Search Results (355)

Background: Protein substitutes are essential in the dietary management of phenylketonuria (PKU). Transition from first-stage phenylalanine (Phe)-free infant formula to second- and third-stage protein substitutes is carefully managed to meet a child’s evolving nutritional needs, feeding abilities, and developmental progression. However, clinical protocols, product access, and reimbursement vary globally. This study assessed international transition practices. Methods: A cross-sectional online survey explored health professionals’ practices on transition timing, influencing factors, product forms, casein-glycomacropeptide (cGMP) use, and perceived barriers and facilitators. Results: A total of 106 professionals from 32 countries participated: Europe (67%), Asia (12%), North America (10%), South America (8%), and Oceania (3%). Dietitians led transitions in 83% of centers. First-stage Phe-free infant formula was typically discontinued at 1–2 years (66%). Second-stage substitutes were introduced at 6–12 months in Europe (61%) and Oceania (100%), but after age one in Asia (69%), North America (72%), and South America (100%). Influencing factors included weaning alignment (46%) and nutritional needs (42%). Semi-solids were preferred in Europe (56%) and Oceania (67%), while powdered drinks dominated in Asia (62%), North America (82%), and South America (100%). Third-stage protein substitutes were introduced at 3–5 years (45%), with later transitions more common in South America (88%) and North America (63%). Ready-to-drink forms were frequent in Oceania (100%), Asia (92%), and Europe (85%). cGMP was prescribed by 61%, mainly guided by preference, Phe tolerance, and adherence; 26% reported no access. Key facilitators for transition included motivation (79%) and sensory properties (69%); barriers included aversion (70%) and poor taste/texture (69%). School involvement was reported by 32%. Conclusions: Protein substitute transition practices in PKU vary globally. International guidance and equitable product access are needed. Full article

Similarly to the short-lived messenger nitric oxide (NO), the more stable carbon monoxide (CO) molecule can also activate soluble guanylyl cyclase (sGC) to increase cGMP levels. However, CO-induced cGMP production is much less efficient. Using an accessible invertebrate model, we dissect a potential interaction between the canonical NO/sGC/cGMP and CO signalling pathways during development. The embryonic midgut of locusts is innervated by neurons that migrate in four discrete chains on its outer surface. Transcellular diffusing NO stimulates enteric neuron migration via cGMP signalling. The application of an NO donor results in virtually all enteric neurons being cGMP-immunoreactive while CO increases cGMP production only in approximately 33% of the migrating neurons. Cellular CO release appears to act as a slow down signal for motility. We quantify how CO specifically increases the interneuronal distance during chain migration. Moreover, time-lapse microscopy shows that CO reduces the directionality of the migrating neurons. These findings support the function of NO and CO as antagonistic signals for the coordination of collective cell migration during the development of the enteric nervous system. These experiments and the resulting insights into basic scientific questions prove once more that locust embryos are not only preparations for basic research, but also relevant models for screening of drugs targeting NO and CO signalling pathways as well as for isolating compounds affecting neuronal motility in general. Full article

The development of functional endothelial monolayers on synthetic vascular grafts remains challenging, particularly for small-diameter vessels (<6 mm) prone to thrombosis. Here, we present a pharmacological strategy combining 8-(4-chlorophenylthio) adenosine 3′,5′-cyclic monophosphate sodium salt (pCPT-cAMP, a tight junction promoter) with nitric oxide/cGMP pathway agonists 3-morpholinosydnonimine (SIN-1), captopril, and sildenafil) to enhance endothelialization. In human umbilical vein endothelial cells (HUVECs), this four-agent cocktail induced a flat, extended phenotype with a 3-fold increased cell area and 57.5% fewer cells required for surface coverage compared to controls. Immunofluorescence analysis revealed enhanced ZO-1 expression and continuous tight junction formation, while sustained nitric oxide (NO) production (3.9-fold increase) and restored prostacyclin (PGI₂) secretion demonstrated preserved endothelial functionality. Anticoagulation assays confirmed a significant reduction in thrombus formation (p < 0.01) via dual inhibition of platelet activation and thrombin binding. These findings establish a synergistic drug combination that promotes rapid endothelialization while maintaining antithrombogenic activity, offering a promising solution for small-diameter vascular grafts. Further studies should validate long-term stability and translational potential in preclinical models. Full article

Starting Active Materials for Synthesis (SAMS) represents a critical stage in drug manufacturing, directly influencing the microbiological quality and safety of the final product. The introduction of SAMS marks the point where Good Manufacturing Practices (GMP) begin to apply, which are essential for ensuring sterility and preventing microbial contamination during the synthesis process. However, defining the exact point in the process that qualifies as the SAMS is subject to uncertainties, as earlier stages are not always governed by stringent GMP standards. The regulatory differences between various countries further contribute to this issue. This study explores the implications of SAMS selection and use in relation to sterility and infection control, analyzing the guidelines of major Regulatory Authorities and comparing their approaches to GMP. Regulations from several international regulatory agencies were examined, with a particular focus on microbiological control measures and infection protection in the SAMS manufacturing process. The analysis focused on the microbiological control requirements and safety measures applicable to the stages preceding the introduction of SAMS into the production of the final Active Pharmaceutical Ingredients (APIs). Documents published between 2015 and 2025 were included based on predefined criteria regarding relevance, accessibility, and regulatory authority. The analysis revealed significant discrepancies between regulations regarding the definition and management of SAMS. In particular, the regulations in Mexico and India have notable gaps, failing to provide clear guidelines on SAMS sterility and protection against infectious contamination. Conversely, China has introduced risk-based approaches and early-stage microbiological controls, especially for sterile products, aligning with international standards. The European Medicines Agency (EMA), the U.S. Food and Drug Administration (FDA), the Pharmaceutical Inspection Co-operation Scheme (PIC/S), and the World Health Organization (WHO) have well-established systems for microbiological quality control of SAMS, including rigorous measures for the validation of suppliers and risk management to ensure that SAMS does not compromise the microbiological safety of the final product. The regulations in Brazil and Canada introduce additional measures to protect the microbiological quality of SAMS, with specifications for contamination control and certification of critical stages. The lack of a harmonized language for the definition of SAMS, coupled with a fragmented regulatory framework, presents a challenge for infection protection in pharmaceutical manufacturing. Key issues include the absence of specific regulations for stages prior to the introduction of SAMS and the lack of standards for inspections related to these stages. A desirable solution would be the mandatory extension of GMPs to the stages before SAMS introduction, with centralized control to ensure sterility and protection against infection throughout the entire manufacturing process. Full article

Integrating artificial intelligence (AI) and machine learning (ML) into pharmaceutical manufacturing processes holds great promise for enhancing efficiency, product quality, and regulatory compliance. However, implementing good manufacturing practices (GMP) in regulated environments introduces complex challenges related to validation, data integrity, risk management, and regulatory oversight. This review article comprehensively analyzes current regulatory frameworks and guidance for AI/ML in pharmaceutical Good Manufacturing Practice (GMP) settings, identifies gaps and uncertainties, and proposes considerations for future policy development. Emphasis is placed on understanding regulatory expectations across various agencies, including the US FDA, EMA, and MHRA. This article examines verified case studies and pilot programs that demonstrate the successful application of AI/ML under regulatory scrutiny, as well as recent developments in regulatory frameworks and implementation strategies. Ultimately, this article emphasizes the importance of a risk-based life cycle approach and the need for advancements in regulatory science to accommodate the dynamic nature of AI/ML technologies. Full article

Background: Recently, cyclic diguanylate monophosphate (c-di-GMP) drug delivery has garnered interest due to its potential in cancer immune modulation. In this pilot study, we developed a novel c-di-GMP formulation based on peptide amyloids. The amyloid depots were formed by combining an amyloidogenic prone 12 amino acid peptide sequence of receptor-interacting protein kinase 3 (RIP3) with cationic lipid ALC-0315, or using lysozyme proteins. Both RIP3 and lysozyme proteins have intrinsic physiological functions. This is the first time intrinsic peptides/protein-based amyloids have been explored for c-di-GMP delivery. The main goal was to evaluate how these amyloid depots could enhance c-di-GMP drug delivery and modulate responses in RAW 264.7 macrophage-like cells. Methods: Physicochemical characterization and cellular assays were utilized to characterize the amyloid structures and assess the efficacy. Results: Our results show that amyloid aggregates significantly improve the therapeutic efficacy of c-di-GMP. When RAW 264.7 cells were treated with c-di-GMP amyloids, we observed at least a 1.5-fold change in IL-6 expression, nitric oxide (NO) production, and reactive oxygen species (ROS) production compared to treatment with 5x free c-di-GMP treatment, which suggests that this system holds promise for enhanced therapeutic effects. Conclusions: Overall, these findings emphasize the potential of amyloid-based delivery systems as a promising approach for c-di-GMP delivery, warranting further investigations into their potential in therapeutic applications. Full article

Objective: Current good manufacturing practice (cGMP) guidance for positron emission tomography (PET) drugs has been established in Europe and the United States. In Japan, the Pharmaceuticals and Medical Devices Agency (PMDA) approved the use of radiosynthesizers as medical devices for the in-house manufacturing of PET drugs in hospitals and clinics, regardless of the cGMP environment. Without adequate facilities, equipment, and personnel required by cGMP regulations, the quality assurance (QA) and clinical effectiveness of PET drugs largely depend on the radiosynthesizers themselves. To bridge the gap between radiochemistry standardization and site qualification, the Japanese Society of Nuclear Medicine (JSNM) has issued guidance for the in-house manufacturing of small-scale PET drugs under academic GMP (a-GMP) environments. The goals of cGMP and a-GMP are different: cGMP focuses on process optimization, certification, and commercialization, while a-GMP facilitates the small-scale, in-house production of PET drugs for clinical trials and patient-specific standard of care. Among PET isotopes, N-13 has a short half-life (10 min) and must be synthesized on site. [¹³N]Ammonia ([¹³N]NH₃) is used for myocardial perfusion imaging under the Japan Health Insurance System (JHIS) and was thus selected as a working example for the manufacturing of PET drugs in an a-GMP environment. Methods: A [¹³N]NH₃-radiosynthesizer was installed in a hot cell within an a-GMP-compliant radiopharmacy unit. To comply with a-GMP regulations, the air flow was adjusted through HEPA filters. All cabinets and cells were disinfected to ensure sterility once a month. Standard operating procedures (SOPs) were applied, including analytical methods. Batch records, QA data, and radiation exposure to staff in the synthesis of [¹³N]NH₃ were measured and documented. Results: 2.52 GBq of [¹³N]NH₃ end-of-synthesis (EOS) was obtained in an average of 13.5 min in 15 production runs. The radiochemical purity was more than 99%. Exposure doses were 11 µSv for one production run and 22 µSv for two production runs. The pre-irradiation background dose rate was 0.12 µSv/h. After irradiation, the exposed dosage in the front of the hot cell was 0.15 µSv/h. The leakage dosage measured at the bench was 0.16 µSv/h. The exposure and leakage dosages in the manufacturing of [¹³N]NH₃ were similar to the background level as measured by radiation monitoring systems in an a-GMP environments. All QAs, environmental data, bacteria assays, and particulates met a-GMP compliance standards. Conclusions: In-house a-GMP environments require dedicated radiosynthesizers, documentation for batch records, validation schedules, radiation protection monitoring, air and particulate systems, and accountable personnel. In this study, the in-house manufacturing of [¹³N]NH₃ under a-GMP conditions was successfully demonstrated. These findings support the international harmonization of small-scale PET drug manufacturing in hospitals and clinics for future multi-center clinical trials and the development of a standard of care. Full article

Pharmaceutical production typically focuses on individual drug types for each production line, which limits flexibility. However, the emergence of Industry 4.0 technologies presents new opportunities for more adaptable and customized manufacturing processes. Despite this promise, the development of innovative design techniques for pharmaceutical production equipment remains incomplete. Manufacturers encounter challenges due to rapid innovation cycles while adhering to stringent Good Manufacturing Practice (GMP) standards. Our research addresses this issue by introducing an information model that organizes the design, development, and testing of pharmaceutical manufacturing equipment. This model is based on an exploratory review of 176 articles concerning design principles in regulated industries and integrates concepts from Axiomatic Design, Quality by Design, Model-Based Systems Engineering, and the V-Model framework. Further refinement was achieved through insights from 10 industry experts. The resultant workflow-based information model can be implemented as software to enhance engineering and project management. This research offers a structured framework that enables pharmaceutical equipment manufacturers and users to collaboratively develop solutions in an iterative manner, effectively closing the gap between industry needs and systematic design methodologies. Full article

Ascorbic acid (AsA) is an essential plant metabolite that acts primarily as an antioxidant, regulates cell division and elongation, and enhances stress tolerance. Despite its crucial physiological role, the biosynthesis of AsA in G. max, a major crop of significant commercial importance, remains largely unexplored. This gap highlights the need for a thorough investigation of AsA biosynthesis pathways and their role in optimizing the nutritional value and stress tolerance of soybeans. This study identified 41 key genes linked to four AsA biosynthesis pathways in G. max, highlighting specific gene duplications compared to Arabidopsis. Their expression levels were assessed by analyzing a diverse set of RNA-Seq data from the NCBI database. Additionally, to cross-validate the expression levels of genes and the accumulation levels of AsA in the principal tissues, G. max plants were grown under controlled conditions following the protocols from selected RNA-seq experiments. Genes associated with the D-mannose/L-galactose pathway exhibited ubiquitous expression, and the expression patterns of genes from alternative pathways reflected their responsiveness to specific tissues or environmental conditions. Germination and leaf development were accompanied by strong expression of gene members from all pathways, whereas leaf aging was characterized by downregulation. Specific gene members, such as GMP_2a (D-mannose/L-galactose pathway), GulLO_1f (L-gulose pathway), and MIOX_3a (Myo-inositol pathway) were highly stress-responsive and linked to stress-resistant genotypes and cultivars. Consistent with gene expression analyses, the quantification of AsA revealed the highest mass fractions in young leaves and germinating seeds. However, AsA mass fractions were significantly reduced or unchanged under stress conditions, depending on the type of stress and the duration of exposure. Overall, this study validated the relevance of AsA biosynthesis pathways in soybeans, highlighting key genes that could be targeted to enhance stress tolerance and improve ascorbate production, thereby boosting the nutritional value of soybeans. Full article

Yeast culture is widely used in ruminants to improve gut health, immunity, and productivity; however, its impact on meat quality remains unclear. This study aimed to investigate the effects of yeast culture supplementation in the basic diet on meat quality of Small-tail Han sheep. A total of 40 Small-tail Han sheep (17.5 ± 1.2 kg) were randomly assigned to two treatment groups, with 20 sheep in each group. The sheep were fed either a basic diet (CON) or the basic diet supplemented with 1% yeast culture (YSD) for 90 days. At the end of the trial, the Longissimus dorsi muscle (LOD) of the sheep was collected for meat quality evaluation, as well as transcriptome and metabolome analyses. Meat quality data were analyzed using t-tests, while transcriptome and metabolome data were analyzed using bioinformatics tools. The results showed that YSD supplementation significantly reduced carcass fat content (p < 0.05) and increased the pH values (p < 0.05) of LOD compared to the CON group. Multi-omics analysis revealed significant changes in the levels of 349 transcripts and 149 metabolites (p < 0.05) in the YSD group relative to the CON group. These changes were primarily associated with immune response pathways and purine metabolism. Further integrated transcriptomics and metabolomics analysis identified significant alterations in the expression of adenylate kinase 4 (AK4) and ribonucleotide reductase M2 (RRM2), which influenced purine metabolites, such as ADP, GMP, 3′-AMP, 3′-GMP, dGDP, adenine, guanosine, and guanine. These metabolites were markedly upregulated in the LOD of the sheep supplemented with yeast culture. In conclusion, yeast culture supplementation improved the meat quality of Small-tail Han sheep, potentially through the enhancement of immune response and purine metabolism. These findings offer valuable insights into the molecular mechanisms underlying the effects of yeast culture on animal health and meat quality. Full article

Background/Objectives: Fructose-1,6-bisphosphate (FBP) is an intermediate product of the glycolytic pathway with analgesic effect in acute inflammatory pain model via the production of adenosine. However, whether FBP is active in neuropathic pain is unknown. Therefore, we reason that it would be suitable to investigate the analgesic effect and mechanism of action of FBP in a model of chronic constriction injury (CCI) of sciatic nerve-induced neuropathic pain in mice. Methods: After CCI induction, mice received FBP, adenosine, A1 and/or A2A receptor antagonists, and/or inhibitors of the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP)/protein kinase G (PKG)/ATP sensitive K channels (KATP) signaling pathway. Results: FBP (up to 85%) and adenosine (up to 84%) inhibited the mechanical hyperalgesia (electronic aesthesiometer) induced by CCI with similar profiles. FBP analgesia was dependent on adenosine because adenosine A1 and A2A receptors antagonists diminished FPB activity (100% and 79%, respectively). FBP analgesia was also dependent on activating the NO/cGMP/PKG/KATP signaling pathway. Furthermore, FBP treatment increased the production of NO in cultured dorsal root ganglia (DRG) neurons (100% increase), whereas neuronal nitric oxide synthase (nNOS) inhibition decreased (up to 70%) the analgesic effect of FBP. We also observed that FBP reduced the calcium levels of transient receptor potential ankyrin 1 (TRPA1)⁺ DRG neurons (85%) and paw-flinching triggered by TRPA1 activation (38%). Conclusions: FBP reduced neuropathic pain by reducing DRG neuron activation. The mechanisms involved the activation of adenosine A1 and A2A receptors to trigger the analgesic NO/cGMP/PKG/KATP signaling pathway and reducing TRPA1⁺ DRG neuron activity. Full article

The dried root of Sanguisorba officinalis L. (commonly known as Diyu) has been studied for its various pharmacological effects, including its antibacterial, antitumor, antioxidant, and anti-inflammatory activities. In the present study, primary cultured vascular endothelial cells (HUVECs) and isolated phenylephrine-precontracted rat thoracic aortic rings were examined to investigate the possible mechanism of a butanol extract of Diyu (BSO) in its vascular relaxant effect. HUVECs treated with BSO produced a significantly higher amount of nitric oxide (NO) compared to the control. However, its production was inhibited by pretreatment with N^G-nitro-L-arginine methylester (L-NAME) or wortmannin. BSO also increased the phosphorylation levels of endothelial nitric oxide synthase (eNOS) and Akt. In the aortic ring, BSO relaxed PE-precontracted rat thoracic aortic rings in a concentration-dependent manner. The absence of the vascular endothelium significantly attenuated BSO-induced vasorelaxation. The non-selective NOS inhibitor, L-NAME, and the selective inhibitor of soluble guanylyl cyclase (sGC), 1H-[1,2,4]-oxadiazolo-[4,3-α]-quinoxalin-1-one (ODQ), dramatically inhibited the BSO-induced relaxation effect of the endothelium-intact aortic ring. Ca²⁺-free buffer and intracellular Ca²⁺ homeostasis regulators (TG, Gd³⁺, and 2–APB) inhibited BSO-induced vasorelaxation. In Ca²⁺-free Krebs solution, BSO markedly reduced PE-induced contraction. Vasodilation induced by BSO was significantly inhibited by wortmannin, an inhibitor of Akt. Pretreatment with the non-selective inhibitor of Ca²⁺-activated K⁺ channels (K_Ca), tetraethylammonium (TEA), significantly attenuated the BSO-induced vasorelaxant effect. Furthermore, BSO decreased the systolic blood pressure and heart rate in a concentration-dependent manner in rats. In conclusion, BSO induces vasorelaxation via endothelium-dependent signaling, primarily through the activation of the PI3K-Akt-eNOS-NO signaling pathway in endothelial cells, and the activation of the NO-sGC-cGMP-K⁺ channels pathway in vascular smooth muscle cells. Additionally, store-operated Ca²⁺ entry (SOCE)-eNOS pathways and the inhibition of Ca²⁺ mobilization from intracellular stores contribute to BSO-induced vasorelaxation. Full article

Background: While gallium-68 has traditionally dominated PET imaging in oncology, copper radionuclides have sparked interest for their potential applications in nuclear medicine and theranostics. Considering the advantageous physical decay properties of copper-61 compared to those of gallium-68, we describe a fully automated GMP-compliant synthesis process for ⁶¹Cu-based radiopharmaceuticals and demonstrate their in vivo application for targeting the overexpressed PSMA by PET/MR imaging. Methods: Copper-61 was obtained through the irradiation of natural zinc liquid targets in a biomedical cyclotron. [⁶¹Cu]Cu-DOTAGA-PSMA-I&T and [⁶¹Cu]Cu-NODAGA-PSMA-I&T were produced without manual intervention in two Synthera^® Extension modules. Radiochemical purity was analyzed by radio-HPLC and iTLC. Cellular uptake was evaluated in LNCaP and DU145 cells. In vivo PET/MRI was performed in control mice to evaluate the biodistribution of both radiopharmaceuticals, and in tumor-bearing mice to assess the targeting ability towards PSMA. Results: The fully automated process developed proved to be effective for the synthesis of ⁶¹Cu-based radiopharmaceuticals, with appropriate molar activities. The final products exhibited high radiochemical purity (>98%) and remained stable for up to 6 h after the EOS. A time-dependent increase in cellular uptake was observed in LNCaP cells, but not in DU145 cells. As opposed to [⁶¹Cu]Cu-NODAGA-PSMA-I&T, [⁶¹Cu]Cu-DOTAGA-PSMA-I&T exhibited poor kinetic stability in vivo. Subsequent PET/MR imaging with [⁶¹Cu]Cu-NODAGA-PSMA-I&T showed tumor uptake lasting up to 4 h post-injection, predominant renal clearance, and no detectable accumulation in non-targeted organs. Conclusions: These results demonstrate the feasibility of the implemented process, which yields adequate amounts of high-quality radiopharmaceuticals and can be adapted to any standard production facility. This streamlined approach enhances reproducibility and scalability, bringing copper-61 closer to widespread clinical use, to the detriment of the conventionally accepted gallium-68. Full article

Background/Objectives: Ambroxol hydrochloride (AMB) is a promising chaperone for treating neurological manifestations in Gaucher disease type 3 (GD3). The Amsterdam University Medical Center planned to conduct an n-of-1 clinical trial using high-dose AMB (25 mg/kg/day). As an adequate commercial AMB formulation is unavailable for this high target dosage, we aimed to develop high-dose AMB capsules and assess the formulated capsule’s quality. Methods: AMB API was sourced and tested according to the requirements of the European Pharmacopoeia. Capsule formulations of 75 mg and 200 mg AMB were developed. Drug product specifications were set following international guidelines (ICH Q6A) and the European Pharmacopoeia. Analytical methods were developed and validated, and three validation batches of each capsule strength were produced and analyzed. Results: The contents and the Acceptance Values (AVs) of the initial AMB batches (both strengths) varied between 89.1% to 92.7% (specification: 90% to 110%) and 12.4 to 17.6 (specification ≤ 15.0), respectively, indicating non-uniform AMB distribution. Consequently, the production of 200 mg capsules was discontinued, and modifications were made to the 75 mg capsule formulation, followed by the production of three optimized 75 mg validation batches. These batches met the specified criteria, with an AMB content and AV values ranging from 93.9% to 96.5% and 12.4 to 14.9, respectively. Furthermore, rapid dissolution profiles were observed (>80% dissolution within 15 min). No degradation products or microbiological impurities were detected after production. Conclusions: The optimized formulation of 75 mg AMB capsules formulated within the hospital pharmacy setting resulted in qualitative and uniform capsules which can be used in clinical trials. Full article

Nicotinic acetylcholine receptor (α7-nAChR) plays a crucial role in cognitive functions like memory and attention. Positron emission tomography (PET) imaging of α7-nAChR is gaining attraction for understanding and monitoring central nervous system disorders, such as Alzheimer’s disease, Parkinson’s disease, and schizophrenia. We developed [¹¹C]KIn83, a novel α7-nAChR radioligand, and evaluated its biological properties. This study focused on two objectives: (1) to validate its Good Manufacturing Practice (GMP)-compliant production, and (2) to assess the dosimetry of [¹¹C]KIn83 using non-human primate (NHP) whole-body PET data. Radiolabeling and drug product delivery of [¹¹C]KIn83 were conducted using an automated synthesis module within a controlled GMP environment. The quality control tests performed adhered to the European Pharmacopoeia guidelines. The production of [¹¹C]KIn83 was validated according to GMP standards, encompassing automated synthesis and quality control measures. For the dosimetry assessment, two female cynomolgus monkeys underwent whole-body PET scans. The radioactivity values injected for [¹¹C]KIn83 were 150 MBq and 155 MBq, respectively, with an estimated radiation dose of 0.0047 mSv/MBq. Our findings pave the way for future clinical studies that investigate the potential of [¹¹C]KIn83 to measure α7-nAChR, aiding our understanding and possibly supporting diagnoses of different cognitive disorders. Full article