Exploring Innovative Approaches in Type-2 Diabetes Management: A Comprehensive Review on Nano-carriers and Transdermal Drug Delivery.

Diabetes is a chronic metabolic disorder characterized by elevated blood sugar levels and encompasses various types like type 1, type 2, gestational, and prediabetes. This review delves into the intricacies of type-2 diabetes mellitus and its ideal management. Presently, a spectrum of herbal and synthetic drugs is employed for type-2 diabetes mellitus management. We gathered information about diabetes mellitus from articles published up to 2024 and listed in PubMed, Web of Science, Elsevier, Google Scholar, and similar databases. The keywords used in our search included "diabetes", "herbal drugs", "nano-carriers", "transdermal drug delivery", etc. By carefully analyzing the research on type-2 diabetes-mellitus, it was found that there is an increase in diabetes-based research, which can be demonstrated by contemplating the PubMed search engine results using transdermal delivery for type-2 diabetes-mellitus as a keyword. The oral consumption of these drugs is associated with numerous side effects, including obesity, pancreatic cancer, and hormonal imbalances. To surmount these challenges, the utilization of nano-carriers and transdermal drug delivery systems emerges as a promising avenue aiming to enhance the therapeutic efficacy of drugs. Nano-carriers represent a revolutionary approach, integrating cutting-edge technologies, inventive strategies, and methodologies to deliver active molecules in concentrations that are both safe and effective, thereby eliciting the desired pharmacological response. This review critically examines the constraints associated with traditional oral administration of anti-diabetic drugs and underscores the manifold initiatives undertaken to revolutionize drug delivery. This review focuses on the limitations associated with the conventional oral administration of anti-diabetic drugs and the many initiatives made so far for the effective and safe delivery of drugs using innovative constituents and techniques.

Therapeutic Potential of Nanocarrier Mediated Delivery of Peptides for Wound Healing: Current Status, Challenges and Future Prospective.

Wound healing presents a complex physiological process that involves a sequence of events orchestrated by various cellular and molecular mechanisms. In recent years, there has been growing interest in leveraging nanomaterials and peptides to enhance wound healing outcomes. Nanocarriers offer unique properties such as high surface area-to-volume ratio, tunable physicochemical characteristics, and the ability to deliver therapeutic agents in a controlled manner. Similarly, peptides, with their diverse biological activities and low immunogenicity, hold great promise as therapeutics in wound healing applications. In this review, authors explore the potential of peptides as bioactive components in wound healing formulations, focusing on their antimicrobial, anti-inflammatory, and pro-regenerative properties. Despite the significant progress made in this field, several challenges remain, including the need for standardized characterization methods, optimization of biocompatibility and safety profiles, and translation from bench to bedside. Furthermore, developing multifunctional nanomaterial-peptide hybrid systems represents promising avenues for future research. Overall, the integration of nanomaterials made up of natural or synthetic polymers with peptide-based formulations holds tremendous therapeutic potential in advancing the field of wound healing and improving clinical outcomes for patients with acute and chronic wounds.

Quality by Design Perspective for Designing Foam-based Formulation: Current State of Art.

Foam-based delivery systems contain one or more active ingredients and dispersed solid or liquid components that transform into gaseous form when the valve is actuated. Foams are an attractive and effective delivery approach for medical, cosmetic, and pharmaceutical uses. The foams-based delivery systems are gaining attention due to ease of application as they allow direct application onto the affected area of skin without using any applicator or finger, hence increasing the compliance and satisfaction of the patients. In order to develop foam-based delivery systems with desired qualities, it is vital to understand which type of material and process parameters impact the quality features of foams and which methodologies may be utilized to investigate foams. For this purpose, Quality-by-Design (QbD) approach is used. It aids in achieving quality-based development during the development process by employing the QbD concept. The critical material attributes (CMAs) and critical process parameters (CPPs) were discovered through the first risk assessment to ensure the requisite critical quality attributes (CQAs). During the initial risk assessment, the high-risk CQAs were identified, which affect the foam characteristics. In this review, the authors discussed the various CMAs, CPPs, CQAs, and risk factors associated in order to develop an ideal foam-based formulation with desired characteristics.

Nanotechnology in Orthodontics: Unveiling Pain Mechanisms, Innovations, and Future Prospects of Nanomaterials in Drug Delivery.

Orthodontic pain is characterized by sensations of tingling, tooth discomfort, and intolerance. According to the oral health report, over forty percent of children and adolescents have undergone orthodontic treatment. The efficacy of orthodontic treatment involving braces can be compromised by the diverse levels of discomfort and suffering experienced by patients, leading to suboptimal treatment outcomes and reduced patient adherence. Nanotechnology has entered all areas of science and technology. This review provides an overview of nanoscience, its application in orthodontics, the underlying processes of orthodontic pain, effective treatment options, and a summary of recent research in Nano-dentistry. The uses of this technology in healthcare span a wide range, including enhanced diagnostics, biosensors, and targeted drug delivery. The reason for this is that nanomaterials possess distinct qualities that depend on their size, which can greatly enhance human well-being and contribute to better health when effectively utilized. The field of dentistry has also experienced significant advancements, particularly in the past decade, especially in the utilization of nanomaterials and technology. Over time, there has been an increase in the availability of dental nanomaterials, and a diverse array of these materials have been extensively studied for both commercial and therapeutic purposes.

Biopolymer based nanoparticles and their therapeutic potential in wound healing - A review.

Nanoparticles (NPs) have been extensively investigated for their potential in nanomedicine. There is a significant level of enthusiasm about the potential of NPs to bring out a transformative impact on modern healthcare. NPs can serve as effective wound dressings or delivery vehicles due to their antibacterial and pro-wound-healing properties. Biopolymer-based NPs can be manufactured using various food-grade biopolymers, such as proteins, polysaccharides, and synthetic polymers, each offering distinct properties suitable for different applications which include collagen, polycaprolactone, chitosan, alginate, and polylactic acid, etc. Their biodegradable and biocompatible nature renders them ideal nanomaterials for applications in wound healing. Additionally, the nanofibers containing biopolymer-based NPs have shown excellent anti-bacterial and wound healing activity like silver NPs. These NPs represent a paradigm shift in wound healing therapies, offering targeted and personalized solutions for enhanced tissue regeneration and accelerated wound closure. The current review focuses on biopolymer NPs with their applications in wound healing.

Nano-gel formulation of polyphenolic fraction of tobacco stem for wound healing and its inhibitory efficacies against the receptors of chronic wound development.

Current investigation deals with the gel formulation of purified polyphenol loaded nanoparticles for enhanced wound healing. Polyphenols purified using column chromatography an were characterized using HPLC in fractions. Silver nanoparticles were characterization using SEM, AFM, TEM, DLS. Cytotoxic effect was checked on L929 (Mouse fibroblast cells). Bioactive loaded nanoparticles were formulated in gel and subjected for physical characterization. Excision wound wistar rat models were established to measure the wound contraction measurement, histopathological studies, and biochemical assays. Docking and Simulation studies were performed to check the binding and stability with receptors progressing the chronic wound. From the column chromatography, B fraction has shown the presence of maximum polyphenolic content and as well as the polyphenol compounds such as quercetin, rutin and tannic acid as confirmed by the HPLC. Synthesize B fraction-AgNP were found to be below 100 nm in size and spherical in shape as per the characterization. No cytotoxic effect was observed on L929 cells treated with B fraction and its nanoparticles. Formulated B fraction-AgNP gel has revealed the better stability and earlier wound contraction, i.e. before the completion of 14 days of topical treatment. Histopathology studies and collagen content has confirmed the re-epithelization in skin wounds. MD simulation revealed the stability with PI3K and AKT. This can be concluded that tobacco stem polyphenol loaded nanoparticles has potent wound healing activity that can be utilized as nano-drug delivery system for suppression of chronic wound development.Communicated by Ramaswamy H. Sarma.

Fused Deposition Modeling 3D-Printed Scaffolds for Bone Tissue Engineering Applications: A Review.

The emergence of bone tissue engineering as a trend in regenerative medicine is forcing scientists to create highly functional materials and scaffold construction techniques. Bone tissue engineering uses 3D bio-printed scaffolds that allow and stimulate the attachment and proliferation of osteoinductive cells on their surfaces. Bone grafting is necessary to expedite the patient's condition because the natural healing process of bones is slow. Fused deposition modeling (FDM) is therefore suggested as a technique for the production process due to its simplicity, ability to create intricate components and movable forms, and low running costs. 3D-printed scaffolds can repair bone defects in vivo and in vitro. For 3D printing, various materials including metals, polymers, and ceramics are often employed but polymeric biofilaments are promising candidates for replacing non-biodegradable materials due to their adaptability and environment friendliness. This review paper majorly focuses on the fused deposition modeling approach for the fabrication of 3D scaffolds. In addition, it also provides information on biofilaments used in FDM 3D printing, applications, and commercial aspects of scaffolds in bone tissue engineering.

Microbubbles: Revolutionizing Biomedical Applications with Tailored Therapeutic Precision.

BACKGROUND: Over the past ten years, tremendous progress has been made in microbubble-based research for a variety of biological applications. Microbubbles emerged as a compelling and dynamic tool in modern drug delivery systems. They are employed to deliver drugs or genes to targeted regions of interest, and then ultrasound is used to burst the microbubbles, causing site-specific delivery of the bioactive materials. OBJECTIVE: The objective of this article is to review the microbubble compositions and physiochemical characteristics in relation to the development of innovative biomedical applications, with a focus on molecular imaging and targeted drug/gene delivery. METHODS: The microbubbles are prepared by using various methods, which include cross-linking polymerization, emulsion solvent evaporation, atomization, and reconstitution. In cross-linking polymerization, a fine foam of the polymer is formed, which serves as a bubble coating agent and colloidal stabilizer, resulting from the vigorous stirring of a polymeric solution. In the case of emulsion solvent evaporation, there are two solutions utilized in the production of microbubbles. In atomization and reconstitution, porous spheres are created by atomising a surfactant solution into a hot gas. They are encapsulated in primary modifier gas. After the addition of the second gas or gas osmotic agent, the package is placed into a vial and sealed after reconstituting with sterile saline solution. RESULTS: Microbubble-based drug delivery is an innovative approach in the field of drug delivery that utilizes microbubbles, which are tiny gas-filled bubbles, act as carriers for therapeutic agents. These microbubbles can be loaded with drugs, imaging agents, or genes and then guided to specific target sites. CONCLUSION: The potential utility of microbubbles in biomedical applications is continually growing as novel formulations and methods. The versatility of microbubbles allows for customization, tailoring the delivery system to various medical applications, including cancer therapy, cardiovascular treatments, and gene therapy.

A Comprehensive Review on Drug Therapies and Nanomaterials used in Orthodontic Treatment.

Orthodontic treatment typically requires an extended duration of 1-2 years to complete the treatment. Accelerating the rate of tooth movement during orthodontic treatment is essential for shortening the overall treatment duration. After the completion of orthodontic treatment, a prominent concern arises in the form of orthodontic relapse, where the teeth tend to revert to their original positions. This issue affects approximately 60% of the global population, underscoring the importance of implementing effective measures to address orthodontic relapse. An approach in this regard involves the targeted administration of herbal and synthetic drugs applied directly to the specific area of interest to facilitate tooth movement and prevent orthodontic relapse. Apart from this, researchers are investigating the feasibility of utilizing different types of nanoparticles to improve the process of orthodontic tooth movement. In recent years, there has been a noticeable increase in the number of studies examining the effects of various drugs on orthodontics. However, the currently available literature does not provide significant evidence relating to orthodontic tooth movement. In this review, the authors provide valuable information about the drugs and nanomaterials that are capable of further enhancing the rate of orthodontic tooth movement and reducing the risk of orthodontic relapse. However, a notable hurdle remains, i.e., there is no marketed formulation available that can enhance orthodontic tooth movement and reduce treatment time. Therefore, researchers should try herbal-synthetic approaches to achieve a synergistic effect that can enhance orthodontic tooth movement. In this nutshell, there is an urgent need to develop a non-invasive, patient-compliant, and cost-effective formulation that will provide quality treatment and ultimately reduce the treatment time. Another critical issue is orthodontic relapse, which can be addressed by employing drugs that slow down osteoclastogenesis, thereby preventing tooth movement after treatment. Nevertheless, extensive research is still required to overcome this challenge in the future.

Marine-derived polysaccharides and their therapeutic potential in wound healing application - A review.

Polysaccharides originating from marine sources have been studied as potential material for use in wound dressings because of their desirable characteristics of biocompatibility, biodegradability, and low toxicity. Marine-derived polysaccharides used as wound dressing, provide several benefits such as promoting wound healing by providing a moist environment that facilitates cell migration and proliferation. They can also act as a barrier against external contaminants and provide a protective layer to prevent further damage to the wound. Research studies have shown that marine-derived polysaccharides can be used to develop different types of wound dressings such as hydrogels, films, and fibres. These dressings can be personalised to meet specific requirements based on the type and severity of the wound. For instance, hydrogels can be used for deep wounds to provide a moist environment, while films can be used for superficial wounds to provide a protective barrier. Additionally, these polysaccharides can be modified to improve their properties, such as enhancing their mechanical strength or increasing their ability to release bioactive molecules that can promote wound healing. Overall, marine-derived polysaccharides show great promise for developing effective and safe wound dressings for various wound types.

Nano-platform Strategies of Herbal Components for the management of Rheumatoid Arthritis: A Review on the Battle for Next-Generation Formulations.

INTRODUCTION: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that initially affects small joints and then spreads to the bigger joints. It also affects other organs of the body such as the lungs, eyes, kidneys, heart, and skin. In RA, there is destruction of cartilage and joints, and ligaments and tendons become brittle. Damage to the joints leads to abnormalities and bone degradation, which may be quite painful for the patient. METHOD: The nano-carriers such as liposomes, phytosomes, nanoparticles, microcapsules, and niosomes are developed to deliver the encapsulated phytoconstituents to targeted sites for the better management of RA. RESULTS: The phytoconstituents loaded nano-carriers have been used in order to increase bioavailability, stability and reduce the dose of an active compound. In one study, the curcumin-loaded phytosomes increase the bioavailability of curcumin and also provides relief from RA symptoms. The drug-loaded nano-carriers are the better option for the management of RA. CONCLUSION: In conclusion, there are many anti-arthritic herbal and synthetic medicine available in the market that are currently used in the treatment of RA. However, chronic use of these medications may result in a variety of side effects. Because therapy for RA is frequently necessary for the rest of ones life. The use of natural products may be a better option for RA management. These phytoconstituents, however, have several disadvantages, including limited bioavailability, low stability, and the need for a greater dosage. These problems can be rectified by using nano-technology.

Therapeutic Potential of Nanocarrier-Mediated Delivery of Phytoconstituents for Wound Healing: Their Current Status and Future Perspective.

The treatment of wounds is a serious problem all over the world and imposes a huge financial burden on each and every nation. For a long time, researchers have explored wound dressing that speeds up wound healing. Traditional wound dressing does not respond effectively to the wound-healing process as expected. Therapeutic active derived from plant extracts and extracted bioactive components have been employed in various regions of the globe since ancient times for the purpose of illness, prevention, and therapy. About 200 years ago, most medical treatments were based on herbal remedies. Especially in the West, the usage of herbal treatments began to wane in the 1960s as a result of the rise of allopathic medicine. In recent years, however, there has been a resurgence of interest in and demand for herbal medicines for a number of reasons, including claims about their efficacy, shifting consumer preferences toward natural medicines, high costs and negative side effects of modern medicines, and advancements in herbal medicines brought about by scientific research and technological innovation. The exploration of medicinal plants and their typical uses could potentially result in advanced pharmaceuticals that exhibit reduced adverse effects. This review aims to present an overview of the utilization of nanocarriers in plant-based therapeutics, including its current status, recent advancements, challenges, and future prospects. The objective is to equip researchers with a comprehensive understanding of the historical background, current state, and potential future developments in this emerging field. In light of this, the advantages of nanocarriers based delivery of natural wound healing treatments have been discussed, with a focus on nanofibers, nanoparticles, nano-emulsion, and nanogels.

A Review on Physicochemical Properties of Polymers Used as Filaments in 3D-Printed Tablets.

Three-dimensional (3D) printing technology has presently been explored widely in the field of pharmaceutical research to produce various conventional as well as novel dosage forms such as tablets, capsules, oral films, pellets, subcutaneous implants, scaffolds, and vaginal rings. The use of this innovative method is a good choice for its advanced technologies and the ability to make tailored medicine specifically for individual patient. There are many 3D printing systems that are used to print tablets, implants, and vaginal rings. Among the available systems, the fused deposition modeling (FDM) is widely utilized. The FDM has been regarded as the best choice of printer as it shows high potential in the production of tablets as a unit dose in 3D printing medicine manufacturing. In order to design a 3D-printed tablet or other dosage forms, the physicochemical properties of polymers play a vital role. One should have proper knowledge about the polymer's properties so that one can select appropriate polymers in order to design 3D-printed dosage form. This review highlighted the various physicochemical properties of polymers that are currently used as filaments in 3D printing. In this manuscript, the authors also discussed various systems that are currently adopted in the 3D printing.

A review on polysaccharides mediated electrospun nanofibers for diabetic wound healing: Their current status with regulatory perspective.

The current treatment strategies for diabetic wound care provide only moderate degree of effectiveness; hence new and improved therapeutic techniques are in great demand. Diabetic wound healing is a complex physiological process that involves synchronisation of various biological events such as haemostasis, inflammation, and remodelling. Nanomaterials like polymeric nanofibers (NFs) offer a promising approach for the treatment of diabetic wounds and have emerged as viable options for wound management. Electrospinning is a powerful and cost-effective method to fabricate versatile NFs with a wide array of raw materials for different biological applications. The electrospun NFs have unique advantages in the development of wound dressings due to their high specific surface area and porosity. The electrospun NFs possess a unique porous structure and biological function similar to the natural extracellular matrix (ECM), and are known to accelerate wound healing. Compared to traditional dressings, the electrospun NFs are more effective in healing wounds owing to their distinct characteristics, good surface functionalisation, better biocompatibility and biodegradability. This review provides a comprehensive overview of the electrospinning procedure and its operating principle, with special emphasis on the role of electrospun NFs in the treatment of diabetic wounds. This review discusses the present techniques applied in the fabrication of NF dressings, and highlights the future prospects of electrospun NFs in medicinal applications.

Gene Therapy for Neuropsychiatric Disorders: Potential Targets and Tools.

Neuropsychiatric disorders that affect the central nervous system cause considerable pressures on the health care system and have a substantial economic burden on modern societies. The present treatments based on available drugs are mostly ineffective and often costly. The molecular process of neuropsychiatric disorders is closely connected to modifying the genetic structures inherited or caused by damage, toxic chemicals, and some current diseases. Gene therapy is presently an experimental concept for neurological disorders. Clinical applications endeavor to alleviate the symptoms, reduce disease progression, and repair defective genes. Implementing gene therapy in inherited and acquired neurological illnesses entails the integration of several scientific disciplines, including virology, neurology, neurosurgery, molecular genetics, and immunology. Genetic manipulation has the power to minimize or cure illness by inducing genetic alterations at endogenous loci. Gene therapy that involves treating the disease by deleting, silencing, or editing defective genes and delivering genetic material to produce therapeutic molecules has excellent potential as a novel approach for treating neuropsychiatric disorders. With the recent advances in gene selection and vector design quality in targeted treatments, gene therapy could be an effective approach. This review article will investigate and report the newest and the most critical molecules and factors in neuropsychiatric disorder gene therapy. Different genome editing techniques available will be evaluated, and the review will highlight preclinical research of genome editing for neuropsychiatric disorders while also evaluating current limitations and potential strategies to overcome genome editing advancements.

Biocompatible phospholipid-based nanovesicular drug delivery system of ketoprofen: Systematic development, optimization, and preclinical evaluation.

The present work involved development of phospholipid-based permeation enhancing nanovesicles (PENVs) for topical delivery of ketoprofen. Screening of phospholipids and process parameters was performed. Central composite design was used for optimization of factors, that is, amount (%, w/w) of phospholipid and ethanol at three levels. The optimized nanovesicles (NVs) were loaded with different terpenes and then incorporated into a gel base. Optimized NVs exhibited 69% entrapment efficiency, 51% transmittance, 328 nm mean vesicle size, and polydispersity index of 0.25. In vitro release kinetics evaluation indicated best fitting as per Korsemeyer-Peppa's model and drug release via Fickian-diffusion mechanism. The optimized NVs loaded with mint terpene showed minimal degree of deformability and maximal elasticity as compared with the conventional NVs and liposomes. Rheology and texture analysis indicated pseudoplastic flow and smooth texture of the vesicle gel formulation. Ex vivo permeation studies across Wistar rat skin indicated low penetration (0.43-fold decrease) and high skin retention (4.26-fold increase) of ketoprofen from the optimized PENVs gel vis-à-vis the conventional gel. Skin irritancy study indicated lower scores for PENVs gel construing its biocompatible nature. Stability studies confirmed cold storage is best suitable for vesicle gel, and optimized PENVs were found to be suitable for topical delivery of ketoprofen.

Preservatives in Pharmaceuticals: Are They Really Safe?

Preservatives are the ingredients that are utilized in order to improve the shelf life of products (Medicines, food). These tend to slow down or stop the degradation or decomposition processes, therefore, enhance the shelf life of the products. These agents either interfere with the chemical reaction or check the growth of microorganisms in the products. Preservatives are classified according to the mode of action or source or chemical nature. The preservation efficacy can be affected by various factors, e.g., interaction with other components, nature of preservatives, type of containers, type of micro-organism, and pH. Despite being vital for various types of products, these chemicals are not safe, if not used appropriately. The review will provide an updated detail of different types of preservatives along with their safety aspect. This review also highlighted the maximum safe concentration of preservatives that can be required to develop a formulation with maximum safety and low toxicity.

Foam-Based Drug Delivery: A Newer Approach for Pharmaceutical Dosage Form.

Foam is a dispersal of gas in solid foam or liquid foam. Solid foams are generally formed through quick curing of liquid foams. Because of their positive characteristics, simplicity of application, and improved patient acceptability/compliance, foams are an appealing and promising delivery strategy for medical, cosmetic, and pharmaceutical, applications. Recent breakthroughs in topical foams for cosmetic and dermal applications are described here, as well as categorization based on foam formulation and recent assessment techniques of critical physical properties of the topical foam. Despite the expanding amount of knowledge on topical foams for cutaneous applications, the majority of research has focused on the stability and structure of foam in contact with solid nonporous surfaces. It is still difficult to figure out how such foams destabilize when they come into touch with porous surfaces like skin or skin-like membranes. The foam-covered wide surface area and easily applied to the affected area. This type of delivery system also eliminates the chance of secondary infection that is associated with ointment and creams, which need to be applied to the affected area with help of fingers or an applicator.

Long-Term Performance of the Magmaris Drug-Eluting Bioresorbable Metallic Scaffold in All-Comers Patients' Population.

Background: The long-term efficacy and safety of bioresorbable vascular scaffolds (BVS) in real world clinical practice including Magmaris need to be elucidated to better understand performance of this new and evolutive technology. The aim of this study was to evaluate long-term performance of Magmaris, drug-eluting bioresorbable metallic scaffold, in all-comers patients' population. Methods: We included in this prospective registry first 54 patients (54 ± 11 years; male 46) treated with Magmaris, with at least 30 months of follow-up. Diabetes mellitus and acute coronary syndrome were present in 33 (61%) and 30 (56%) of the patients, respectively. Patients were followed for device- and patient-oriented cardiac events during a median follow-up of 47 months (DOCE-cardiac death, target vessel myocardial infarction, and target lesion revascularization; POCE-all cause death, any myocardial infarction, any revascularization). Results: Event-free survivals for DOCE and POCE were 86.8% and 79.2%, respectively. The rate of DOCE was 7/54 (13%), including in total target vessel myocardial infarction in two patients (4%), target lesion revascularization in six patients (11%), and no cardiac deaths. The rate of POCE was 11/54 (21%), including in total any myocardial infarctions in 3 patients (6%), any revascularization in 11 patients (20%), and no deaths. Definite Magmaris thrombosis occurred in two patients (3.7%), and in-scaffold restenosis developed in five patients (9.3%). Variables associated with DOCE were implantation of ≥2 Magmaris BVS (HR: 5.4; 95%CI: 1.21-24.456; p = 0.027) and total length of Magmaris BVS ≥ 40 mm (HR: 6.4; 95%CI: 1.419-28.855; p = 0.016), whereas previous PCI was the only independent predictor of POCE (HR: 7.4; 95%CI: 2.216-24.613; p = 0.001). Conclusions: The results of the long-term clinical outcome following Magmaris implantation in patients with complex clinical and angiographic features were acceptable and promising. Patients with multi-BVS and longer multi-BVS in lesion implantation were associated with worse clinical outcome.