Saliva – Volatile Biomarkers and Profiles

Total Antioxidant Capacity of Saliva and Its Correlation with pH Levels among Dental Students under Different Stressful Conditions

(1) Background: This cross-sectional study conducted at the Faculty of Dental Medicine, Timisoara, Romania, between December 2022 and February 2023 aims to assess salivary total antioxidant capacity and pH levels in dental students experiencing non-stressful and stressful situations and explore potential correlations between these factors. (2) Methods: Saliva samples were collected during two different periods: before an Oral Health course and before the Oral Health exam, under stressful conditions. Ethical principles were followed, and informed consent was obtained. Data on age, gender, health status, drug use, smoking habits, and anxiety levels were recorded. Saliva was collected using the draining method and pH was measured using indicator paper strips. Total antioxidant capacity (TAC) was determined using a commercial assay kit. Statistical analysis involved descriptive statistics, Student's t-test to compare pH and TAC between study groups, and Pearson's correlation coefficient to analyze the correlation between salivary pH and TAC within each group, with p < 0.05 indicating significance. (3) Results: This study involved 80 participants, comprising 26 males and 54 females, all enrolled in the 5th year of the Oral Health course, with ages ranging from 20 to 53 and a mean age of 23.62 (±4.19) years. Pearson's correlation results show a statistically significant negative relationship between the STAI test and TAC during the stress-free period (-0.02 **, N = 80, p < 0.01). (4) Conclusions: There are variations in saliva's antioxidant capacity in response to different stress conditions. Dental students experienced a higher level of stress before academic assessments compared to the non-stress period during the course.

Detection of Propionic Acids Trapped in Thin Zeolite Layer Using Thermal Desorption Analysis

Volatile organic compounds (VOCs) have recently received considerable attention for the analysis and monitoring of different biochemical processes in biological systems such as humans, plants, and microorganisms. The advantage of using VOCs to gather information about a specific process is that they can be extracted using different types of samples, even at low concentrations. Therefore, VOC levels represent the fingerprints of specific biochemical processes. The aim of this work was to develop a sensor based on a photoionization detector (PID) and a zeolite layer, used as an alternative analytic separation technique for the analysis of VOCs. The identification of VOCs occurred through the evaluation of the emissive profile during the thermal desorption phase, using a stainless-steel chamber for analysis. Emission profiles were evaluated using a double exponential mathematical model, which fit well if compared with the physical system, describing both the evaporation and diffusion processes. The results showed that the zeolite layer was selective for propionic acid molecules if compared to succinic acid molecules, showing linear behavior even at low concentrations. The process to define the optimal adsorption time between the propionic acid molecules was performed in the range of 5 to 60 min, followed by a thermal desorption process at 100 °C. An investigation of the relationship between the evaporation and diffusion rates showed that the maximum concentration of detected propionic acid molecules occurred in 15 min. Other analyses were performed to study how the concentration of VOCs depended on the desorption temperature and the volume of the analysis chamber. For this purpose, tests were performed using three analysis chambers with volumes of 25 × 10-6, 50 × 10-6, and 150 × 10-6 m3 at three different desorption temperatures of 20 °C, 50 °C, and 100 °C, respectively. The results demonstrated that the evaporation rate of the VOCs increased rapidly with an increasing temperature, while the diffusion rate remained almost constant and was characterized by a slow decay time. The diffusion ratio increased when using a chamber with a larger volume. These results highlight the capabilities of this alternative technique for VOC analysis, even for samples with low concentrations. The coupling of a zeolite layer and a PID improves the detection selectivity in portable devices, demonstrating the feasibility of extending its use to a wide range of new applications.

Saliva biomarkers in oral disease

Saliva is a versatile biofluid that contains a wide variety of biomarkers reflecting both physiologic and pathophysiologic states. Saliva collection is noninvasive and highly applicable for tests requiring serial sampling. Furthermore, advances in test accuracy, sensitivity and precision for saliva has improved diagnostic performance as well as the identification of novel markers especially in oral disease processes. These include dental caries, periodontitis, oral squamous cell carcinoma (OSCC) and Sjögren's syndrome (SS). Numerous growth factors, enzymes, interleukins and cytokines have been identified and are the subject of much research investigation. This review highlights current procedures for successful determination of saliva biomarkers including preanalytical factors associated with sampling, storage and pretreatment as well as subsequent analysis. Moreover, it provides an overview of the diagnostic applications of these salivary biomarkers in common oral diseases.

Salivary Biomarkers of Anti-Epileptic Drugs: A Narrative Review

Saliva is a biofluid that reflects general health and that can be collected in order to evaluate and determine various pathologies and treatments. Biomarker analysis through saliva sampling is an emerging method of accurately screening and diagnosing diseases. Anti-epileptic drugs (AEDs) are prescribed generally in seizure treatment. The dose-response relationship of AEDs is influenced by numerous factors and varies from patient to patient, hence the need for the careful supervision of drug intake. The therapeutic drug monitoring (TDM) of AEDs was traditionally performed through repeated blood withdrawals. Saliva sampling in order to determine and monitor AEDs is a novel, fast, low-cost and non-invasive approach. This narrative review focuses on the characteristics of various AEDs and the possibility of determining active plasma concentrations from saliva samples. Additionally, this study aims to highlight the significant correlations between AED blood, urine and oral fluid levels and the applicability of saliva TDM for AEDs. The study also focuses on emphasizing the applicability of saliva sampling for epileptic patients.

High-Throughput and Rapid Screening of Drugs of Abuse in Saliva by Multi-Segment Injection Using Solid-Phase Microextraction-Automated Microfluidic Open Interface-Mass Spectrometry

There is great demand for analytical methods capable of providing high-throughput and rapid screening, especially for anti-doping and clinical point-of-care applications. In this work, automated microfluidic open interface-mass spectrometry (MOI-MS) was used for coupling with high-throughput, automated solid-phase microextraction (SPME) to achieve this objective. The design of the MOI-MS interface provides a continuous and stable electrospray fluid flow to the MS without introducing any bubble, a feature that we exploit to introduce the concept of multi-segment injection for the determination of multiple samples in a single MS run. By eliminating the need to start a new MS run between sample assays, the developed approach provides significantly simplified protocols controlled by programmed software and increased reproducibility. Furthermore, the biocompatible SPME device, which utilizes coating consisting of hydrophilic-lipophilic balanced particles embedded in a polyacrylonitrile (PAN) binder, can be directly used for biological sample analysis, as the PAN acts as both a binder and a matrix-compatible barrier, thus enabling the enrichment of small molecules while eliminating interferences associated with the presence of interfering macromolecules. The above design was employed to develop a fast, quantitative method capable of analyzing drugs of abuse in saliva samples in as little as 75 s per sample. The findings indicate that the developed method provides good analytical performance, with limits of detection ranging between 0.05 and 5 ng/mL for analysis of 16 drugs of abuse, good calibration linear correlation coefficients (R2 ≥ 0.9957), accuracy between 81 and 120%, and excellent precision (RSD% < 13%). Finally, a proof-of-concept experiment was performed to demonstrate the method's suitability for real-time analysis in anti-doping applications.

The Potential Use of Volatile Biomarkers for Malaria Diagnosis

Pathogens may change the odor and odor-related biting behavior of the vector and host to enhance pathogen transmission. In recent years, volatile biomarker investigations have emerged to identify odors that are differentially and specifically released by pathogens and plants, or the pathogen-infected or even cancer patients. Several studies have reported odors or volatile biomarkers specifically detected from the breath and skin of malaria-infected individuals. This review will discuss the potential use of these odors or volatile biomarkers for the diagnosis of malaria. This approach not only allows for the non-invasive mean of sample collection but also opens up the opportunity to develop a biosensor for malaria diagnosis in low-resource settings.

The potential impact of salivary peptides in periodontitis

Periodontitis is a complex immune-inflammatory condition characterized by the disruption of the periodontal ligament and subsequent formation of periodontal pockets, and by alveolar bone loss, often resulting in tooth loss. A myriad of factors, namely, genetic, metabolic, immunological, and inflammatory, is associated with progression of periodontitis. Periodontitis is also associated with systemic conditions such as neoplastic disorders, obesity, and diabetes. The current diagnosis of this disease relies on clinical measurements such as clinical attachment loss and probing depth, which have poor precision due to patient, operator and probe-related factors. Thus, there is a need to develop reliable, objective, and reproducible biomarkers for early diagnosis of periodontitis. In this regard, saliva, with contributions from the gingival crevicular fluid, holds great potential. However, most of the information on biomarkers of periodontium-related salivary proteins has come from studies on the molecular pathogenesis of periodontitis. In periodontitis, a more holistic approach, such as the use of -omics technologies, for biomarker discovery, is needed. Herein, we review the biomarkers proposed to date for the assessment of periodontitis, with emphasis on the role of salivary peptides in periodontitis and their assessment by high-throughput saliva proteomics. We also discuss the challenges pertaining to the identification of new periodontitis biomarkers in saliva.

Evaluation of salivary VOC profile composition directed towards oral cancer and oral lesion assessment

OBJECTIVES

Endogenous substances have been analyzed in biological samples in order to be related with metabolic dysfunctions and diseases. The study aimed to investigate profiles of volatile organic compounds (VOCs) from fresh and incubated saliva donated by healthy controls, individuals with oral tissue lesions and with oral cancer, in order to assess case-specific biomarkers of oxidative stress.

MATERIALS AND METHODS

VOCs were pre-concentrated using headspace-solid phase microextraction and analyzed using gas chromatography-mass spectrometry. Then, VOCs positively modulated by incubation process were subtracted, yielding profiles with selected features. Principal component analysis and hierarchical cluster analysis were used to inspect data distribution, while univariate statistics was applied to indicate potential markers of oral cancer. Machine learning algorithm was implemented, aiming multiclass prediction.

RESULTS

The removal of bacterial contribution to VOC profiles allowed the obtaining of more specific case-related patterns. Artificial neural network model included 9 most relevant compounds (1-octen-3-ol, hexanoic acid, E-2-octenal, heptanoic acid, octanoic acid, E-2-nonenal, nonanoic acid, 2,4-decadienal and 9-undecenoic acid). Model performance was assessed using 10-fold cross validation and receiver operating characteristic curves. Obtained overall accuracy was 90%. Oral cancer cases were predicted with 100% of sensitivity and specificity.

CONCLUSIONS

The selected VOCs were ascribed to lipid oxidation mechanism and presented potential to differentiate oral cancer from other inflammatory conditions.

CLINICAL RELEVANCE

These results highlight the importance of interpretation of saliva composition and the clinical value of salivary VOCs. Elucidated metabolic alterations have the potential to aid the early detection of oral cancer and the monitoring of oral lesions.

Amine/phenyl gradient derived base layer as a comprehensive extractive phase for headspace cooled in-tube microextraction of volatile organic compounds in saliva

A gradient derived base layer extractive phase was synthesized and applied for the determination of volatile organic compounds (VOCs) in saliva samples using the headspace cooled in-tube microextraction (HS-CITME) method. The base layers from three different sols of phenyltriethoxysilane (PTES), octyltrimethoxysilane (OTMS) and methyltrimethoxysilane (MTMS) as nonpolar precursors were individually dip coated on the stainless steel wires (SSW). Then, the hydrolyzed polar precursor aminopropyltriethoxysilane (APTES) reacted with the silanol groups already formed on the surface of SSWs via controlled rate infusion (CRI) method. The presence of polar and non-polar functional groups on the surface of substrate was evaluated by Fourier-transform infrared spectroscopy (FTIR) while the morphology and thickness of the most suitable gradient coating (amine/phenyl) were also investigated by scanning electron microscopy (SEM). Assessment of the gradient extractive phase efficiency was carried out determining a group of VOCs with different polarities coupled with gas chromatography-mass spectrometry (GCMS) and the improved performance of the synthesized base layer coatings was observed. Furthermore, a cooling device was designed and implemented to the extracting system to improve the efficiency by influencing the exothermic nature of process. The data were analyzed by principal component analysis (PCA), and hierarchical cluster analysis (HCA) and the results were interpreted by polarities of analytes. Finally, under the optimized conditions, the limits of detection (LOD) and limits of quantification (LOQ) were 0.15 and 0.50 ng L^-1, respectively. The intra-day and inter-day relative standard deviations (RSDs) at 5 and 50 ng L^-1 (n = 3) using a single extractive phase were 2-6 and 10-17, respectively. The data associated with RSDs% for three extractive phases were between 16 and 19 %. Eventually, the method was conveniently applied to the extraction of VOCs from saliva samples of smokers and satisfactory relative recoveries (RR%) (95-108 %) were achieved and low quantities of VOCs were detected.

Artificial oral fluid characterisation: Potential for use as a reference matrix in drug testing

Quality assurance schemes for drug-screening programmes require access to large quantities of biological matrices for reference or control samples. This presents problems when the availability of a matrix, such as oral fluid (OF) for screening or for confirmatory purposes, limits the collection of large volumes. In such cases, synthetic alternatives of OF may provide a solution. The preparation of an artificial (synthetic) oral fluid (AOF) was conducted by dissolving its components (salts, surfactant, antimicrobial agent and mucin) in water. We characterised the physical properties of AOF to determine its suitability as a matrix for quality assurance purposes. The evaluation of pH, specific gravity (SG), conductivity (mS cm^-1 ), freezing point depression (°C), light-scattering and kinematic viscosity (mm² s^-1 ) showed AOF to be a stable, reliable matrix. Synthetic OF was prepared using components (mucin, surfactants and so on) obtained from different suppliers and a comparison was performed. Our results suggest that AOF is a feasible matrix for the preparation of quality assurance samples for confirmatory or drug screening programmes.

Unravelling the Potential of Salivary Volatile Metabolites in Oral Diseases. A Review

Fostered by the advances in the instrumental and analytical fields, in recent years the analysis of volatile organic compounds (VOCs) has emerged as a new frontier in medical diagnostics. VOCs analysis is a non-invasive, rapid and inexpensive strategy with promising potential in clinical diagnostic procedures. Since cellular metabolism is altered by diseases, the resulting metabolic effects on VOCs may serve as biomarkers for any given pathophysiologic condition. Human VOCs are released from biomatrices such as saliva, urine, skin emanations and exhaled breath and are derived from many metabolic pathways. In this review, the potential of VOCs present in saliva will be explored as a monitoring tool for several oral diseases, including gingivitis and periodontal disease, dental caries, and oral cancer. Moreover, the analytical state-of-the-art for salivary volatomics, e.g., the most common extraction techniques along with the current challenges and future perspectives will be addressed unequivocally.

Microbiota and Malodor-Etiology and Management

Accumulating evidence indicates that microbiota plays a critical role in physiological processes in humans. However, it might also contribute to body malodor by producing numerous odorous molecules such as ammonia, volatile sulfur compounds or trimethylamine. Although malodor is commonly overlooked by physicians, it constitutes a major problem for many otherwise healthy people. Thus, this review aims to investigate most common causes of malodor and describe potential therapeutic options. We searched PUBMED and Google Scholar databases to identify the clinical and pre-clinical studies on bad body smell, malodor, halitosis and microbiota. Unpleasant smell might originate from the mouth, skin, urine or reproductive fluids and is usually caused by odorants that are produced by resident bacterial flora. The accumulation of odorous compounds might result from diet, specific composition of microbiota, as well as compromised function of the liver, intestines and kidneys. Evidence-based guidelines for management of body malodor are lacking and no universal treatment exists. However, the alleviation of the symptoms may be achieved by controlling the diet and physical elimination of bacteria and/or accumulated odorants.

A salivary metabolite signature that reflects gingival host-microbe interactions: instability predicts gingivitis susceptibility

Several proteins and peptides in saliva were shown to stimulate gingival wound repair, but the role of salivary metabolites in this process remains unexplored. In vitro gingival re-epithelialization kinetics were determined using unstimulated saliva samples from healthy individuals collected during an experimental gingivitis study. Elastic net regression with stability selection identified a specific metabolite signature in a training dataset that was associated with the observed re-epithelialization kinetics and enabled its prediction for all saliva samples obtained in the clinical study. This signature encompassed ten metabolites, including plasmalogens, diacylglycerol and amino acid derivatives, which reflect enhanced host-microbe interactions. This association is in agreement with the positive correlation of the metabolite signature with the individual’s gingival bleeding index. Remarkably, intra-individual signature-variation over time was associated with elevated risk for gingivitis development. Unravelling how these metabolites stimulate wound repair could provide novel avenues towards therapeutic approaches in patients with impaired wound healing capacity.

Monitoring of Bactericidal Effects of Silver Nanoparticles Based on Protein Signatures and VOC Emissions from Escherichia coli and Selected Salivary Bacteria

Escherichia coli and salivary Klebsiella oxytoca and Staphylococcus saccharolyticus were subjected to different concentrations of silver nanoparticles (AgNPs), namely: 12.5, 50, and 100 µg mL-1. Matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS) spectra were acquired after specified periods: 0, 1, 4, and 12 h. For study of volatile metabolites, headspace solid-phase microextraction coupled to gas chromatography/mass spectrometry (HS-SPME-GC-MS) was employed-AgNPs were added to bacteria cultures and the headspace was analyzed immediately and after 12 h of incubation. Principal components analysis provided discrimination between clusters of protein profiles belonging to different strains. Canonical correlation, network analysis, and multiple linear regression approach revealed that dimethyl disulfide, dimethyl trisulfide, 2-heptanone, and dodecanal (related to the metabolism of sulfur-containing amino acids and fatty acids synthesis) are exemplary molecular indicators, whose response variation deeply correlated to the interaction with bacteria. Therefore, such species can serve as biomarkers of the agent's effectiveness. The present investigation pointed out that the used approaches can be useful in the monitoring of response to therapeutic treatment based on AgNPs. Furthermore, biochemical mechanisms enrolled in the bactericidal action of nanoparticles can be applied in the development of new agents with enhanced properties.

VOC Profiles of Saliva in Assessment of Halitosis and Submandibular Abscesses Using HS-SPME-GC/MS Technique

Halitosis and submandibular abscesses are examples of mouth-related diseases with the possible bacterial origin. Salivary volatile organic compounds (VOCs) are potential biomarkers of them, once they can be addressed as metabolites of bacterial activity. Healthy patients (n = 15), subjects with submandibular abscesses located in fascial deep space (n = 10), and subjects with halitosis (n = 5) were enrolled in the study. Saliva samples were subjected to headspace solid-phase microextraction (HS-SPME) and gas chromatography coupled to mass spectrometry (GC/MS) analysis. A total number of 164 VOCs was detected by the developed methodology, 23 specific for halitosis and 41 for abscess. Halitosis’ profiles were characterized by a larger number of sulfur compounds, while for abscess they had a higher variety of alcohols, aldehydes, and hydrocarbons—biomarkers of inflammatory processes. Principal components analysis allowed visualization of clusters formed according to the evaluated conditions. Kruskal-Wallis test indicated that 39 VOCs presented differentiated responses between the studied groups, with statistical relevance (p < 0.05). Random forest was applied, and a prediction model based on eight VOCs (2-butanone, methyl thioacetate, 2-methylbutanoic acid, S-methyl pentanethioate, dimethyl tetrasulfide, indolizine, pentadecane, and octadecanal) provided 100% of sensitivity, 82% of specificity, and 91% of balanced accuracy, indicating the specific presence of submandibular abscess.

Release of volatile organic compounds (VOCs) from colorectal cancer cell line LS174T

Colorectal cancer (CRC) is the third most common cancer worldwide. To date, no non-invasive and specific biomarkers have been identified for the diagnosis of CRC. The analysis of volatile organic compounds (VOCs) is attracting increasing attention and provides the possibility of a non-invasive diagnosis. Solid-phase microextraction (SPME) and gas chromatography-mass spectrometry (GC-MS) have been used to analyze the VOCs released from the headspace gas of LS174T (Dukes' type B colorectal adenocarcinoma) cells, arsenic trioxide (ATO)-treated LS174T cells and the blood from tumor-bearing mice. The data were processed using principal component analysis (PCA) and orthogonal partial least-squares discriminant analysis (OPLS-DA), which showed that the levels of decanal, 2,4-dimethyl- heptane, and twelve other metabolites were significantly greater in the headspace gas of the LS174T cells and blood of tumor-bearing mice. Additionally, in vivo experiments indicated that formic acid, ethenyl ester and p-trimethylsilyloxyphenyl-(trimethylsilyloxy)trimethylsilylacrylate were consumed during tumor growth. In conclusion, VOCs such as 1-methoxy-hexane and 2,4-dimethyl-heptane could be useful diagnostic markers for CRC. Further research should focus on the potential metabolic pathways associated with these profiles.

Contact analysis of gap formation at dental implant-abutment interface under oblique loading: A numerical-experimental study

PURPOSE

To develop numerical and experimental methods for investigating the formation of micro-gaps and the change in contact area at the implant-abutment interface of two different connector designs under oblique cyclic loading.

MATERIALS AND METHODS

Samples (n = 10 per group) of two-piece implant systems with the conical connection (group A) and the external hexagonal connection (group B) were subjected to cyclic loading with increasing load amplitudes up to 220 N. After loading, the samples were scanned using micro-CT, with silver nitrate as a high-contrast penetrant, and the level of leakage was assessed using a discrete scoring system. Three-dimensional finite element (FE) analyses of the two implant systems were also conducted to reveal the micro-gap formation process, especially bridging of the internal abutment screw space. The experimental and numerical results for the bridging load were then compared.

RESULTS

90% of the samples in group A showed leakage into the internal implant space at a load of around 100 N; while over 80% of those in group B did so at a load of around 40 N. This agreed with the FE analysis, which showed bridging of the internal implant space at loads similar to those measured for the two implant systems. Residual gaps of less than 1.49 μm were predicted for group A only after unloading.

CONCLUSIONS

The FE-predicted loads for bridging agreed well with those found experimentally for leakage to occur. The conical connection showed more resistance against formation of micro-gaps at the implant-abutment interface than the external hexagonal connection. Although the minimum load required to bridge the internal implant space was within the range of human biting force, the relation between bacterial invasion and micro-gaps needs further research.

Profiling of VOCs released from different salivary bacteria treated with non-lethal concentrations of silver nitrate

Considering the shortcomings related to antibiotics usage, the introduction of other bacteriostatic and bactericidal agents that present synergetic effects or standalone properties is urgently needed. AgNO₃ is an important bactericidal agent, which imparts various functions on bacteria dependent on its concentration. Therefore, an understanding of its mechanisms of action in infinitesimal concentrations plays an important role which can ultimately lead to AgNO₃ involvement in the pharmaceutical industry. The monitoring of VOC (volatile organic compound) profiles emitted by bacteria is a simple method to assess changes occurring in bacterial metabolism. In this study, VOCs of Hafnia alvei, Pseudomonas luteola and Staphylococcus warneri cultures were analyzed both in the absence and in the presence of three concentrations of AgNO₃. Headspace solid-phase microextraction gas chromatography/mass spectrometry (HS-SPME-GC/MS) was employed for extraction and analysis. After supplementation with AgNO₃, changes in the emitted fingerprints were investigated. Odorants associated with mouth-related and systemic diseases, like dimethyl trisulfide, indole (halitosis) and 2-hexanone (celiac disease), were also affected by addition of AgNO₃. Statistical tests proved discrimination between obtained profiles with more that 90% variability. Moreover, physiological states of bacteria after dosage with various concentration of stressing agent were investigated and explained by the mechanisms of action.

Screening of salivary volatiles for putative breast cancer discrimination: an exploratory study involving geographically distant populations

Saliva is possibly the easiest biofluid to analyse and, despite its simple composition, contains relevant metabolic information. In this work, we explored the potential of the volatile composition of saliva samples as biosignatures for breast cancer (BC) non-invasive diagnosis. To achieve this, 106 saliva samples of BC patients and controls in two distinct geographic regions in Portugal and India were extracted and analysed using optimised headspace solid-phase microextraction gas chromatography mass spectrometry (HS-SPME/GC-MS, 2 mL acidified saliva containing 10% NaCl, stirred (800 rpm) for 45 min at 38 °C and using the CAR/PDMS SPME fibre) followed by multivariate statistical analysis (MVSA). Over 120 volatiles from distinct chemical classes, with significant variations among the groups, were identified. MVSA retrieved a limited number of volatiles, viz. 3-methyl-pentanoic acid, 4-methyl-pentanoic acid, phenol and p-tert-butyl-phenol (Portuguese samples) and acetic, propanoic, benzoic acids, 1,2-decanediol, 2-decanone, and decanal (Indian samples), statistically relevant for the discrimination of BC patients in the populations analysed. This work defines an experimental layout, HS-SPME/GC-MS followed by MVSA, suitable to characterise volatile fingerprints for saliva as putative biosignatures for BC non-invasive diagnosis. Here, it was applied to BC samples from geographically distant populations and good disease separation was obtained. Further studies using larger cohorts are therefore very pertinent to challenge and strengthen this proof-of-concept study. Graphical abstract ᅟ.