Generate an explanation for the given claim using the provided supporting material from the paragraph. Please consider the following points while generating an output. 1) The claim will always have supporting proof in the paragraph, and the paragraph will have a clear point of view supporting the claim. 2) There can be instances where direct correlation to the claim is not available. Make use of the sentences in the paragraph to provide a corresponding output supporting the claim. 3) The explanation should be at least one and at most twelve sentences long.

Ex Input:
Paragraph: Costs are mentioned reasonably early in the story, and with specificity. This was good to see. Benefits of these tests are touted, but not quantified. An officer of the National Ovarian Cancer Research Fund Alliance, an advocacy group, testifies that the outcomes of women who have surgery from a gynecologic oncologist “are much better.” But we don’t know what that means. Is it longer survival? Later the story explains that combining the two blood tests with assessment by a clinician “better determined the patients who should be referred to a [gynecological oncologist], identifying well over 90 percent of the women who actually had cancer.”  (Note that this statistic reflects only referral to a gyn-onc, not patient survival.) But how does that compare to the standard assessment tools? A 2016 study described as publication “of the first clinical utility data” demonstrating that use of OVA1 resulted in referral of ovarian patients to gynecologic oncologists offers similar outcomes but is not mentioned in the story. We’re told that experts fear that these tests could lead to unnecessary surgery or delayed diagnosis, and that’s sufficient for a Satisfactory rating. The story could have delved into a bit more of the specifics: What is the evidence for these concerns? What are the false positive and false negative rates? These details are useful because the point of the story is that clinicians are not using these tests to try to improve outcomes of ovarian cancer patients. Are the possible debits–or uncertainties driven by lack of clinical data–contributing to these decisions? There isn’t sufficient information on the evidence behind these tests. The FDA has approved ROMA and OVA1 for use, but the studies that led to that decision are not discussed. Nor is there sufficient discussion of why the physician groups that write guidelines haven’t endorsed the tests. Their concerns are raised, but the evidence is not presented or analyzed. A late diagnosis of ovarian cancer is way too common, and the outcome is grim. At the same time, the anecdotes seem to highlight the sad aspect of the disease without necessarily providing a relevant case in which the tests described would have helped (any more than a basic blood test would have). The companies responsible for developing and marketing these two tests are front and center in this story, with scientists affiliated with the companies clearly identified. At least two sources in the story—one of them a scientist affiliated with the National Comprehensive Cancer Network—appear to be independent of the companies. The story makes it clear that no effective early detection screening test exists. Existing strategies—the CA125 blood test and vaginal ultrasound—are mentioned and then discounted, in part via a personal narrative of a young woman who received a late diagnosis of cancer. While data-driven specifics aren’t included on why standard methods aren’t sufficient, this is enough to rate Satisfactory. A direct comparison of survival stemming from existing diagnostic tests relative to survival stemming from ROMA and OVA1 would have strengthened the story. If those numbers aren’t available, that should have been pointed out. The story makes it clear that the two blood tests have been available since 2009. The story mentions that the tests are combinations of existing tests with a “proprietary” formula (essentially a risk prediction tool) to translate the results to likelihood of cancer. But, the article should have talked about whether the tests, other than CA-125, have been used before. This appears to be an enterprise story, and does not rely on a news release. Claim: Ovarian cancer blood tests: Available, not widely used

Ex Output:
This is a story about the apparent underuse of two blood tests—ROMA and OVA1—that are FDA approved to help clinicians decide whether surgery to investigate abnormal growths should be performed by a gynecologic oncologist (“gyn-onc”) trained to remove malignant ovarian cancer, rather than an obstetrician-gynecologist or a general surgeon. The gist of the story is that the tests have not been widely adopted in the ensuing years, “largely because they haven’t been recommended by the physician groups that write the care guidelines.” The story hit on a lot of important notes–it told readers the cost of these tests, and it included comments from independent sources. What is not clear is the extent to which clinical evidence supports the increased use of the two tests. We’re told they accurately picked up about 90 percent of cancer cases. But we’re not told how that compares to standard methods of detection. As the story notes, surviving ovarian cancer is an uphill battle–it is often a deadly disease caught too late. Any procedure that increases the probability of survival is worth careful consideration.


Ex Input:
Paragraph: "This is the only of the five stories to actually put a dollar figure on the classes. ""Even the cost of a class, which can top $50 a month, is modest compared with the cost of many medications. And unlike drugs, tai chi had no harmful side effects, she says."" Unlike the AP story, which made the mistake of saying that ""symptoms improved significantly for the tai chi group and little for the others,"" this story, at least, presents some numbers. The trouble is, those numbers are in relative terms. So, instead of saying that three months after the classes ended, 27 patients who took tai chi classes felt better and 17 who tried other therapies also felt better, it presents the difference as 82% versus 53%. That seems more dramatic. Absolute data would be more meaningful. Why make the reader do the math? The story is one of the few stories that covered this study to actually point out that ""unlike drugs, tai chi had no harmful side effects."" In the end, because of the comments from Gloria Yeh, the story puts the appropriate caveats on the findings. This sentence does a great job of summarizing some of the problems with the study: ""Yeh notes that researchers don’t know which aspects of tai chi were most helpful: the exercise, deep breathing, relaxation exercise, meeting new friends or learning from a charismatic teacher."" This story actually spends too little time talking about the condition itself. The AP devoted a whole paragraph in an eight paragaph story to the condition, and the LA Times led its piece by describing the disease. USA Today instead went with a very nice description of tai chi, putting the emphasis on the beauty and simiplicity of the therapy rather than the difficulty clinicians have had correctly diagnosing and treating fibromyalgia. This is the only story to include the phrase ""white crane spreads its wings"" or anything like that. The story doesn’t actually quote any of the authors and instead quotes two outside experts, one of whom wrote an accompanying editorial. It fails to fully attribute the comments made by ""Callahan."" It appears that the writer means Leigh F. Callahan, who just completed a study of tai chi for arthritis and was quoted by other reporters. (How did this slip through copy editing? Was this a slip-up only in the online version?) But we can’t give credit to an independent source that the story doesn’t adequately identify. The story does not compare the therapy to existing alternatives or even discuss existing alternatives, aside from a passing reference at the very end to medications. This is the only one of the five stories to note that ""A study in 2007 from the National Institutes of Health found that 2.3 million American adults had used tai chi in the past year."" This doesn’t tell you whether tai chi classes are as readily available in Oklahoma as they are in New Mexico, but it does give you a sense of how popular they are. It is unclear from this story whether tai chi has been studied before for other conditions. It has. It also is unclear what fibromyalgia patients now do for therapy. The LA Times, for example, pointed out that patients in the study stopped taking drugs for treatment, for example. The story does not rely on a news release." Claim: Tai chi may ease fibromyalgia pain

Ex Output:
"The story does two things better than all the other stories. It puts a dollar figure to the cost of tai chi therapy, and it gives people a better sense of how popular tai chi is. It could have done a better job evaluating the evidence and providing some absolute numbers to help readers decide how seriously to take these results. Why not just give the absolute numbers? How many out of how many? Why make the reader do the math? ""79% of tai chi participants said their symptoms had improved, compared with 39% of those in the educational class…Even three months after the classes ended, 82% of tai chi students still felt better, compared with 53% of the comparison group."" Sure, the denominators are in the story but we shouldn’t need to pull out the calculator to figure out 79% of x, vs. 39% of x."


Ex Input:
Paragraph: A University of Iowa study shows the state’s contribution to the Gulf dead zone spiked 47 percent to 618 million pounds in 2016, based on five-year running annual averages. “Just based on water quality data, I think we can say we’ve not made much progress over the past 20 years in terms of nitrogen,” said Chris Jones, a research engineer at the UI’s IIHR-Hydroscience & Engineering. Environmentalists say the study raises new questions about the effectiveness of Iowa’s approach to improving water quality and its reliance on voluntary ag compliance. “We’ve been pouring state and federal money into cutting nutrient pollution for decades, and this highlights the fact that the voluntary approach is not working,” said Jennifer Terry, executive director of the Iowa Environmental Council. “We’re not headed in the right direction. ... We need to follow the lead of other states and pass some environmental laws that will actually reduce loads and result in cleaner water,” Terry said. The Des Moines Register reports that the news comes as Iowa marks the five-year anniversary of the Iowa Nutrient Reduction Strategy, a plan designed to cut by 45 percent the nitrogen and phosphorus levels that leave Iowa and feed Gulf hypoxia — or the dead zone. Oxygen levels within the zone are so low that marine life can no longer survive, threatening the Gulf’s seafood industry. Most of the nutrient losses come from farming, although the strategy also targets losses from urban wastewater and industrial operations. Last year, Iowa invested $420 million in those water quality improvements, including helping farmers plant cover crops, build terraces and tackle other conservation practices that hold nutrients in place. But farmers expanding their drainage tile systems — along with increasing hog, cattle and chicken feeding operations, which provide manure to fertilize crops — likely outweigh those conservation efforts, UI scientists say. The nutrient reduction practices “being implemented are a tiny, tiny portion of what needs to be done, and it’s occurring in a system that’s changing,” Jones said. “We appreciate all that is being done with nutrient management and conservation farming. Unfortunately, we’re just impacting too few acres with too few practices,” added Larry Weber, executive associate dean for UI’s College of Engineering. Jones wrote the study with Weber and Keith Schilling, another UI research engineer. Increased nutrient pollution in water creates problems for people and animals beyond the dead zone. High phosphorus levels can lead to toxic algae blooms that can befoul lakes, rivers and streams, potentially killing pets and making people ill. And the federal government limits the amount of nitrates in drinking water to 10 milligrams per liter. Higher levels can be fatal to babies under 6 months old. Increased levels translate to higher costs for utilities for nitrate removal. “We need a dramatic increase, a rapidly-scaled up increase in conservation practices and more funding,” said Cindy Lane, the Iowa Environmental Council’s water program director. Schilling said the study shows that targeting nutrient reduction investment in Iowa can have a significant impact downstream. “Iowa has a dominant role in this Gulf hypoxia issue,” Schilling said. “Let’s invest the resources here, where we really need it. “If we solve Iowa, we solve the Gulf,” he said. The UI study gives Iowans new information in the fight to reduce the nitrogen levels that flow from the state into the Mississippi and Missouri rivers, which make their way to the Gulf of Mexico. Looking at Iowa Department of Natural Resources data from 23 monitoring stations, the study shows Iowa on average over the past 18 years contributed 29 percent of the total nitrogen headed to the Gulf from the Mississippi-Atchafalaya river basin. The river basin is a massive watershed that includes all or part of 31 states. Iowa’s nitrogen impact was even greater in other watersheds. The state averaged 45 percent of the nitrogen levels going into the Upper Mississippi River basin, and 55 percent of the nitrogen going into to the Missouri River basin. “When you look at the entire Missouri (River) watershed, our land comprises 3.3 percent of the total area ... and Iowa contributes nearly 12 percent of the water,” Jones said. But “we contribute 55 percent of the nitrate,” he said. “The way that pencils out is that the amount of water coming from Iowa has seven times more nitrates than the rest of the Missouri River watershed,” Jones said. If Iowa’s contributions were removed, the Missouri River would have little nitrogen contributions in some years. “We really need to take seriously the Missouri River’s contribution as a driver for Gulf hypoxia,” Jones said. The growing concentration of livestock feeding operations in western Iowa might account for Iowa’s large contribution to the Missouri River nitrate levels, the scientists said. “People tend to dismiss livestock influences, but maybe there’s more to it than people give credit it for,” Schilling said, adding that it would require more study to determine the impact. Iowa’s nitrogen levels, based on running five-year annual averages, have been above the 2003 value for 10 consecutive years, the study says. The scientists say 2003 was the first year the five-year rolling average could be calculated, with data that starts in 1999. The goal of the Gulf Hypoxia Task Force, made up of federal, state and tribal leaders, “will be very difficult to achieve if nitrate retention cannot be improved in Iowa,” the report said. The task force, with Iowa Agriculture Secretary Mike Naig as chairman, seeks to reduce the dead zone to 1,900 square miles by 2035. The deadline was extended from 2015. Last year, the dead zone set a record, which, at 8,776 square miles, was more than four times the goal size. The report says about 90 percent of Iowa’s nitrogen levels “can be sourced to the 72 percent of the state’s land area that is in crop cultivation.” Iowa, an agriculture powerhouse, is a national leader in corn, soybean, pork, egg and beef production. “This intense production of carbohydrates and protein has resulted in the state being a leading contributor” to the nitrogen loads and Gulf hypoxia, the report said. Naig said farmers understand the important role they play in improving water quality and are scaling up efforts across the state “as we move from demonstration projects to larger, watershed-scale implementation projects. “We recognize that there is still a lot of work to be done, but we are on the right path,” said Naig, who adds farmers are working with more than 250 partners in 65 rural and urban demonstration projects. The UI scientists doubt that increased cropping is the reason for the increased nitrogen impact. Iowa’s cropped area has increased only 4 percent over the past 18 years, while other states’ farmed land has climbed 21 percent, particularly in Minnesota, North and South Dakota and Kansas. About 85 percent of Iowa’s acres are farmed, making it the fifth-highest in the nation, based on the 2012 U.S. Agriculture Census, so there are few acres left that can be brought into production compared with other states. “Iowa’s decline in the share of the region’s soybean area was especially pronounced, dropping from 18.6 percent in 1999 to 14.5 percent in 2016,” the report said. “One would expect our (nitrogen) contributions relative to the other areas would be diminished,” Jones said. “But the opposite has occurred.” Jones said it’s led the scientists to consider other factors. The scientists doubt that Iowa farmers are using significantly more fertilizer. “When we look at nitrogen sales data, it might change a little year over year. But on a per acre basis, that hasn’t changed a lot since 1990,” he said. And with little increase in corn and soybean acres, the scientists speculate that Iowa’s increased nitrogen levels could be coming from more drainage tiles. Or farmers could be using more manure as fertilizer from animal feeding operations. Without Iowa, the Gulf’s overall nitrate loads would have declined 43,400 tons over 18 years, based on five-year running annual averages, the scientists’ data show. Instead nitrate loads grew by 52,000 tons. “It’s pretty clear these loads from the Ohio basin have to be declining,” Jones said. “A lot that is coming from Indiana.” That state’s high level of cover crop adoption by farmers could be the reason, he said, and should be studied. Cover crops such as cereal rye slow the rate of water runoff, reduce erosion and improve soil fertility. Iowa also needs to honestly discuss the impact that drainage tiling has on nitrogen losses, Jones said. Iowa doesn’t collect data on how much underground drainage runs through the state, although officials estimate about 9 million acres are drained through tile. Environmentalists believe the number is much higher. Underground drainage tile helps improve yields by quickly removing excess water from fields. Iowa’s tiling system consists of a network of drainage lines that feed into large pipes. The massive network, first constructed in the 1920s, ’30s and ’40s, turned once swampy lands into some of the nation’s most productive farmland. But water quickly carried away by the tiling system misses cleansing that would naturally occur by filtering through soil or the roots of trees, shrubs and grasses in riparian buffers along streams. Des Moines Water Works unsuccessfully sued drainage districts in three north Iowa counties in 2015, claiming underground tiles funneled high levels of nitrates into the Raccoon River, a source of drinking water for 500,000 central Iowa residents. “We acknowledge that it’s important to track implemented conservation, and we encourage that,” Jones said. “But we also need to have the courage to talk about these things that drive the system in the other direction.” Terry said Iowa is “one of the most heavily tiled states in the nation,” and its 110-year-old law regulating the practice does little to protect water quality. ___ Information from: The Des Moines Register, http://www.desmoinesregister.com Claim: Study: Iowa nitrogen pollution in the water is getting worse.

Ex Output:

Nitrogen pollution flowing out of Iowa to the Gulf of Mexico has grown by close to 50 percent over nearly two decades, a new report shows, despite hundreds of millions of dollars spent to stem nutrients entering the state’s waterways.