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Ayyappan K, Unger L, Kitchen P, Bill RM, Salman MM. Measuring glymphatic function: Assessing the toolkit. Neural Regen Res 2026; 21:534-541. [PMID: 40145955 DOI: 10.4103/nrr.nrr-d-24-01013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Accepted: 01/27/2025] [Indexed: 03/28/2025] Open
Abstract
Glymphatic flow has been proposed to clear brain waste while we sleep. Cerebrospinal fluid moves from periarterial to perivenous spaces through the parenchyma, with subsequent cerebrospinal fluid drainage to dural lymphatics. Glymphatic disruption is associated with neurological conditions such as Alzheimer's disease and traumatic brain injury. Therefore, investigating its structure and function may improve understanding of pathophysiology. The recent controversy on whether glymphatic flow increases or decreases during sleep demonstrates that the glymphatic hypothesis remains contentious. However, discrepancies between different studies could be due to limitations of the specific techniques used and confounding factors. Here, we review the methods used to study glymphatic function and provide a toolkit from which researchers can choose. We conclude that tracer analysis has been useful, ex vivo techniques are unreliable, and in vivo imaging is still limited. Finally, we explore the potential for future methods and highlight the need for in vitro models, such as microfluidic devices, which may address technique limitations and enable progression of the field.
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Affiliation(s)
- Koushikk Ayyappan
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Lucas Unger
- College of Health and Life Sciences, Aston University, Birmingham, UK
- Aston Institute for Membrane Excellence and the School of Biosciences, Aston University, Birmingham, UK
| | - Philip Kitchen
- College of Health and Life Sciences, Aston University, Birmingham, UK
- Aston Institute for Membrane Excellence and the School of Biosciences, Aston University, Birmingham, UK
| | - Roslyn M Bill
- College of Health and Life Sciences, Aston University, Birmingham, UK
- Aston Institute for Membrane Excellence and the School of Biosciences, Aston University, Birmingham, UK
| | - Mootaz M Salman
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
- BHF Oxford Centre of Research Excellence, University of Oxford, Oxford, UK
- Kavli Institute for NanoScience Discovery, University of Oxford, Oxford, UK
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2
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Zeng S, Liu L, Cheng Q, Chen W, Wang M, Wu M, Wang Z, Du J, Xiang R, Qi Q, Jia T. Novel Mitochondria-Targeted Asymmetric Heptamethine Cyanine Dye for Cancer Targeted NIR Imaging and Potent Necrosis and Senescence Induction with Prolonged Retention. J Med Chem 2025; 68:8174-8189. [PMID: 40211757 DOI: 10.1021/acs.jmedchem.4c02879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2025]
Abstract
Developing small molecules that inherently integrate highly tumor-targeted near-infrared fluorescence (NIRF) imaging with potent therapeutic effects remains challenging in anticancer theranostics. Here, we synthesized and characterized a series of heptamethine cyanine PSs with symmetric and asymmetric structures. Among them, we first discovered that asymmetric structures significantly enhanced tumor targeting. Also, a novel mitochondria-targeted asymmetric compound 17 exhibited superior NIRF imaging capability, exceptional tumor selectivity (TNR = 8.54), and strong antitumor activity. Compound 17 selectively accumulates in mitochondria, driven by MMP, where it generates ROS, induces DNA damage, and triggers senescence, apoptosis, and necrosis. Its strong therapeutic efficacy was demonstrated across multiple models, including patient-derived xenograft (PDX), where it allowed precise tumor visualization, significantly suppressed tumor growth with a single administration, and showed no detectable toxicity. Notably, the single-dye small molecule 17 was retained in tumors for over 120 h, enabling prolonged imaging, targeted therapy, and drug delivery for integrated antitumor treatment.
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Affiliation(s)
- Siyi Zeng
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Linxia Liu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Qi Cheng
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Wanlei Chen
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Maolin Wang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Mingxia Wu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Zhu Wang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Junrong Du
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Run Xiang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu 610041, China
| | - Qingrong Qi
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Tao Jia
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
- NHC Key Laboratory of Nuclear Technology Medical Transformation (Mianyang Central Hospital), Mianyang 621000, China
- Sichuan Provincial Engineering Research Center of Nuclear Medical Equipment Translation and Application (Mianyang Central Hospital), Mianyang 621000, China
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Hu Z, Bao Y, Li X, Li Z, Teng P, Liu G, Wang Z. PD-L1 blockade peptide-functionalized NaGdF 4 nanodots for efficient magnetic resonance imaging-guided immunotherapy for breast cancer. RSC Adv 2025; 15:9027-9033. [PMID: 40134683 PMCID: PMC11934231 DOI: 10.1039/d4ra08800j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Accepted: 03/09/2025] [Indexed: 03/27/2025] Open
Abstract
Immune checkpoint blockade (ICB) inhibitors have shown great promise for the treatment of numerous types of cancers, including triple-negative breast cancer (TNBC), by interrupting immunosuppressive checkpoints. Herein, programmed cell death ligand 1 (PD-L1) blockade peptide-functionalized NaGdF4 nanodots (designated as PDL1-NaGdF4 NDs) were prepared for magnetic resonance imaging (MRI)-guided TNBC immunotherapy through covalent conjugation of the PD-L1 blockade peptide (sequence, CALNNCVRARTR) with tryptone-capped NaGdF4 NDs (designated as Try-NaGdF4 NDs). MDA-MB-231 tumor could be easily tracked using in vivo MRI with PDL1-NaGdF4 ND enhancement because the as-prepared PDL1-NaGdF4 NDs have a high longitudinal relaxivity (r 1) value (22.8 mM-1 S-1) and accumulate in the tumor site through binding with programmed cell death ligand-1 (PD-L1)-overexpressed cells. A series of in vitro/in vivo results demonstrated that the PDL1-NaGdF4 NDs could effectively suppress MDA-MB-231 tumor growth in mice (66% volume ratio) by inhibiting migration and proliferation of tumor cells. In addition, the results of pharmacokinetic study showed that the PDL1-NaGdF4 NDs were excreted from the body through the kidneys. These results highlight the potential of PDL1-NaGdF4 NDs as a biocompatible nanomedicine for TNBC diagnosis and immunotherapy.
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Affiliation(s)
- Zhenzhen Hu
- Department of Radiology, China-Japan Union Hospital of Jilin University Changchun 130033 P. R. China
| | - Yunkai Bao
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun 130022 P. R. China
| | - Xiaodong Li
- Department of Radiology, China-Japan Union Hospital of Jilin University Changchun 130033 P. R. China
| | - Zhuheng Li
- Jilin Provincial Institute of Education Changchun 130024 P. R. China
| | - Peihong Teng
- Department of Radiology, China-Japan Union Hospital of Jilin University Changchun 130033 P. R. China
| | - Guifeng Liu
- Department of Radiology, China-Japan Union Hospital of Jilin University Changchun 130033 P. R. China
| | - Zhenxin Wang
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun 130022 P. R. China
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Yuan Y, Gao H, Jiang S, You Q, Zhou J, Chen J. Magnetic resonance imaging contrast agents based on albumin nanoparticles. Biomater Sci 2025; 13:408-421. [PMID: 39663837 DOI: 10.1039/d4bm01226g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2024]
Abstract
Despite the potential safety hazards and side effects, small molecular magnetic resonance imaging (MRI) contrast agents have been generally used in clinical medical imaging. The development of stable, but low-toxicity and high-efficiency magnetic resonance contrast agents has been receiving continuous attention and research interest. With the deepening of studies, the combination of small molecular magnetic resonance contrast agents and albumin-based carriers is an effective strategy to obtain new MRI contrast agents with safety, low toxicity, high relaxation efficiency and targeting capability. In particular, the relaxivity values of some albumin-based nano-magnetic resonance contrast agents are greater than 100 mM-1 s-1, which is much higher than the relaxivity values of some small molecule MRI contrast agents. Therefore, herein, current research on albumin nanoparticle related MRI contrast agents is summarized, which is of great significance for clarifying the development direction of contrast agents.
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Affiliation(s)
- Yuan Yuan
- Wuxi Maternity and Child Health Care Hospital, Affiliated Women's Hospital of Jiangnan University, Wuxi, 214002, China
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China.
| | - Hui Gao
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China.
| | - Sunmin Jiang
- Wuxi Maternity and Child Health Care Hospital, Affiliated Women's Hospital of Jiangnan University, Wuxi, 214002, China
| | - Qingjun You
- Wuxi School of Medicine, Jiangnan University, Wuxi, 214122, China
| | - Juan Zhou
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China.
| | - Jinghua Chen
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China.
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Wu L, Lu X, Lu Y, Shi M, Guo S, Feng J, Yang S, Xiong W, Xu Y, Yan C, Shen Z. Kilogram-Scale Synthesis of Extremely Small Gadolinium Oxide Nanoparticles as a T 1-Weighted Contrast Agent for Magnetic Resonance Imaging. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2308547. [PMID: 37988646 DOI: 10.1002/smll.202308547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/31/2023] [Indexed: 11/23/2023]
Abstract
Magnetic resonance imaging contrast agents are frequently used in clinics to enhance the contrast between diseased and normal tissues. The previously reported poly(acrylic acid) stabilized exceedingly small gadolinium oxide nanoparticles (ES-GdON-PAA) overcame the problems of commercial Gd chelates, but limitations still exist, i.e., high r2/r1 ratio, long blood circulation half-life, and no data for large scale synthesis and formulation optimization. In this study, polymaleic acid (PMA) is found to be an ideal stabilizer to synthesize ES-GdONs. Compared with ES-GdON-PAA, the PMA-stabilized ES-GdON (ES-GdON-PMA) has a lower r2/r1 ratio (2.05, 7.0 T) and a lower blood circulation half-life (37.51 min). The optimized ES-GdON-PMA-9 has an exceedingly small particle size (2.1 nm), excellent water dispersibility, and stability. A facile, efficient, and environmental friendly synthetic method is developed for large-scale synthesis of the ES-GdONs-PMA. The weight of the optimized freeze-dried ES-GdON-PMA-26 synthesized in a 20 L of reactor reaches the kilogram level. The formulation optimization is also finished, and the concentrated ES-GdON-PMA-26 formulation (CGd = 100 mm) after high-pressure steam sterilization possesses eligible physicochemical properties (i.e., pH value, osmolality, viscosity, and density) for investigational new drug application.
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Affiliation(s)
- Lihe Wu
- School of Biomedical Engineering, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Xuanyi Lu
- School of Biomedical Engineering, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Yudie Lu
- School of Biomedical Engineering, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Meng Shi
- School of Biomedical Engineering, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Shuai Guo
- School of Biomedical Engineering, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Jie Feng
- Medical Imaging Center, Nanfang Hospital, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Sugeun Yang
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, Incheon, 22212, South Korea
| | - Wei Xiong
- Medical Imaging Center, Nanfang Hospital, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Yikai Xu
- Medical Imaging Center, Nanfang Hospital, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Chenggong Yan
- Medical Imaging Center, Nanfang Hospital, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
| | - Zheyu Shen
- School of Biomedical Engineering, Southern Medical University, 1023 Shatai South Road, Baiyun, Guangzhou, Guangdong, 510515, China
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Gu Y, Fan C, Yang H, Sun H, Wang X, Qiu X, Chen B, Li CM, Guo C. Fluorogenic RNA Aptamer-Based Amplification and Transcription Strategy for Label-free Sensing of Methyltransferase Activity in Complex Matrixes. Adv Biol (Weinh) 2024; 8:e2300668. [PMID: 38327153 DOI: 10.1002/adbi.202300668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Indexed: 02/09/2024]
Abstract
DNA methyltransferase is significant in cellular activities and gene expression, and its aberrant expression is closely linked to various cancers during initiation and progression. Currently, there is a great demand for reliable and label-free techniques for DNA methyltransferase evaluation in tumor diagnosis and cancer therapy. Herein, a low-background fluorescent RNA aptamer-based sensing approach for label-free quantification of cytosine-guanine (CpG) dinucleotides methyltransferase (M.SssI) is reported. The fluorogenic light-up RNA aptamers-based strategy exhibits high selectivity via restriction endonuclease, padlock-based recognition, and RNA transcription. By combining rolling circle amplification (RCA), and RNA transcription with fluorescence response of RNA aptamers of Spinach-dye compound, the proposed platform exhibited efficiently ultrahigh sensitivity toward M.SssI. Eventually, the detection can be achieved in a linear range of 0.02-100 U mL-1 with a detection limit of 1.6 × 10-3 U mL-1. Owing to these superior features, the method is further applied in serum samples spiked M.SssI, which delivers a recovery ranging from 92.0 to 107.0% and a relative standard deviation <7.0%, providing a promising and practical tool for determining M.SssI in complex biological matrices.
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Affiliation(s)
- Yu Gu
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Cunxia Fan
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Hongbin Yang
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Huiping Sun
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Xiaobao Wang
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Xingchen Qiu
- School of Environmental Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Bo Chen
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
- Jiangsu Key Laboratory for Biomaterials and Devices, Department of Biological Science and Medical Engineering, Southeast University, Nanjing, 210009, P. R. China
| | - Chang-Ming Li
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
| | - Chunxian Guo
- Institute for Materials Science and Devices, School of Materials Science and Engineering, Suzhou University of Science and Technology, Kerui Road, Suzhou, 215009, P.R. China
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Batarchuk V, Shepelytskyi Y, Grynko V, Kovacs AH, Hodgson A, Rodriguez K, Aldossary R, Talwar T, Hasselbrink C, Ruset IC, DeBoef B, Albert MS. Hyperpolarized Xenon-129 Chemical Exchange Saturation Transfer (HyperCEST) Molecular Imaging: Achievements and Future Challenges. Int J Mol Sci 2024; 25:1939. [PMID: 38339217 PMCID: PMC10856220 DOI: 10.3390/ijms25031939] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Molecular magnetic resonance imaging (MRI) is an emerging field that is set to revolutionize our perspective of disease diagnosis, treatment efficacy monitoring, and precision medicine in full concordance with personalized medicine. A wide range of hyperpolarized (HP) 129Xe biosensors have been recently developed, demonstrating their potential applications in molecular settings, and achieving notable success within in vitro studies. The favorable nuclear magnetic resonance properties of 129Xe, coupled with its non-toxic nature, high solubility in biological tissues, and capacity to dissolve in blood and diffuse across membranes, highlight its superior role for applications in molecular MRI settings. The incorporation of reporters that combine signal enhancement from both hyperpolarized 129Xe and chemical exchange saturation transfer holds the potential to address the primary limitation of low sensitivity observed in conventional MRI. This review provides a summary of the various applications of HP 129Xe biosensors developed over the last decade, specifically highlighting their use in MRI. Moreover, this paper addresses the evolution of in vivo applications of HP 129Xe, discussing its potential transition into clinical settings.
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Affiliation(s)
- Viktoriia Batarchuk
- Chemistry Department, Lakehead University, Thunder Bay, ON P7B 5E1, Canada; (V.B.)
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
| | - Yurii Shepelytskyi
- Chemistry Department, Lakehead University, Thunder Bay, ON P7B 5E1, Canada; (V.B.)
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
| | - Vira Grynko
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
- Chemistry and Materials Science Program, Lakehead University, Thunder Bay, ON P7B 5E1, Canada
| | - Antal Halen Kovacs
- Applied Life Science Program, Lakehead University, Thunder Bay, ON P7B 5E1, Canada
| | - Aaron Hodgson
- Physics Program, Lakehead University, Thunder Bay, ON P7B 5E1, Canada
| | - Karla Rodriguez
- Chemistry Department, Lakehead University, Thunder Bay, ON P7B 5E1, Canada; (V.B.)
| | - Ruba Aldossary
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
| | - Tanu Talwar
- Chemistry Department, Lakehead University, Thunder Bay, ON P7B 5E1, Canada; (V.B.)
| | - Carson Hasselbrink
- Chemistry & Biochemistry Department, California Polytechnic State University, San Luis Obispo, CA 93407-005, USA
| | | | - Brenton DeBoef
- Department of Chemistry, University of Rhode Island, Kingston, RI 02881, USA
| | - Mitchell S. Albert
- Chemistry Department, Lakehead University, Thunder Bay, ON P7B 5E1, Canada; (V.B.)
- Thunder Bay Regional Health Research Institute, Thunder Bay, ON P7B 6V4, Canada
- Faculty of Medical Sciences, Northern Ontario School of Medicine, Thunder Bay, ON P7B 5E1, Canada
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