorly characterized. In part, this is attributable to methodological issues relating to the overlap in spectra of hemoglobin and melanin. We describe a new method, based on the recording of reflectance properties following iontophoresis of a potent vasoconstrictor, noradrenaline. This removes the influence of blood, allowing measurement of pigmentation, represented as L* on the L*a*b* scale. Blood flow was separately assessed using laser Doppler flowmetry. We show that there is a clear dose response with the dose of UVR administered, that pigmentation peaks at 1 wk and declines over the following 10 wk, but does not return to baseline within this period. We show clear differences in the degree, but not the temporal pattern of pigmentation between different pigmentary groups. We also report that the relation between facultative pigment and constitutive pigment is incomplete, with a wide scatter of responses for the development of pigmentation irrespective of constitutive levels. For comparison we also document overall photoadaptation and relate changes in pigmentation to the overall changes in photoadaptation.

Larval Melanocyte Regeneration Following Laser Ablation in Zebrafish

A method to specifically ablate melanocytes in a genetically tractable organism would facilitate the analysis of melanocyte regeneration and regulation. We have demonstrated that a Q-switched neodymium:yttrium-aluminum-garnet dermatology laser kills larval melanocytes in zebrafish. Following melanocyte ablation, new melanocytes regenerate from unpigmented precursors. We show that melanocyte regeneration following laser ablation requires kit receptor tyrosine kinase.

Melanin pigmentation in mammalian skin and its hormonal regulation

Cutaneous melanin pigment plays a critical role in camouflage, mimicry, social communication, and protection against harmful effects of solar radiation. Melanogenesis is under complex regulatory control by multiple agents interacting via pathways activated by receptor-dependent and -independent mechanisms, in hormonal, auto-, para-, or intracrine fashion. Because of the multidirectional nature and heterogeneous character of the melanogenesis modifying agents, its controlling factors are not organized into simple linear sequences, but they interphase instead in a multidimensional network, with extensive functional overlapping with connections arranged both in series and in parallel. The most important positive regulator of melanogenesis is the MC1 receptor with its ligands melanocortins and ACTH, whereas among the negative regulators agouti protein stands out, determining intensity of melanogenesis and also the type of melanin synthesized. Within the context of the skin as a stress organ, melanogenic activity serves as a unique molecular sensor and transducer of noxious signals and as regulator of local homeostasis. In keeping with these multiple roles, melanogenesis is controlled by a highly structured system, active since early embryogenesis and capable of superselective functional regulation that may reach down to the cellular level represented by single melanocytes. Indeed, the significance of melanogenesis extends beyond the mere assignment of a color trait.

Beyond skin color: emerging roles of melanin-concentrating hormone in energy homeostasis and other physiological functions

Melanin-concentrating hormone (MCH) is a cyclic peptide that mediates its effects by the activation of two G-protein-coupled seven transmembrane receptors (MCHR1 and MCHR2) in humans. In contrast to its primary role in regulating skin color in fish, MCH has evolved in mammals to regulate dynamic physiological functions, from food intake and energy expenditure to behavior and emotion. Chronic infusion or transgenic expression of MCH stimulates feeding and increases adipocity, whereas targeted deletion of MCH or its receptor (MCHR1) leads to resistance to diet-induced obesity with increased energy expenditure and thermogenesis. The involvement of MCH in energy homeostasis and in brain activity has also been validated in mice treated with non-peptide antagonists, suggesting that blockade of MCHR1 could provide a viable approach for treatment of obesity and certain neurological disorders. This review focuses on emerging roles of MCH in regulating central and peripheral mechanisms.

The Combined Effects of Extracts Containing Carotenoids and Vitamins E and C on Growth and Pigmentation of Cultured Human Melanocytes

In the present study, we investigated the effects of tomato extract (TE) containing lycopene and palm fruit extract (PE) rich in carotenoids on the growth and pigmentation of melanocyte cultures of Caucasian origin. The extracts were tested at different concentrations and in combination with vitamins E and C. Melanocytes with basic and increased (tyrosine-induced) pigmentation were treated in short-term and long-term experiments. Prevention of UVA-induced DNA damage was studied by using the comet assay. Melanocytes with stimulated melanin production showed reduced growth. Incubation of the cells with TE/PE (20/4 microg/ml) in combination with 35 microM vitamin E and 100 microM vitamin C (COMB 20/4) reduced this growth inhibition, especially in the long-term cultures. Increased production of melanin pigment was obtained when the cells were treated with 2.5 x and 10 x higher concentrations of the TE/PE and the same concentration of vitamins E and C (COMB 50/10 and 200/40). Reduced DNA damage was found after UVA irradiation in cells preincubated with COMB 50/10. The results indicate that the presence of carotenoids from TE and PE in combination with vitamins E and C may influence growth and pigmentation in melanocyte monocultures. Depending on the concentration of the carotenoid mixtures, their presence may provide some protection against the melanogenic intermediates and/or exogenous DNA damage.

Mesenchymal-epithelial interactions in the skin: increased expression of dickkopf1 by palmoplantar fibroblasts inhibits melanocyte growth and differentiation

We investigated whether or not the topographic regulation of melanocyte differentiation is determined by mesenchymal–epithelial interactions via fibroblast-derived factors. The melanocyte density in palmoplantar human skin (i.e., skin on the palms and the soles) is five times lower than that found in nonpalmoplantar sites. Palmoplantar fibroblasts significantly suppressed the growth and pigmentation of melanocytes compared with nonpalmoplantar fibroblasts. Using cDNA microarray analysis, fibroblasts derived from palmoplantar skin expressed high levels of dickkopf 1 (DKK1; an inhibitor of the canonical Wnt signaling pathway), whereas nonpalmoplantar fibroblasts expressed higher levels of DKK3. Transfection studies revealed that DKK1 decreased melanocyte function, probably through β-catenin–mediated regulation of microphthalmia-associated transcription factor activity, which in turn modulates the growth and differentiation of melanocytes. Thus, our results provide a basis to explain why skin on the palms and the soles is generally hypopigmented compared with other areas of the body, and might explain why melanocytes stop migrating in the palmoplantar area during human embryogenesis.