| Antibody Providers Antibodies in Current Research Antitoxins Synthetic Antibodies Vaccines Vaccine Development Strategies |
Development of monoclonal and polyclonal antibody-based botulinum
neurotoxin vaccines and antitoxins for prophylaxis and postexposure
treatment is a high biodefense priority.
BoNT antibodies for serotypes A to F isolated from a number of
organisms are commercially available.
Antitoxins are currently available in the United States from the CDC.
Vaccines, including monovalent, trivalent, pentavalent, and heptavalent
toxoids are under development.
Antibodies reported in current research involving the study of antibodies to
neutralize botulinum neurotoxins are presented with associated study
information including antibody name, neutralizing activity,
reactive component, experimental applications, immunoglobulin type,
immunoglobulin isotype and publication. Additional details are
presented here describing these key terms.
Neutralizing Activity
Yes = the antibody neutralizes specified serotype neurotoxin in vivo or in vitro
No = the antibody does not neutralize specified serotype neurotoxin
Blank, Null = no data available
Reactive Component (the component of the botulinum neurotoxin that binds to the antibody)
HA1, HA2, or HA3b = subcomponent of hemagglutinin
Hc = heavy chain
HC or H2 = C-terminal of heavy chain
HN or H1 = N-terminal of heavy chain
Lc = light chain
Experimental Applications
DB = Dot Blotting
ELISA = Enzyme Linked Immunosorbent Assay
IP = Immunoprecipitation
WB = Western Blotting or Immunoblotting
Immunoglobulin Type
monoclonal
polyclonal
Immunoglobulin Isotype
IgG1 or IgG2 = subclass of IgG
k = kappa
scFv = single chain variable fragment
Antibody |
Neutralizing |
Reactive |
Experimental |
Immunoglobulin |
Immunoglobulin |
PubMed ID |
| BT57-1 | Yes | BoNT/A Lc | WB | monoclonal | IgG1 | PMID: 11425742 |
| BT150-3 | Yes | BoNT/A Hc | WB | monoclonal | IgG1 | PMID: 11425742 |
| S25 | Yes | BoNT/A Hc | ELISA | monoclonal | IgG1k | PMID: 11553596 |
| C25 | Yes | BoNT/A Hc | ELISA | monoclonal | IgG1k | PMID: 11553596 |
| 3D12 | Yes | BoNT/A Hc | ELISA, WB | monoclonal | IgG1k | PMID: 11553596 |
| CHA1-489 | Yes | BoNT/C HA1 | ELISA, WB | monoclonal | IgG2ak | PMID: 11926732 |
| CHA1-394 | Yes | BoNT/C HA1 | ELISA, WB | monoclonal | IgG2bk | PMID: 11926732 |
| CHA1-28 | No | BoNT/C HA1 | ELISA, WB | monoclonal | IgGk | PMID: 11926732 |
| CHA1-15 | BoNT/C HA1 | ELISA | monoclonal | IgG1k | PMID: 11926732 | |
| CHA1-23 | Yes | BoNT/C HA1 | ELISA | monoclonal | IgG1k | PMID: 11926732 |
| CHA1-29 | Yes | BoNT/C HA1 | ELISA | monoclonal | IgG2bk | PMID: 11926732 |
| CHA1-54 | Yes | BoNT/C HA1 | ELISA | monoclonal | IgG1k | PMID: 11926732 |
| CHA3b-62 | BoNT/C HA3b | ELISA, WB | monoclonal | IgG1k | PMID: 11926732 | |
| CHA3b-6 | No | BoNT/C HA3b | ELISA, WB | monoclonal | IgG2bk | PMID: 11926732 |
| CHA3b-12 | No | BoNT/C HA3b | ELISA, WB | monoclonal | IgG1k | PMID: 11926732 |
| CHA2-14 | No | BoNT/C HA2 | ELISA, WB | monoclonal | IgG1k | PMID: 11926732 |
| BTBH-N1 | Yes | BoNT/B HN | ELISA, WB | monoclonal | IgG1k | PMID: 15225558 |
| LE15-5 | Yes | BoNT/E Hc | WB | monoclonal | IgG1k | PMID: 2450068 |
| LE34-6 | Yes | BoNT/E Hc | WB | monoclonal | IgG1k | PMID: 2450068 |
| EK18-2 | No | BoNT/E Hc | WB | monoclonal | IgG1k | PMID: 2450068 |
| EK19-7 | Yes | BoNT/E Hc | WB | monoclonal | IgG1k | PMID: 2450068 |
| EK21-4 | Yes | BoNT/E Hc | WB | monoclonal | IgG1k | PMID: 2450068 |
| AE27-9 | Yes | BoNT/E Hc | WB | monoclonal | IgG1k | PMID: 2450068 |
| EL161-38 | No | Lc of BoNT/E, BoNT/B, BoNT/CI, BoNT/D, tetanus |
DB, ELISA, WB | monoclonal | IgG1k | PMID: 2450068 |
| EL211-3 | No | BoNT/E Lc | WB | monoclonal | IgG1k | PMID: 2450068 |
| EL219-15 | No | BoNT/E Lc | WB | monoclonal | IgG1k | PMID: 2450068 |
| C-9 | No | BoNT/C Hc | ELISA | monoclonal | IgG1k | PMID: 2581939 |
| CA-12 | Yes | BoNT/C Hc | ELISA | monoclonal | IgG1k | PMID: 2581939 |
| C-14 | No | BoNT/C Hc | ELISA | monoclonal | IgG1k | PMID: 6183207 |
| C-17 | Yes | BoNT/C Hc | ELISA | monoclonal | IgG1k | PMID: 6183207 |
| 3A6 | Yes | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 11858873 |
| 2A1 | Yes | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 11858873 |
| 3B8 | No | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 11858873 |
| 3F10 | No | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 11858873 |
| 2B11 | No | BoNT/A HN | ELISA | monoclonal | scFv | PMID: 11858873 |
| 3D4 | No | BoNT/A HN | ELISA | monoclonal | scFv | PMID: 11858873 |
| 3A11 | No | BoNT/A HN | ELISA | monoclonal | scFv | PMID: 11858873 |
| 4A4 | No | BoNT/A HN | ELISA | monoclonal | scFv | PMID: 11858873 |
| 3G4 | No | BoNT/A HN | ELISA | monoclonal | scFv | PMID: 11858873 |
| 6B2-2 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG1 | PMID: 9795391 |
| 6C2-4 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG1 | PMID: 9795391 |
| 4A2-2 | Yes | BoNT/A H2 | ELISA, IP, WB | monoclonal | IgG2a | PMID: 9795391 |
| 6E10-10 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 9795391 |
| 6E9-12 | Yes | BoNT/A H2 | ELISA, IP, WB | monoclonal | PMID: 9795391 | |
| 6C2-2 | Yes | BoNT/A H2 | ELISA, IP, WB | monoclonal | PMID: 9795391 | |
| N-C-45 | No | ELISA | monoclonal | PMID: 6198281 | ||
| N-C-109 | Yes | ELISA | monoclonal | PMID: 6198281 | ||
| D-26 | No | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| D34 | No | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| N-D-6 | No | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| D-162 | Yes | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| D-210 | Yes | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| D-28 | Yes | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| N-D-1 | Yes | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| N-D-2 | Yes | BoNT/D Hc | ELISA | monoclonal | PMID: 6198281 | |
| N-A-70 | Yes | ELISA | monoclonal | PMID: 6198281 | ||
| N-A-145 | Yes | ELISA | monoclonal | PMID: 6198281 | ||
| CA-12 | Yes | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CA-137 | Yes | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CA-11 | Yes | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CA-27 | Yes | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-DA-20 | No | ELISA | monoclonal | PMID: 6198281 | ||
| N-DA-75 | Yes | BoNT/D Lc | ELISA | monoclonal | PMID: 6198281 | |
| N-DA-122 | Yes | BoNT/D Lc | ELISA | monoclonal | PMID: 6198281 | |
| CDA-69 | Yes | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CDA-14 | Yes | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CDA-175 | No | Hc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| CDA-30 | No | Lc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CDA-5 | No | Lc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| N-CDA-135 | No | Lc of BoNT/C and BoNT/D | ELISA | monoclonal | PMID: 6198281 | |
| anti-C-ST | Yes | polyclonal | PMID: 6198281 | |||
| anti-C-ST-Hc | Yes | BoNT/C Hc | polyclonal | PMID: 6198281 | ||
| anti-C-ST-Lc | Yes | BoNT/C Lc | polyclonal | PMID: 6198281 | ||
| anti-D-1873 | Yes | polyclonal | PMID: 6198281 | |||
| anti-D-1873-Hc | Yes | BoNT/D Hc | polyclonal | PMID: 6198281 | ||
| anti-D-1873-Lc | Yes | BoNT/D Lc | polyclonal | PMID: 6198281 | ||
| anti-D-SA | Yes | polyclonal | PMID: 6198281 | |||
| A101 | Yes | BoNT/A H2 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A102 | No | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A108 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A109 | Yes | BoNT/A Lc | ELISA, WB | monoclonal | PMID: 8577267 | |
| A115 | Yes | BoNT/A Lc | ELISA, WB | monoclonal | PMID: 8577267 | |
| A116 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A119 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A122 | Yes | BoNT/A Lc | ELISA, WB | monoclonal | PMID: 8577267 | |
| A123 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A124 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A125 | Yes | BoNT/A H2 | ELISA, WB | monoclonal | PMID: 8577267 | |
| AI-3 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| AI-6 | Yes | BoNT/A H2 | ELISA, WB | monoclonal | PMID: 8577267 | |
| A1-13 | Yes | BoNT/A | ELISA, WB | monoclonal | PMID: 8577267 | |
| A1-15 | Yes | BoNT/A | ELISA, WB | monoclonal | PMID: 8577267 | |
| A1-16 | Yes | BoNT/A Lc | ELISA, WB | monoclonal | PMID: 8577267 | |
| A1-17 | Yes | BoNT/A H1 | ELISA, WB | monoclonal | PMID: 8577267 | |
| E14 | No | BoNT/E H1 | monoclonal | IgG1 | PMID: 2423459 | |
| E16 | Yes | BoNT/E H2 | ELISA, WB | monoclonal | IgG2b | PMID: 2423459 |
| E17 | No | BoNT/E H2 | ELISA, WB | monoclonal | IgG1 | PMID: 2423459 |
| E19 | Yes | BoNT/E H1 | ELISA, WB | monoclonal | IgG1 | PMID: 2423459 |
| E22 | No | BoNT/E H1 | ELISA, WB | monoclonal | IgG1 | PMID: 2423459 |
| E30 | Yes | BoNT/E Lc | ELISA, WB | monoclonal | IgG1 | PMID: 2423459 |
| B4 | No | BoNT/A Hc | ELISA | monoclonal | IgG1k | PMID: 16113261 |
| 9D8 | No | BoNT/A HN | ELISA | monoclonal | IgG1k | PMID: 16113261 |
| 7C1 | No | BoNT/A Lc | ELISA | monoclonal | IgG1k | PMID: 16113261 |
| 3a6 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3d4 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 4a4 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3a2 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3e3 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3e8 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3a11 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3e7 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3h3 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| 3a1 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| w3 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| w42 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| g23 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| g3 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| g11 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| w7 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| w9 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| g7 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| w20 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| w36 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| w43 | ELISA | monoclonal | scFv | PMID: 9125539 | ||
| g53 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| g57 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| c9 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| c15 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3f6 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2a2 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2b10 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2b1 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3e6 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2e6 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3d1 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2b6 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2h6 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2a8 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| id5 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| ie8 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| ig7 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3c3 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 2c3 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3e2 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 3c5 | BoNT/A Hc | ELISA | monoclonal | scFv | PMID: 9125539 | |
| 4A2-4 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
| 6E9-1 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
| 6E9-3 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
| 6E9-4 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
| 6E10-4 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
| 6E10-5 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
| 6E10-8 | Yes | BoNT/A Hc | ELISA, IP, WB | monoclonal | IgG2a | PMID: 11119555 |
Currently, the main treatment for human botulism is the administration
of botulinum neurotoxin antitoxin to neutralize the unbound circulating
toxin. Antitoxin treatment is most effective in reducing the severity
of symptoms if administered in the first 24 hours post exposure.
Skin tests for horse serum sensitivity prior to treatment are needed
for the equine derived antitoxins.
Therapeutic and prophylactic immunobiologics products distributed by the CDC can
be found at the CDC Drug Service Formulary.
Physicians can contact the CDC for antitoxins at: 770-488-7100
(24-hour emergency number). Human-derived botulism immune globulin
(BIG) for the treatment of infant botulism is available by contacting
the California Department of Health Services (24-hour telephone:
510-540-2646).
To learn more, visit the California Department of Health Services
Infant
Botulism Treatment & Prevention Program or view the
Infant Botulism Chapter from the Textbook of Pediatric Infectious
Disease, 4th Edition.
Antitoxin |
Source |
Type |
Source or Reference |
Status |
| bivalent | equine | A, B | CDC Botulism Handbook |
Licensed |
| Botulism Immune Globulin Intravenous (BabyBIG or BIG-IV) | human | A, B | PMID: 16452558 |
Licensed |
| despeciated heptavalent botulism immune globulin (dBIG) | equine | A, B, C, D, E, F, G | PMID: 8842274 | Investigational New Drug |
| monovalent | equine | E | CDC Drug Service Formulary Type E | Investigational New Drug |
| quadrivalent | A, B, E, F | CDC MMWR April 21, 2006/55(15);434 | ||
| recombinant | Medscape Infectious Disease | Preclinical | ||
| trivalent | equine | A, B, E | CDC Botulism Handbook |
Licensed |
Synthetic antibodies are obtained from phage display, a new technique used to develop antibodies with target-recognition qualities of natural antibodies. Single-chain variable fragment (scFv) phage antibodies are presented with PubMed ID and Protein Accession.
Synthetic Antibody |
PubMed ID |
Protein Accession |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26550 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26549 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26548 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26546 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26545 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26544 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26543 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26542 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26541 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26540 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26539 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26538 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26537 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26536 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26535 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26534 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26533 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26532 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26531 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26530 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26547 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26528 |
| Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AAC26529 |
| scFv Antibody V-region | PMID: 11858873 | AAC98378 |
| 2A1 scFv Antibody V-region mRNA | PMID: 11858873 | AF090405 |
| 3F6 scFv Antibody V-region mRNA | PMID: 11858873 | AF090420 |
| 3H4 Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AF003702 |
| S25 Anti BoNT/A Hc scFv Antibody | PMID: 9284147 | AF003725 |
Botulism vaccine work began in the 1940s. Individuals considered to be at risk of exposure to botulism, such as laboratory and military personnel, are currently vaccinated. At this time, a pentavalent (A-E) BoNT toxoid vaccine and a monovalent (F) vaccine are available under Investigational New Drugs (IND) status from the CDC. Toxoid and recombinant botulinum vaccines are under development with the aim of providing protection against the seven serotypes of botulism.
Vaccine |
Type |
Reference/ PubMed ID |
Status |
| BoNToxoid/A | A | PMID: 15699151 | mucosal immunization |
| bivalent | C, D | Department of Primary Industries and Fisheries, Queensland | Available |
| BT-VACC | multivalent | DOR BioPharma, Inc. | Under development (successful in animals) |
| monovalent | F | PMID: 11086225 | Investigational New Drug |
| multivalent | multivalent | Cambridge Biostability | Under development |
| pentavalent (PBT) | A, B, C, D, E | PMID: 11086225 | Investigational New Drug |
| recombinant (rBV A/B) | A, B | DVC JVAP (DOD) | Phase I: Initial safety trial |
| recombinant | C, D, E, G | DVC JVAP (DOD) | Under development |
| recombinant | A, B, C, E, F | Medscape | Clinical trials |
| recombinant | D, G | Medscape | Clinical trials |
| recombinant bivalent (rBOT) | A, B | Emergent BioSolutions | Pre-clinical |
Current research efforts are focused on the production of nontoxic recombinant proteins or vectored vaccines to obtain recombinant vaccines. The vaccine development strategies listed below are geared to eliminate the need to treat BoNT toxin with formalin and allow a high level of toxin production (Dertzbaugh MT and MW West 1996, PMID: 9014296).