Nanoparticle-mediated stimulus-responsive antibacterial therapy

Stimuli-responsive mesoporous silica nanoplatforms for smart antibacterial therapies: From single to combination strategies

The demand for new antibacterial therapies is urgent and crucial in the clinical setting because of the growing degree of antibiotic resistance and the limits of conventional antibacterial therapies. Stimuli- responsive nanoplatforms, are sensitive to endogenous or exogenous stimulus (pH, temperature, light, and magnetic fields, etc.) which activate cargo release locally and on-demand, hold great potential in developing next generation personalized precision medicine. For instance, pH-sensitive nanoplatforms can selectively release antibacterial agents in the acidic environment of infection sites. To achieve the stimuli-responsive delivery, mesoporous silica nanoplatforms (MSNs) have demonstrated as prospective candidates for efficient cargo loading and controlled release through strategies such as tunable pore engineering, versatile surface modification/coating, and tailored framework composition. Furthermore, aiming for more precise delivery of MSNs, current research interests are increasingly shifting from single-stimuli antibacterial strategy to integrated strategy that combine multiple-stimulus. In this review, we briefly discuss the microenvironment of bacterial infections and provide a comprehensive summary of current stimuli-responsive strategies, and associated materials design principles of stimuli-responsive mesoporous silica-based smart nanoplatforms (SRMSNs). Additionally, integrative antibacterial strategies with synergistic effects, combining chemodynamic, photodynamic, photothermal, sonodynamic and gas therapies, have also been elaborated. Present research advances and limitations of SRMSNs-based antibacterial therapies, such as limited biodegradability and potential cytotoxicity, have been overviewed with future outlooks presented. This review aims to inspire and guide future research in developing novel antibacterial strategies with integrative solutions.

Encapsulation nanoarchitectonics of glabridin with sophorolipid micelles for addressing biofilm hazards via extracellular polymeric substance permeation and srtA gene suppression

BACKGROUND

Biofilm, a common drug-resistant phenotype of Staphylococcus aureus (S. aureus), demonstrates significant drug resistance and recurrence due to its extracellular polymeric substance (EPS) barrier and subsequent bacterial migration. Hence, there is an urgent need for effective solutions to mitigate the hazards posed by biofilms.

RESULT

This study developed a stable, low-toxicity multifunctional nanomicelle, GLA@SOL/EYL, by encapsulating glabridin (GLA) using sophorolipid (SOL) and egg yolk lecithin (EYL). Optimizations were performed for the hydration medium, the ratio of carrier materials to GLA, and EYL additions. GLA@SOL/EYL exhibited a particle size of 122.1 ± 0.8 nm and a surface potential of -66.4 ± 1.7 mV, endowing it with the ability to permeate biofilms EPS effectively. GLA@SOL/EYL encapsulated 98.3 ± 1.2 % of GLA and demonstrated a slow-release effect, significantly enhancing the bioavailability of GLA. The addition of EYL reduced the hemolytic toxicity of GLA@SOL/EYL and improved its encapsulation rate and stability. GLA@SOL/EYL reduced the minimum inhibitory concentration of GLA to 8 μg/mL and extended its inhibitory effect at low concentrations by rapidly disrupting the structural integrity of S. aureus. GLA@SOL/EYL may penetrate biofilms to disperse EPS and remove twice as much biofilm as GLA alone, thereby eliminating 99.99 % of S. aureus within biofilms, compared to 99 % bactericidal efficacy of GLA. Additionally, GLA@SOL/EYL inhibited 63.8 ± 1.8 % of biofilm formation by affecting the expression of the srtA gene, thereby reducing the expression of cell wall-anchoring protein genes. In contrast, the biofilm inhibition rates of GLA and blank micelles were less than 10 %.

CONCLUSION

GLA@SOL/EYL utilizes the nanoparticle effect to penetrate biofilms and deliver antimicrobial GLA. The SOL disperses the biofilm matrix while GLA is released to kill S. aureus, preventing bacterial dissemination and colonization. Thus, GLA@SOL/EYL presents an innovative strategy for effectively eradicating S. aureus biofilms and preventing new hazards in a one-step approach.

Sustained antibacterial release of zwitterionic globular hyperbranched polymer dots intercalated into layered double hydroxides

This study introduces zwitterionic hyperbranched polymer (HBP) dots intercalated into layered double hydroxides (LDHs) for sustained antibacterial release. The proposed zwitterionic HBPs possess a three-dimensional spherical structure; unconventional blue fluorescent luminescence; water solubility; abundant COOH, amine, and amide functional groups; anionic exchangeability for intercalating into LDH interlayers; and sustained-release antibacterial activity. The intercalation for the layered nanomaterials was determined by adding different weight ratios of HBPs to Mg-Al LDHs to investigate the changes in the interlayer distance. X-ray diffraction revealed that the LDH layer spacing increased from 8.6 to 25.5 Å, effectively expanding the interlayer spacing with increasing HBP intercalation. Additionally, Fourier-transform infrared spectroscopy revealed the functional groups of the intercalated nanohybrids. Because the peripheral functional groups of HBPs are amino (-NH2) groups, preliminary evaluations revealed that pristine HBPs exhibited antibacterial properties. We further examined the antibacterial properties of the HBP/LDH nanohybrids. The results showed that HBPs combined with LDHs' controllable release properties can effectively achieve long-term sustained antibacterial release.

Preparation and characterization of a ciprofloxacin-loaded nanoparticles incorporated polymeric film dressing

In an effort to prepare a modern polysaccharide-based dressing for sustained/prolonged delivery of the antibacterial agent to prevent and control skin wound infection, ciprofloxacin (CP)-loaded sodium alginate (SA)-chitosan (CS) nanoparticles (NPs) were incorporated into novel arabinoxylan (AX)-pectin (PC) blended polymeric films by solvent casting. The CP-NPs were prepared by a two-step ionic interaction method with < 300 nm size, about 25 mV zeta potential, 74% CP-loading efficiency, and approximately round shape. The CP-NPs were incorporated in optimized AX-PC polymeric film prepared by using 2% AX and 2% PC with a plasticizer (2% glycerol) and then these films were characterized for suitability as a film dressing. The transparency, improved mechanical strength, thermal stability, water transmission, and exudate uptake characteristics indicated that CP-NPs incorporated AX-PC polymeric films were suitable for dressing applications. The CP-NPs incorporated AX-PC films exhibited sustained CP release (90% release in 36 h) and better antibacterial susceptibility as compared to free CP-containing AX-PC films. Thus, CP-NPs incorporated AX-PC films are promising dressing materials to prevent and control wound infection with prolonged antibiotic release.

Biomedical applications of stimuli-responsive nanomaterials

Nanomaterials have aroused great interests in drug delivery due to their nanoscale structure, facile modifiability, and multifunctional physicochemical properties. Currently, stimuli-responsive nanomaterials that can respond to endogenous or exogenous stimulus display strong potentials in biomedical applications. In comparison with conventional nanomaterials, stimuli-responsive nanomaterials can improve therapeutic efficiency and reduce the toxicity of drugs toward normal tissues through specific targeting and on-demand drug release at pathological sites. In this review, we summarize the responsive mechanism of a variety of stimulus, including pH, redox, and enzymes within pathological microenvironment, as well as exogenous stimulus such as thermal effect, magnetic field, light, and ultrasound. After that, biomedical applications (e.g., drug delivery, imaging, and theranostics) of stimuli-responsive nanomaterials in a diverse array of common diseases, including cardiovascular diseases, cancer, neurological disorders, inflammation, and bacterial infection, are presented and discussed. Finally, the remaining challenges and outlooks of future research directions for the biomedical applications of stimuli-responsive nanomaterials are also discussed. We hope that this review can provide valuable guidance for developing stimuli-responsive nanomaterials and accelerate their biomedical applications in diseases diagnosis and treatment.

Breaking the barrier: Nanoparticle-enhanced radiotherapy as the new vanguard in brain tumor treatment

The pursuit of effective treatments for brain tumors has increasingly focused on the promising area of nanoparticle-enhanced radiotherapy (NERT). This review elucidates the context and significance of NERT, with a particular emphasis on its application in brain tumor therapy-a field where traditional treatments often encounter obstacles due to the blood-brain barrier (BBB) and tumor cells' inherent resistance. The aims of this review include synthesizing recent advancements, analyzing action mechanisms, and assessing the clinical potential and challenges associated with nanoparticle (NP) use in radiotherapy enhancement. Preliminary preclinical studies have established a foundation for NERT, demonstrating that nanoparticles (NPs) can serve as radiosensitizers, thereby intensifying radiotherapy's efficacy. Investigations into various NP types, such as metallic, magnetic, and polymeric, have each unveiled distinct interactions with ionizing radiation, leading to an augmented destruction of tumor cells. These interactions, encompassing physical dose enhancement and biological and chemical radio sensitization, are crucial to the NERT strategy. Although clinical studies are in their early phases, initial trials have shown promising results in terms of tumor response rates and survival, albeit with mindful consideration of toxicity profiles. This review examines pivotal studies affirming NERT's efficacy and safety. NPs have the potential to revolutionize radiotherapy by overcoming challenges in targeted delivery, reducing off-target effects, and harmonizing with other modalities. Future directions include refining NP formulations, personalizing therapies, and navigating regulatory pathways. NERT holds promise to transform brain tumor treatment and provide hope for patients.

Near-Infrared Light-Triggered NO Nanogenerator for Gas-Enhanced Photodynamic Therapy and Low-Temperature Photothermal Therapy to Eliminate Biofilms

Purpose

Owing to its noninvasive nature, broad-spectrum effectiveness, minimal bacterial resistance, and high efficiency, phototherapy has significant potential for antibiotic-free antibacterial interventions and combating antibacterial biofilms. However, finding effective strategies to mitigate the detrimental effects of excessive temperature and elevated concentrations of reactive oxygen species (ROS) remains a pressing issue that requires immediate attention.

Methods

In this study, we designed a pH-responsive cationic polymer sodium nitroside dihydrate/branched polyethylenimine-indocyanine green@polyethylene glycol (SNP/PEI-ICG@PEG) nanoplatform using the electrostatic adsorption method and Schiff's base reaction. Relevant testing techniques were applied to characterize and analyze SNP/PEI-ICG@PEG, proving the successful synthesis of the nanomaterials. In vivo and in vitro experiments were performed to evaluate the antimicrobial properties of SNP/PEI-ICG@PEG.

Results

The morphology and particle size of SNP/PEI-ICG@PEG were observed via TEM. The zeta potential and UV-visible (UV-vis) results indicated the synthesis of the nanomaterials. The negligible cytotoxicity of up to 1 mg/mL of SNP/PEI-ICG@PEG in the presence or absence of light demonstrated its biosafety. Systematic in vivo and in vitro antimicrobial assays confirmed that SNP/PEI-ICG@PEG had good water solubility and biosafety and could be activated by near-infrared (NIR) light and synergistically treated using four therapeutic modes, photodynamic therapy (PDT), gaseous therapy (GT), mild photothermal therapy (PTT, 46 °C), and cation. Ultimately, the development of Gram-positive (G+) Staphylococcus aureus (S. aureus) and Gram-negative (G-) Escherichia coli (E. coli) were both completely killed in the free state, and the biofilm that had formed was eliminated.

Conclusion

SNP/PEI-ICG@PEG demonstrated remarkable efficacy in achieving controlled multimodal synergistic antibacterial activity and biofilm infection treatment. The nanoplatform thus holds promise for future clinical applications.

Design and optimization of ε-poly-l-lysine with specific functions for diverse applications

ε-Poly-l-lysine (ε-PL) is a natural homo-poly(amino acid) which can be produced by microorganisms. With the advantages in broad-spectrum antimicrobial activity, biodegradability, and biocompatibility, ε-PL has been widely used as a preservative in the food industry. Different molecular architectures endow ε-PL and ε-PL-based materials with versatile applications. However, the microbial synthesis of ε-PL is currently limited by low efficiencies in genetic engineering and molecular architecture modification. This review presents recent advances in ε-PL production and molecular architecture modification of microbial ε-PL, with a focus on the current challenges and solutions for the improvement of the productivity and diversity of ε-PL. In addition, we highlight recent examples where ε-PL has been applied to expand the versability of edible films and nanoparticles in various applications. Commercial production and the challenges and future research directions in ε-PL biosynthesis are also discussed. Currently, although the main use of ε-PL is as a food preservative, ε-PL and ε-PL-based polymers have shown excellent application potential in biomedical fields. With the development of synthetic biology, the design and synthesis of ε-PL with a customized molecular architecture are possible in the near future. ε-PL-based polymers with specific functions will be a new trend in biopolymer manufacturing.

Nanozyme-Engineered Hydrogels for Anti-Inflammation and Skin Regeneration

Inflammatory skin disorders can cause chronic scarring and functional impairments, posing a significant burden on patients and the healthcare system. Conventional therapies, such as corticosteroids and nonsteroidal anti-inflammatory drugs, are limited in efficacy and associated with adverse effects. Recently, nanozyme (NZ)-based hydrogels have shown great promise in addressing these challenges. NZ-based hydrogels possess unique therapeutic abilities by combining the therapeutic benefits of redox nanomaterials with enzymatic activity and the water-retaining capacity of hydrogels. The multifaceted therapeutic effects of these hydrogels include scavenging reactive oxygen species and other inflammatory mediators modulating immune responses toward a pro-regenerative environment and enhancing regenerative potential by triggering cell migration and differentiation. This review highlights the current state of the art in NZ-engineered hydrogels (NZ@hydrogels) for anti-inflammatory and skin regeneration applications. It also discusses the underlying chemo-mechano-biological mechanisms behind their effectiveness. Additionally, the challenges and future directions in this ground, particularly their clinical translation, are addressed. The insights provided in this review can aid in the design and engineering of novel NZ-based hydrogels, offering new possibilities for targeted and personalized skin-care therapies.

Stimuli-Actuated Turn-On Theranostic Nanoplatforms for Imaging-Guided Antibacterial Treatment

Antibacterial theranostic nanoplatforms, which integrate diagnostic and therapeutic properties, exhibit gigantic application prospects in precision medicine. However, traditional theranostic nanoplatforms usually present an always-on signal output, which leads to poor specificity or selectivity in the treatment of bacterial infections. To address this challenge, stimuli-actuated turn-on nanoplatforms are developed for simultaneous activation of diagnostic signals (e.g., fluorescent, photoacoustic, magnetic signals) and initiation of antibacterial treatment. Specifically, by combining the infection microenvironment-responsive activation of visual signals and antibacterial activity, these theranostic nanoplatforms exert both higher accurate diagnosis rates and more effective treatment effects. In this review, the imaging and treatment strategies that are commonly used in the clinic are first briefly introduced. Next, the recent progress of stimuli-actuated turn-on theranostic nanoplatforms for treating bacterial infectious diseases is summarized in detail. Finally, current bottlenecks and future opportunities of antibacterial theranostic nanoplatforms are also outlined and discussed.

Precise antibacterial therapeutics based on stimuli-responsive nanomaterials

Bacterial infection refers to the process in which bacteria invade, grow, reproduce, and interact with the body, ultimately causing a series of pathological changes. Nowadays, bacterial infection remains a significant public health issue, posing a huge threat to human health and a serious financial burden. In the post-antibiotic era, traditional antibiotics are prone to inducing bacterial resistance and difficulty in removing bacterial biofilm. In recent years, antibacterial therapy based on nanomaterials has developed rapidly. Compared with traditional antibiotics, nanomaterials effectively remove bacterial biofilms and rarely result in bacterial resistance. However, due to nanomaterials' strong permeability and effectiveness, they will easily cause cytotoxicity when they are not controlled. In addition, the antibacterial effect of non-responsive nanomaterials cannot be perfectly exerted since the drug release property or other antibacterial effects of these nano-materials are not be positively correlated with the intensity of bacterial infection. Stimuli-responsive antibacterial nanomaterials are a more advanced and intelligent class of nano drugs, which are controlled by exogenous stimuli and microenvironmental stimuli to change the dosage and intensity of treatment. The excellent spatiotemporal controllability enables stimuli-responsive nanomaterials to treat bacterial infections precisely. In this review, we first elaborate on the design principles of various stimuli-responsive antibacterial nanomaterials. Then, we analyze and summarizes the antibacterial properties, advantages and shortcomings of different applied anti-bacterial strategies based on stimuli-responsive nanomaterials. Finally, we propose the challenges of employing stimuli-responsive nanomaterials and corresponding potential solutions.

Silver nanoparticles-decorated extracellular matrix graft: fabrication and tendon reconstruction performance

BACKGROUND

The reconstruction of tendons with large defects requires grafts with high mechanical strength and is often hindered by complications such as infection and adhesion. Hence, grafts combining the advantages of mechanical resilience and antibacterial/antiadhesion activity are highly sought after.

METHODS

The silver nanoparticles (GA-Ag NPs) synthesized from gallic acid and silver nitrate were attached to a decellularized extracellular matrix (Decellularized Tendon crosslinking GA-AgNPs, DT-Ag). We examined the histological structure, mechanical property, morphology, Zeta potential, cytotoxicity, antibacterial properties, antioxidant and anti-inflammatory properties, and ability of the DT-Ag to treat tendon defects in animals.

RESULTS

Approximately 108.57 ± 0.94 μg GA-Ag NPs loaded per 50 mg DT, the cross-linked part of GA-Ag NPs was 65.47 ± 0.57%, which provided DT-Ag with long-lasting antibacterial activity. Meanwhile, GA endowed DT-Ag with good antioxidant and anti-inflammatory activities. Additionally, The DT-Ag facilitated M2 macrophage polarization, and suppressed fibrin deposition by hindering fibroblast adhesion. Mormore, the main advantages of DT-Ag, namely its long-lasting antibacterial activity (tested using Escherichia coli and Staphylococcus aureus as models) and the ability to prevent tissue adhesion were confirmed in vivo.

CONCLUSION

The fabricated multifunctional tendon graft was highly hydrophilic, biocompatible, and mechanically resilient, and concluded to be well suited for dealing with the main complications of surgical tendon reconstruction and has bright application prospects.

Collagen-Hyaluronic Acid Composite Hydrogels with Applications for Chronic Diabetic Wound Repair

Chronic diabetic wounds have become a major healthcare challenge worldwide. Improper treatment may lead to serious complications. Current treatment methods including biological and physical methods and skin grafting have limitations and disadvantages, such as poor efficacy, inconvenience of use, and high cost. Therefore, developing a more effective and feasible treatment is of great significance for the repair of chronic diabetic wounds. Hydrogels can be designed to serve multiple functions to promote the repair of chronic diabetic wounds. Furthermore, 3D bioprinting enables hydrogel customization to fit chronic diabetic wounds, thus facilitating the healing process. This paper reports a study of 3D printing of a collagen-hyaluronic acid composite hydrogels with application for chronic diabetic wound repair. In situ printed hydrogels were developed by a macromolecular crosslinking network using methacrylated recombinant human collagen (RHCMA) and methacrylated hyaluronic acid (HAMA), both of which can respond to ultraviolet (UV) irradiation. The hydrogels were also loaded with silver nanoclusters (AgNCs) with ultra-small-size nanoparticles, which have the advantages of deep penetration ability and broad-spectrum high-efficiency antibacterial properties. The results of this study show that the developed RHCMA, HAMA, and AgNCs (RHAg) composite hydrogels present good UV responsiveness, porosity, mechanical properties, printability, and biocompatibility, all of which are beneficial to wound healing. The results of this study further show that the developed RHAg hydrogels not only effectively inhibited Staphylococcus aureus and Pseudomonas aeruginosa but also promoted the proliferation and migration of fibroblasts in vitro and tissue regeneration and collagen deposition in vivo, thus producing a desirable wound repair effect and can be used as an effective functional biomaterial to promote chronic diabetic wound repair.

Promotion of ICD via Nanotechnology

Immunotherapy represents the most promising treatment strategy for cancer, but suffers from compromised therapeutic efficiency due to low immune activity of tumor cells and an immunosuppressive microenvironment, which significantly hampers the clinical translations of this treatment strategy. To promote immunotherapy with desired therapeutic efficiency, immunogenic cell death (ICD), a particular type of death capable of reshaping body's antitumor immune activity, has drawn considerable attention due to the potential to stimulate a potent immune response. Still, the potential of ICD effect remains unsatisfactory because of the intricate tumor microenvironment and multiple drawbacks of the used inducing agents. ICD has been thoroughly reviewed so far with a general classification of ICD as a kind of immunotherapy strategy and repeated discussion of the related mechanism. However, there are no published reviews, to the authors' knowledge, providing a systematic summarization on the enhancement of ICD via nanotechnology. For this purpose, this review first discusses the four stages of ICD according to the development mechanisms, followed by a comprehensive description on the use of nanotechnology to enhance ICD in the corresponding four stages. The challenges of ICD inducers and possible solutions are finally summarized for future ICD-based enhanced immunotherapy.

Piezodynamic Eradication of Both Gram-Positive and Gram-Negative Bacteria by Using a Nanoparticle Embedded Polymeric Membrane

Nowadays, bacterial infection is regarded as a serious threat to humankind, which needs to be taken care of. The emergence of antibiotic resistance and multidrug resistance (MDR) is rendering this situation more troublesome. However, several alternative treatment regimens have aided such diseases quite well in the recent past, among which dynamic antibacterial therapies combat this situation quite well. Among various dynamic therapies, piezodynamic therapy is a very recent avenue, in which mechanical stimuli have been exploited to treat bacterial infections. Herein, piezo-active bismuth ferrite-loaded poly(vinylidene fluoride-co-hexafluoropropylene) polymer has been utilized to eradicate gram-positive bacteria (E. faecalis) and gram-negative bacteria (E. coli). The sample has been designed in a free-standing membrane form, which, under soft ultrasound (~10 kHz), generates reactive radicals to ablate bacteria. Initially, the structure and morphology of the membrane have been substantiated by using X-ray diffraction and scanning electron microscopy methods; besides, Fourier transform infrared spectrum of the sample depicts a tremendously high value of polarizability and further confirms the piezo-activity of the membrane. More than 99% of E. coli and E. faecalis have been successfully eradicated within 30 min of ultrasound. Moreover, the solid-state structure and hydrophobic nature of the membrane help us to reuse it in a cyclic manner, which is possibly reported herein for the very first time. This novel membrane could be deployed in healthcare systems and pigment industries and could be exploited as a self-cleaning material.

Advances in Nanotechnology for Biofilm Inhibition

Biofilm-associated infections have emerged as a significant public health challenge due to their persistent nature and increased resistance to conventional treatment methods. The indiscriminate usage of antibiotics has made us susceptible to a range of multidrug-resistant pathogens. These pathogens show reduced susceptibility to antibiotics and increased intracellular survival. However, current methods for treating biofilms, such as smart materials and targeted drug delivery systems, have not been found effective in preventing biofilm formation. To address this challenge, nanotechnology has provided innovative solutions for preventing and treating biofilm formation by clinically relevant pathogens. Recent advances in nanotechnological strategies, including metallic nanoparticles, functionalized metallic nanoparticles, dendrimers, polymeric nanoparticles, cyclodextrin-based delivery, solid lipid nanoparticles, polymer drug conjugates, and liposomes, may provide valuable technological solutions against infectious diseases. Therefore, it is imperative to conduct a comprehensive review to summarize the recent advancements and limitations of advanced nanotechnologies. The present Review encompasses a summary of infectious agents, the mechanisms that lead to biofilm formation, and the impact of pathogens on human health. In a nutshell, this Review offers a comprehensive survey of the advanced nanotechnological solutions for managing infections. A detailed presentation has been made as to how these strategies may improve biofilm control and prevent infections. The key objective of this Review is to summarize the mechanisms, applications, and prospects of advanced nanotechnologies to provide a better understanding of their impact on biofilm formation by clinically relevant pathogens.

Nanomaterials as multimodal photothermal agents (PTAs) against 'Superbugs'

Superbugs, also known as multidrug-resistant bacteria, have become a lethal and persistent threat due to their unresponsiveness toward conventional antibiotics. The main reason for this is that superbugs can rapidly mutate and restrict any foreign drug/molecule in their vicinity. Herein, nanomaterial-mediated therapies have set their path and shown burgeoning efficiency toward the ablation of superbugs. Notably, treatment modalities like photothermal therapy (PTT) have shown prominence in killing multidrug-resistant bacteria with their ability to generate local heat shock-mediated hyperthermia in such species. However, photothermal treatment has some serious limitations, such as high cost, complexity, and even toxicity to some extent. Hence, it is important to resolve such shortcomings of PTTs as they provide substantial tissue penetration. This is why multimodal PTTs have emerged and taken over this domain of research for the past few years. In this work, we have summarized and critically reviewed such exceptional works of recent times and provided a perspective to enhance their efficiencies. Profoundly, we discuss the design rationales of some novel photothermal agents (PTAs) and shed light on their mechanisms. Finally, challenges for PTT-derived multimodal therapy are presented, and capable synergistic bactericidal prospects are anticipated.