Folic acid-conjugated cationic Ag2S quantum dots for optical imaging and selective doxorubicin delivery to HeLa cells

Cyanine dyes in the mitochondria-targeting photodynamic and photothermal therapy

Mitochondrial dysregulation plays a significant role in the carcinogenesis. On the other hand, its destabilization strongly represses the viability and metastatic potential of cancer cells. Photodynamic and photothermal therapies (PDT and PTT) target mitochondria effectively, providing innovative and non-invasive anticancer therapeutic modalities. Cyanine dyes, with strong mitochondrial selectivity, show significant potential in enhancing PDT and PTT. The potential and limitations of cyanine dyes for mitochondrial PDT and PTT are discussed, along with their applications in combination therapies, theranostic techniques, and optimal delivery systems. Additionally, novel approaches for sonodynamic therapy using photoactive cyanine dyes are presented, highlighting advances in cancer treatment.

CA IX-targeted Ag2S quantum dots bioprobe for NIR-II imaging-guided hypoxia tumor chemo-photothermal therapy

Hypoxia is the common characteristic of almost all solid tumors, which prevents therapeutic drugs from reaching the tumors. Therefore, the development of new targeted agents for the accurate diagnosis of hypoxia tumors is widely concerned. As carbonic anhydrase IX (CA IX) is abundantly distributed on the hypoxia tumor cells, it is considered as a potential tumor biomarker. 4-(2-Aminoethyl)benzenesulfonamide (ABS) as a CA IX inhibitor has inherent inhibitory activity and good targeting effect. In this study, Ag2S quantum dots (QDs) were used as the carrier to prepare a novel diagnostic and therapeutic bioprobe (Ag2S@polyethylene glycol (PEG)-ABS) through ligand exchange and amide condensation reaction. Ag2S@PEG-ABS can selectively target tumors by surface-modified ABS and achieve accurate tumor imaging by the near infrared-II (NIR-II) fluorescence characteristics of Ag2S QDs. PEG modification of Ag2S QDs greatly improves its water solubility and stability, and therefore achieves high photothermal stability and high photothermal conversion efficiency (PCE) of 45.17%. Under laser irradiation, Ag2S@PEG-ABS has powerful photothermal and inherent antitumor combinations on colon cancer cells (CT-26) in vitro. It also has been proved that Ag2S@PEG-ABS can realize the effective treatment of hypoxia tumors in vivo and show good biocompatibility. Therefore, it is a new efficient integrated platform for the diagnosis and treatment of hypoxia tumors.

The location of metastatic lymph nodes and the evaluation of lymphadenectomy by near-infrared photoacoustic imaging with iridium complex nanoparticles

Histopathology evaluation and lymphadenectomy of node-positive patients is the usual procedure in clinical therapy. However, it requires days for the histopathology result analysis, which impedes intraoperative decision-making and immediate treatment. Noninvasive real-time imaging of metastatic lymph nodes can overcome these defects and help medical workers evaluate lymph nodes and make the operation decision more efficiently. Herein we developed iridium(III)-cyanine complex/bovine serum albumin (BSA)-based nanoparticles which are conjugated with folic acid (FA) (IrCy-FA NPs). The synthesized IrCy-FA NPs exhibit good biocompatibility, strong near-infrared absorption, and impressive lymph node accumulation and can serve as a photoacoustic (PA) imaging probe for lymph node imaging. Besides, the lymph nodes enriched with IrCy-FA NPs showing green color are easily visible to the naked eye, suggesting their potential as an intraoperative indicator. The real-time PA imaging with excellent contrast and high spatial resolution can promote efficient and reliable quantitative analysis of lymph nodes in vivo. By employing IrCy-FA NPs as the PA agent for lymph node imaging, we achieve effective pre-operative and post-operative evaluations of metastatic lymph nodes in lymphadenectomy. This study may provide helpful information for PA imaging guided colocalization and evaluation of lymph nodes and facilitate this method towards clinical trials.

Recent Progress Toward Imaging Application of Multifunction Sonosensitizers in Sonodynamic Therapy

Sonodynamic therapy (SDT) is a rapidly developing non-surgical therapy that initiates sensitizers’ catalytic reaction using ultrasound, showing great potential for cancer treatment due to its high safety and non-invasive nature. In addition, recent research has found that using different diagnostic and therapeutic methods in tandem can lead to better anticancer outcomes. Therefore, as essential components of SDT, sonosensitizers have been extensively explored to optimize their functions and integrate multiple medical fields. The review is based on five years of articles evaluating the combined use of SDT and imaging in treating cancer. By developing multifunctional sonosensitive particles that combine imaging and sonodynamic therapy, we have integrated diagnosis into the treatment of precision medicine applications, improving SDT cell uptake and antitumor efficacy utilizing different tumour models. This paper describes the imaging principle and the results of cellular and animal imaging of the multifunctional sonosensitizers. Efforts are made in this paper to provide data and design references for future SDT combined imaging research and clinical application development and to provide offer suggestions.

Targeted drug delivery in cervical cancer: Current perspectives

Cervical cancer is preventable yet one of the most prevalent cancers among women around the globe. Though regular screening has resulted in the decline in incidence, the disease claims a high number of lives every year, especially in the developing countries. Owing to rather aggressive and non-specific nature of the conventional chemotherapeutics, there is a growing need for newer treatment modalities. The advent of nanotechnology has assisted in this through the use of nanocarriers for targeted drug delivery. A number of nanocarriers are continuously being developed and studied for their application in drug delivery. The present review summarises the different drug delivery approaches and nanocarriers that can be useful, their advantages and limitation.

COOH-Terminated Silicon Quantum Dots as a Highly Efficient Drug Nanocarrier for Targeted Tumor Cell Imaging

Fluorescent silicon quantum dots (SiQDs) characterized by exceptional photostability and colloidal robustness as well as beneficial biocompatibility are fast becoming new pharmaceutical nanocarriers. With a view to efficiently loading cisplatin (CDDP) onto SiQDs, carboxylate group (COOH) terminated SiQDs were imperative because of chelate formation with CDDP. In this work, we employed a facial microwave irradiation route for rapidly synthesizing high-quality COOH-SiQDs through the use of 3-aminopropyl trimethoxy silane (APTMS) molecules to fulfil the role of silicon precursor and maleic acid (MA) as the agent for facilitating reduction. The SiQDs showed blue fluorescence with an associated photoluminescence quantum yield (PLQY) of 40.2%, the size of which was small at 3.2 ±0.6 nm, and long-lasting stability (an extensive range in pH (4-12) and concentrations of electrolytes reaching 3 Molarity of a solution of sodium chloride). As nanocarriers, carboxylic acids chelation generated a high loading of CDDP onto SiQDs (drug loading capacity, DLC up to 32.2% at pH = 9) and a drug release of CDDP up to 57.6% at pH = 5. Furthermore, the MTT assays demonstrated the non or low cytotoxicity of SiQDs and the role of the controlled release of SiQD-CDDP Finally, the prepared SiQD-CDDP were used for cell imaging, and further targeted labeling of some tumors after folic acid (FA) conjugation. These characteristics allow for the deployment of SiQDs as a highly efficient nanocarrier that facilitate the delivery of clinical drugs for the future.

Synthesis and Bioapplications of Ag2 S Quantum Dots with Near-Infrared Fluorescence

Quantum dots (QDs) with near-infrared fluorescence (NIR) are an emerging class of QDs with unique capabilities owing to the deeper tissue penetrability of NIR light compared with visible light. NIR light also effectively overcomes organism autofluorescence, making NIR QDs particularly attractive in biological imaging applications for disease diagnosis. Considering latest developments, Ag₂ S QDs are a rising star among NIR QDs due to their excellent NIR fluorescence properties and biocompatibility. This review presents the various methods to synthesize NIR Ag₂ S QDs, and systematically discusses their applications in biosensing, bioimaging, and theranostics. Major challenges and future perspectives concerning the synthesis and bioapplications of NIR Ag₂ S QDs are discussed.

Applications of nanoscale metal-organic frameworks as imaging agents in biology and medicine

Nanoscale metal-organic frameworks (NMOFs) are an interesting and unique class of hybrid porous materials constructed by the self-assembly of metal ions/clusters with organic linkers. The high storage capacities, facile synthesis, easy surface functionalization, diverse compositions and excellent biocompatibilities of NMOFs have made them promising agents for theranostic applications. By combination of a large variety of metal ions and organic ligands, and incorporation of desired molecular functionalities including imaging modalities and therapeutic molecules, diverse MOF structures with versatile functionalities can be obtained and utilized in biomedical imaging and drug delivery. In recent years, NMOFs have attracted great interest as imaging agents in optical imaging (OI), magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET) and photoacoustic imaging (PAI). Furthermore, the significant porosity of MOFs allows them to be loaded with multiple imaging agents and therapeutics simultaneously and applied for multimodal imaging and therapy as a single entity. In this review, which is intended as an introduction to the use of MOFs in biomedical imaging for a reader entering the subject, we summarize the up-to-date progress of NMOFs as bioimaging agents, giving (i) a broad perspective of the varying imaging techniques that MOFs can enable, (ii) the different routes to manufacturing functionalised MOF nanoparticles and hybrids, and (iii) the integration of imaging with differing therapeutic techniques. The current challenges and perspectives of NMOFs for their further clinical translation are also highlighted and discussed.

Quantum dots as targeted doxorubicin drug delivery nanosystems in human lung cancer cells

Background

Lung cancer is one of the most frequently diagnosed cancers all over the world and is also one of the leading causes of cancer-related mortality. The main treatment option for small cell lung cancer, conventional chemotherapy, is characterized by a lack of specificity, resulting in severe adverse effects. Therefore, this study aimed at developing a new targeted drug delivery (TDD) system based on Ag–In–Zn–S quantum dots (QDs). For this purpose, the QD nanocrystals were modified with 11-mercaptoundecanoic acid (MUA), L-cysteine, and lipoic acid decorated with folic acid (FA) and used as a novel TDD system for targeting doxorubicin (DOX) to folate receptors (FARs) on adenocarcinomic human alveolar basal epithelial cells (A549). NIH/3T3 cells were used as FAR-negative controls. Comprehensive physicochemical, cytotoxicity, and genotoxicity studies were performed to characterize the developed novel TDDs.

Results

Fourier transformation infrared spectroscopy, dynamic light scattering, and fluorescence quenching confirmed the successful attachment of FA to the QD nanocrystals and of DOX to the QD–FA nanocarriers. UV–Vis analysis helped in determining the amount of FA and DOX covalently anchored to the surface of the QD nanocrystals. Biological screening revealed that the QD–FA–DOX nanoconjugates had higher cytotoxicity in comparison to the other forms of synthesized QD samples, suggesting the cytotoxic effect of DOX liberated from the QD constructs. Contrary to the QD–MUA–FA–DOX nanoconjugates which occurred to be the most cytotoxic against A549 cells among others, no such effect was observed for NIH/3T3 cells, confirming FARs as molecular targets. In vitro scratch assay also revealed significant inhibition of A549 cell migration after treatment with QD–MUA–FA–DOX. The performed studies evidenced that at IC50 all the nanoconjugates induced significantly more DNA breaks than that observed in nontreated cells. Overall, the QD–MUA–FA–DOX nanoconjugates showed the greatest cytotoxicity and genotoxicity, while significantly inhibiting the migratory potential of A549 cells.

Conclusion

QD–MUA–FA–DOX nanoconjugates can thus be considered as a potential drug delivery system for the effective treatment of adenocarcinomic human alveolar basal epithelial cells.

Ag2S quantum dot theragnostics

Silver sulfide quantum dots (Ag₂S QDs) as a theragnostic agent have received much attention because they provide excellent optical and chemical properties to facilitate diagnosis and therapy simultaneously.

Multimodal image-guided folic acid targeted Ag-based quantum dots for the combination of selective methotrexate delivery and photothermal therapy

Multifunctional quantum dots (QDs) with photothermal therapy (PTT) potential loaded with an anticancer drug and labelled with a targeting agent can be highly effective nano-agents for tumour specific, image-guided PTT/chemo combination therapy of cancer. Ag-chalcogenides are promising QDs with good biocompatibility. Ag₂S QDs are popular theranostic agents for imaging in near-infrared with PTT potential. However, theranostic applications of AgInS2 QDs emitting in the visible region and its PTT potential need to be explored. Here, we first present a simple synthesis of small, glutathione (GSH) coated AgInS₂ QDs with peak emission at 634 nm, 21% quantum yield, and excellent long-term stability without an inorganic shell. Ag2S-GSH QDs emitting in the near-infrared region (peak emission = 822 nm) were also produced. Both QDs were tagged with folic acid (FA) and conjugated with methotrexate (MTX). About 3-fold higher internalization of FA-tagged QDs by folate-receptor (FR) overexpressing HeLa cells than HT29 and A549 cells was observed. Delivery of MTX by QD-FA-MTX reduced the IC50 of the drug from 10 μg/mL to 2.5-5 μg/mL. MTX release was triggered at acidic pH, which was further enhanced with local temperature increase created by laser irradiation. Irradiation of AgInS₂-GSH QDs at 640 nm (300 mW) for 10 min, caused about 10 °C temperature increase but did not cause any thermal ablation of cells. On the other hand, Ag₂S-GSH-FA based PTT effectively and selectively killed HeLa cells with 10 min 808 nm laser irradiation via mostly necrosis with an IC₅₀ of 5 μg Ag/mL. Under the same conditions, IC₅₀ of MTX was reduced to 0.21 μg/mL if Ag₂S-GSH-FA.

Toxicity of different types of quantum dots to mammalian cells in vitro: An update review

Currently, there are a great quantity type of quantum dots (QDs) that has been developed by researchers. Depending on the core material, they can be roughly divided into cadmium, silver, indium, carbon and silicon QDs. And studies on the toxicity of QDs are also increasing rapidly, but in vivo tests in model animals fail to reach a consistent conclusion. Therefore, we review the literatures dealing with the cytotoxicity of QDs in mammalian cells in vitro. After a short summary of the application characteristics of five types of QDs, the fate of QDs in cells will be discussed, ranging from the uptake, transportation, sublocation and excretion. A substantial part of the review will be focused on in vitro toxicity, in which the type of QDs is combined with their adverse effect and toxic mechanism. Because of their different luminescent properties, different subcellular fate, and different degree of cytotoxicity, we provide an overview on the balance of optical stability and biocompatibility of QDs and give a short outlook on future direction of cytotoxicology of QDs.

Biomedical applications of dendritic fibrous nanosilica (DFNS): recent progress and challenges

Dendritic fibrous nanosilica (DFNS), with multi-component and hierarchically complex structures, has recently been receiving significant attention in various fields of nano-biomedicine. DFNS is an emerging class of mesoporous nanoparticles that has attracted great interest due to unique structures such as open three-dimensional dendritic superstructures with large pore channels and highly accessible internal surface areas. This overview aims to study the application of DFNS towards biomedical investigations. This review is divided into four main sections. Sections 1–3 are related to the synthesis and characterization of DFNS. The biomedical potential of DFNS, such as cell therapy, gene therapy, immune therapy, drug delivery, imaging, photothermal therapy, bioanalysis, biocatalysis, and tissue engineering, is discussed based on advantages and limitations. Finally, the perspectives and challenges in terms of controlled synthesis and potential nano-biomedical applications towards future studies are discussed.

Dendritic fibrous nanosilica (DFNS) , with multi-component and hierarchically complex structures, has recently been receiving significant attention in various fields of nano-biomedicine.

Ag2S-Glutathione quantum dots for NIR image guided photothermal therapy

Synthesis of ultrasmall, colloidally stable, biocompatible Ag₂S-gluthatione quantum dots for NIR image guided-long wavelength photothermal therapy agents.

Bypassing pro-survival and resistance mechanisms of autophagy in EGFR-positive lung cancer cells by targeted delivery of 5FU using theranostic Ag2S quantum dots

Targeted drug delivery systems that combine imaging and therapeutic functions in a single structure have become very popular in nanomedicine. Near-infrared (NIR) emitting Ag₂S quantum dots (QDs) are excellent candidates for this task. Here, we have developed PEGylated Ag₂S QDs functionalized with Cetuximab (Cet) antibody and loaded with an anticancer drug, 5-fluorouracil (5FU). These theranostic QDs were used for targeted NIR imaging and treatment of lung cancer using low (H1299) and high (A549) Epidermal Growth Factor Receptor (EGFR) overexpressing cell lines. The Cet conjugated QDs effectively and selectively delivered 5FU to A549 cells and provided significantly enhanced cell death associated with apoptosis. Interestingly, while treatment of cells with free 5FU activated autophagy, a cellular mechanism conferring resistance to cell death, these EGFR targeting multimodal QDs significantly overcame drug resistance compared to 5FU treatment alone. The improved therapeutic outcome of 5FU delivered to A549 cells by Cet conjugated Ag₂S QDs is suggested as the synergistic outcome of enhanced receptor mediated uptake of nanoparticles, and hence the drug, coupled with suppressed autophagy even in the absence of addition of an autophagy suppressor.

In vitro interaction of glutathione S-transferase-pi enzyme with glutathione-coated silver sulfide quantum dots: A novel method for biodetection of glutathione S-transferase enzyme

Quantum dots (QD) are being evaluated as inorganic nanoparticles for both in vitro and in vivo optical imaging. They are also used as sensors or vehicles for targeted drug delivery combined with optical imaging. In this study, we demonstrated that glutathione-coated Ag₂ S QDs (GSH-Ag₂ S QDs) act as a substrate analogue of glutathione S-transferase (GST) enzymes for the first time in the literature. The GSTs belong to a major group of detoxification enzymes involved in the detoxification metabolism responsible for the protection of cells against reactive oxygen species (ROS) or electrophiles. GST isozymes are impaired in the various diseases such as neurological diseases and cancer. We evaluated the interaction of GST-pi enzyme with GSH-Ag₂ S QDs, which have never been studied in the literature before, using both fluorometric and spectrophotometric methods. Our data showed that GSH-Ag₂ S QDs gave reaction with GST enzyme as a substrate analogue. In conclusion, our data may help to guide researchers for further development of sensing systems for GST activity which is impaired in various diseases including cancer.

Next-generation nanotheranostics targeting cancer stem cells

Cancer is depicted as the most aggressive malignancy and is one the major causes of death worldwide. It originates from immortal tumor-initiating cells called 'cancer stem cells' (CSCs). This devastating subpopulation exhibit potent self-renewal, proliferation and differentiation characteristics. Dynamic DNA repair mechanisms can sustain the immortality phenotype of cancer to evade all treatment strategies. To date, current conventional chemo- and radio-therapeutic strategies adopted against cancer fail in tackling CSCs. However, new advances in nanotechnology have paved the way for creating next-generation nanotheranostics as multifunctional smart 'all-in-one' nanoparticles. These particles integrate diagnostic, therapeutic and targeting agents into one single biocompatible and biodegradable carrier, opening up new avenues for breakthroughs in early detection, diagnosis and treatment of cancer through efficient targeting of CSCs.

Towards biocompatible NIR-II nanoprobes - transfer of hydrophobic Ag2S quantum dots to aqueous solutions using phase transfer catalysed hydrolysis of poly(maleic anhydride-alt-1-octadecene)

Development of protocols for transferring of hydrophobic quantum dots (QDs) into aqueous solution is of special importance for their biomedical applications. Particularly, hydrophilization of Ag₂S without quenching of photoluminescence is a great challenge. Application of standard protocol for amphiphilic polymer coating of hydrophobic Ag₂S nanocrystals failed, whereas ligand exchange and direct synthesis of Ag₂S in aqueous solution leads to poorly emitting materials. In this paper we present the facile method for transferring of hydrophobic Ag₂S QDs into aqueous solution employing the phase transfer catalysed hydrolysis of a commercially available polymer - poly(maleic anhydride-alt-1-octadecene), (PMAO) in the presence of tetramethylammonium hydroxide. Because the original surface ligands are retained and we do not use solvents (like THF) detrimental for Ag₂S emission, the modification does not deteriorate photoluminescence properties and quantum yield of modified QDs in aqueous solution reaches 60% of that for hydrophobic QDs in chloroform. The hydrodynamic diameter of modified, water soluble Ag₂S QDs is about 10 nm and is only slightly larger than their original size. Moreover, the polymer coated nanocrystals are not aggregated and are stable for months. Surface characterization of QDs by NMR and IR spectroscopy indicates that polymer chains intercalate alkyl chains of dodecanethiol (DDT) bound to the surface of Ag₂S. The cytotoxicity studies indicate that the presented method should be regarded as a notable progress towards the biocompatible Ag₂S NIR-II emitting nanoprobes.

Targeted Delivery of Nanoparticulate Cytochrome C into Glioma Cells Through the Proton-Coupled Folate Transporter

In this study, we identified the proton-coupled folate transporter (PCFT) as a route for targeted delivery of drugs to some gliomas. Using the techniques of confocal imaging, quantitative reverse transcription-polymerase chain reaction (qRT-PCR), and small interfering (siRNA) knockdown against the PCFT, we demonstrated that Gl261 and A172 glioma cells, but not U87 and primary cultured astrocytes, express the PCFT, which provides selective internalization of folic acid (FA)-conjugated cytochrome c-containing nanoparticles (FA-Cyt c NPs), followed by cell death. The FA-Cyt c NPs (100 µg/mL), had no cytotoxic effects in astrocytes but caused death in glioma cells, according to their level of expression of PCFT. Whole-cell patch clamp recording revealed FA-induced membrane currents in FA-Cyt c NPs-sensitive gliomas, that were reduced by siRNA PCFT knockdown in a similar manner as by application of FA-Cyt c NPs, indicating that the PCFT is a route for internalization of FA-conjugated NPs in these glioma cells. Analysis of human glioblastoma specimens revealed that at least 25% of glioblastomas express elevated level of either PCFT or folate receptor (FOLR1). We conclude that the PCFT provides a mechanism for targeted delivery of drugs to some gliomas as a starting point for the development of efficient methods for treating gliomas with high expression of PCFT and/or FOLR1.

Fluorescence Guidance in Surgical Oncology: Challenges, Opportunities, and Translation

Surgical resection continues to function as the primary treatment option for most solid tumors. However, the detection of cancerous tissue remains predominantly subjective and reliant on the expertise of the surgeon. Surgery that is guided by fluorescence imaging has shown clinical relevance as a new approach to detecting the primary tumor, tumor margins, and metastatic lymph nodes. It is a technique to reduce recurrence and increase the possibility of a curative resection. While significant progress has been made in developing this emerging technology as a tool to assist the surgeon, further improvements are still necessary. Refining imaging agents and tumor targeting strategies to be a precise and reliable surgical strategy is essential in order to translate this technology into patient care settings. This review seeks to provide a comprehensive update on the most recent progress of fluorescence-guided surgery and its translation into the clinic. By highlighting the current status and recent developments of fluorescence image-guided surgery in the field of surgical oncology, we aim to offer insight into the challenges and opportunities that require further investigation.

Efficacy of Surface-Modified PLGA Nanoparticles as a Function of Cervical Cancer Type

PURPOSE

Hypovascularization of cervical tumors, coupled with intrinsic and acquired drug resistance, has contributed to marginal therapeutic outcomes by hindering chemotherapeutic transport and efficacy. Recently, the heterogeneous penetration and distribution of cell penetrating peptide (CPP, here MPG) and polyethylene glycol (PEG) modified poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) were evaluated as a function of tumor type and morphology in cervical cancer spheroids modeling hypovascularized tumor nodules. Building upon this work, this study investigates the efficacy imparted by surface-modified Doxorubicin-loaded NPs transported into hypovascularized tissue.

METHODS

NP efficacy was measured in HeLa, CaSki, and SiHa cells. NP internalization and association, and associated cell viability, were determined in monolayer and spheroid models.

RESULTS

MPG and PEG-NP co-treatment was most efficacious in HeLa cells, while PEG NPs were most efficacious in CaSki cells. NP surface-modifications were unable to improve efficacy, relative to unmodified NPs, in SiHa cells.

CONCLUSIONS

The results highlight the dependence of efficacy on tumor type and the associated microenvironment. The results further relate previous NP transport studies to efficacy, as a function of surface-modification and cell type. Longer-term, this information may help guide the design of NP-mediated strategies to maximize efficacy based on patient-specific cervical tumor origin and characteristics.

Fluorescent Nanoparticles for the Guided Surgery of Ovarian Peritoneal Carcinomatosis

Complete surgical resection is the ideal cure for ovarian peritoneal carcinomatosis, but remains challenging. Fluorescent guided surgery can be a promising approach for precise cytoreduction when appropriate fluorophore is used. In the presence paper, we review already developed near- and short-wave infrared fluorescent nanoparticles, which are currently under investigation for peritoneal carcinomatosis fluorescence imaging. We also highlight the main ways to improve the safety of nanoparticles, for fulfilling prerequisites of clinical application.