a number of synthetic anticoagulant pharmaceuticals. One subset, 4-hydroxycoumarins, act as vitamin K antagonists. They block the regeneration and recycling of vitamin K. Some of the 4-hydroxycoumarin anticoagulant class of chemicals are designed to have high potency and long residence times in the body, and these are used specifically as second generation rodenticides ("rat poison"). Death occurs after a period of several days to two weeks, usually from internal hemorrhaging. For humans, and for animals that have consumed either the rodenticide or rats poisoned by the rodenticide, treatment is prolonged administration of large amounts of vitamin K. This dosing must sometimes be continued for up to nine months in cases of poisoning by "superwarfarin" rodenticides such as brodifacoum. Oral vitamin K1 is preferred over other vitamin K1 routes of administration because it has fewer side effects. Methods of assessment An increase in prothrombin time, a coagulation assay, has been used as an indicator of vitamin K status, but it lacks sufficient sensitivity and specificity for this application. Serum phylloquinone is the most commonly used marker of vitamin K status. Concentrations <0.15 µg/L are indicative of deficiency. Disadvantages include exclusion of the other vitamin K vitamers and interference from recent dietary intake. Vitamin K is required for the gamma-carboxylation of specific glutamic acid residues within the Gla domain of the 17 vitamin K–dependent proteins. Thus, a rise in uncarboxylated versions of these proteins is an indirect but sensitive and specific marker for vitamin K deficiency. If uncarboxylated prothrombin is being measured, this "Protein induced by Vitamin K Absence/antagonism (PIVKA-II)" is elevated in vitamin K deficiency. The test is used to assess risk of vitamin K–deficient bleeding in newborn infants. Osteocalcin is involved in calcification of bone tissue. The ratio of uncarboxylated osteocalcin to carboxylated osteocalcin increases with vitamin K deficiency. Vitamin K2 has been shown to lower this ratio and improve lumbar vertebrae bone mineral density. Matrix Gla protein must undergo vitamin K dependent phosphorylation and carboxylation. Elevated plasma concentration of dephosphorylated, uncarboxylated MGP is indicative of vitamin K deficiency. Side effects No known toxicity is associated with high oral doses of the vitamin K1 or vitamin K2 forms of vitamin K, so regulatory agencies from US, Japan and European Union concur that no tolerable upper intake levels needs to be set. However, vitamin K1 has been associated with severe adverse reactions such as bronchospasm and cardiac arrest when given intravenously.