Imaging Of Bacterial Infections Research Articles

Noninvasive Imaging of Stored Red Blood Cell-Transfusion Aggravating Sepsis-Induced Liver Injury Associated with Increased Activation of M1-Polarized Kupffer Cells.

Liver injury has a critical effect on the severity and outcome of sepsis. The impact of stored red blood cells (RBCs) on the pathogenesis of sepsis-associated hepatic injury is not well understood. Therefore, to investigate the effects of stored-RBC transfusion on sepsis-induced liver damage as well as the associated mechanism, we constructed a sepsis mouse model enabling noninvasive imaging of bacterial infection caused by Pseudomonas aeruginosa, a common gram-negative respiratory pathogen. We showed that transfusions with stored RBCs enhanced sepsis-induced liver injury in vivo, and liver injury exacerbated the severity of sepsis and decreased survival in P aeruginosa-infected mice. Stored-RBC transfusions enhanced the production of proinflammatory cytokines such as tumor necrosis factor (TNF)-α, interleukin 6 (IL-6), and IL-1β, which play important roles in sepsis-associated liver injury in P aeruginosa-infected mice. Further study showed that the enhanced inflammation observed was associated with increased activation of M1-polarized Kupffer cells, which produce many inflammatory cytokines, including TNF-α and IL-6. Moreover, the M1-polarized Kupffer cells and secreted proinflammatory cytokines exerted their effects on hepatocytes through enhanced Jun N-terminal kinase activation and inhibited nuclear factor-kappaB activation, demonstrating that transfusion with stored RBCs disrupted the balance between cell survival and cell death in the liver. Understanding the mechanisms whereby stored RBCs might contribute to these complications will likely be helpful in providing guidance toward making transfusions safer.

Validation of 2-18F-Fluorodeoxysorbitol as a Potential Radiopharmaceutical for Imaging Bacterial Infection in the Lung.

2-18F-fluorodeoxysorbitol (18F-FDS) has been shown to be a promising agent with high selectivity and sensitivity in imaging bacterial infection. The objective of our study was to validate 18F-FDS as a potential radiopharmaceutical for imaging bacterial infection longitudinally in the lung. Methods: Albino C57 female mice were intratracheally inoculated with either live or dead Klebsiella pneumoniae to induce either lung infection or lung inflammation. One group of mice was imaged to monitor disease progression. PET/CT was performed on days 0, 1, 2, and 3 after inoculation using either 18F-FDS or 18F-FDG (n = 12 for each tracer). The other group was first screened by bioluminescent imaging (BLI) to select only mice with visible infection (region of interest > 108 ph/s) for PET/CT imaging with 18F-FDS (n = 12). For the inflammation group, 5 mice each were imaged with PET/CT using either 18F-FDS or 18F-FDG from days 1 to 4 after inoculation. Results: For studies of disease progression, BLI showed noticeable lung infection on day 2 after inoculation and significantly greater infection on day 3. Baseline imaging before inoculation showed no focal areas of lung consolidation on CT and low uptake in the lung for both PET radiotracers. On day 2, an area of lung consolidation was identified on CT, with a corresponding 2.5-fold increase over baseline for both PET radiotracers. On day 3, widespread areas of patchy lung consolidation were found on CT, with a drastic increase in uptake for both 18F-FDS and 18F-FDG (9.2 and 3.9). PET and BLI studies showed a marginal correlation between 18F-FDG uptake and colony-forming units (r = 0.63) but a much better correlation for 18F-FDS (r = 0.85). The uptake ratio of infected lung over inflamed lung was 8.5 and 1.7 for 18F-FDS and 18F-FDG on day 3. Conclusion: Uptake of both 18F-FDS and 18F-FDG in infected lung could be used to track the degree of bacterial infection measured by BLI, with a minimum detection limit of 107 bacteria. 18F-FDS, however, is more specific than 18F-FDG in differentiating K. pneumoniae lung infection from lung inflammation.

Bacterial infection imaging with [18F]fluoropropyl-trimethoprim

There is often overlap in the diagnostic features of common pathologic processes such as infection, sterile inflammation, and cancer both clinically and using conventional imaging techniques. Here, we report the development of a positron emission tomography probe for live bacterial infection based on the small-molecule antibiotic trimethoprim (TMP). [18F]fluoropropyl-trimethoprim, or [18F]FPTMP, shows a greater than 100-fold increased uptake in vitro in live bacteria (Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa) relative to controls. In a rodent myositis model, [18F]FPTMP identified live bacterial infection without demonstrating confounding increased signal in the same animal from other etiologies including chemical inflammation (turpentine) and cancer (breast carcinoma). Additionally, the biodistribution of [18F]FPTMP in a nonhuman primate shows low background in many important tissues that may be sites of infection such as the lungs and soft tissues. These results suggest that [18F]FPTMP could be a broadly useful agent for the sensitive and specific imaging of bacterial infection with strong translational potential.

Multivalent Siderophore-DOTAM Conjugates as Theranostics for Imaging and Treatment of Bacterial Infections.

There is a strong need to better diagnose infections at deep body sites through noninvasive molecular imaging methods. Herein, we describe the synthesis and characterization of probes based on siderophore conjugates with catechol moieties and a central DOTAM scaffold. The probes can accommodate a metal ion as well as an antibiotic moiety and are therefore suited for theranostic purposes. The translocation of the conjugates across the outer and inner cell membranes of E. coli was confirmed by growth recovery experiments with enterobactin-deficient strains, by the antibacterial activity of ampicillin conjugates, and by confocal imaging using a fluorogen-activating protein-malachite green system adapted to E. coli. The suitability of the probes for in vivo imaging was demonstrated with a Cy5.5 conjugate in mice infected with P. aeruginosa.

67Ga-labeled deferoxamine derivatives for imaging bacterial infection: Preparation and screening of functionalized siderophore complexes

IntroductionDeferoxamine (DFO) is a siderophore that bacteria use to scavenge iron and could serve as a targeting vector to image bacterial infection where current techniques have critical limitations. [67Ga]-DFO, which is a mimetic of the corresponding iron complex, is taken up by bacteria in culture, however in vivo it clears too rapidly to allow for imaging of infection. In response, we developed several new DFO derivatives to identify those that accumulate in bacteria, and at sites of infection, and that could potentially have improved pharmacokinetics. MethodsA library of DFO derivatives was synthesized by functionalizing the terminal amine group of DFO using three different carbamate-forming reactions. Uptake of [67Ga]-DFO and the 67Ga-labeled derivatives by bacteria and the biodistribution of lead compounds were studied. Results67Ga-labeled DFO derivatives were prepared and isolated in >90% radiochemical yield and >95% radiochemical purity. The derivatives had significant but slower uptake rates in Staphylococcus aureus than [67Ga]-DFO (6% to 60% of the control rate), with no uptake for the most lipophilic derivatives. Biodistribution studies in mice with a S. aureus infection in one thigh revealed that the ethyl carbamate derivative had an excellent infected-to-non-infected ratio (11:1), but high non-specific localization in the gall bladder, liver and small intestine. ConclusionsThe work reported shows that it is possible to functionalize DFO-type siderophores and retain active uptake of the 67Ga-labeled complexes by bacteria. Novel 67Ga-labeled DFO derivatives were specifically taken up by S. aureus and selected derivatives demonstrated in vivo localization at sites of infection. Advances in knowledge and implications for patient care67Ga-labeled DFO derivatives were actively transported by bacteria using the iron-siderophore pathway, suggesting that it is possible to develop siderophore-based radiopharmaceuticals for imaging bacterial infection.

Synthesis, in vitro evaluation, and 68 Ga-radiolabeling of CDP1 toward PET/CT imaging of bacterial infection.

Bacterial infections are a major concern in the human health sector due to poor diagnosis and development of multidrug-resistant strains. PET/CT provides a means for the non-invasive detection and localization of the infectious foci; however, the radiotracers available are either cumbersome to prepare or their exact contribution toward the imaging is not yet established. Human antimicrobial peptides are of interest for development as PET radiotracers as they are an integral component of the immune system, non-immunogenic toward the recipient, and show selectivity toward pathogens such as bacteria. Herein we report on the potential of LL37, a human cathelicidin antimicrobial peptide, as a radiotracer for bacterial imaging. Bifunctional chelator 1,4,7-triazacyclononane,1-glutaric acid-4,7-acetic acid was utilized to functionalize the antimicrobial peptide, which in turn was capable of chelating gallium. The synthesized nat Ga-CDP1 showed bacterial selectivity and low affinity toward hepatic cells, which are favorable characteristics for further preclinical application.

Dual Fluorescent- and Isotopic-Labelled Self-Assembling Vancomycin for in vivo Imaging of Bacterial Infections.

The increase of bacterial resistance demands rapid and accurate diagnosis of bacterial infections. Biosurface-induced supramolecular assembly for diagnosis and therapy has received little attention in detecting bacterial infections. Herein we present a dual fluorescent-nuclear probe based on self-assembly of vancomycin (Van) on Gram-positive bacteria for imaging bacterial infection. A Van- and rhodamine-modified peptide derivative (Rho-FF-Van), as the imaging agent, binds to the terminal peptide of the methicillin-resistant staphylococcus aureus (MRSA) and self-assembles to form nanoaggregates on the surface of MRSA. In an in vivo myositis model, Rho-FF-Van results in a significant increased fluorescence signal at the MRSA infected site. Radiolabeled with iodine-125, Rho-FF-Van shows strong radioactive signal in the MRSA-infected lungs in a murine model. This novel dual fluorescent and nuclear probe promises a new way for in vivo imaging of bacterial infections.

Dual Fluorescent‐ and Isotopic‐Labelled Self‐Assembling Vancomycin for in vivo Imaging of Bacterial Infections

AbstractThe increase of bacterial resistance demands rapid and accurate diagnosis of bacterial infections. Biosurface‐induced supramolecular assembly for diagnosis and therapy has received little attention in detecting bacterial infections. Herein we present a dual fluorescent‐nuclear probe based on self‐assembly of vancomycin (Van) on Gram‐positive bacteria for imaging bacterial infection. A Van‐ and rhodamine‐modified peptide derivative (Rho‐FF‐Van), as the imaging agent, binds to the terminal peptide of the methicillin‐resistant staphylococcus aureus (MRSA) and self‐assembles to form nanoaggregates on the surface of MRSA. In an in vivo myositis model, Rho‐FF‐Van results in a significant increased fluorescence signal at the MRSA infected site. Radiolabeled with iodine‐125, Rho‐FF‐Van shows strong radioactive signal in the MRSA‐infected lungs in a murine model. This novel dual fluorescent and nuclear probe promises a new way for in vivo imaging of bacterial infections.

Microbial pathogenesis revealed by intravital microscopy: pros, cons and cautions.

Intravital multiphoton imaging allows visualization of infections and pathogenic mechanisms within intact organs in their physiological context. Today, most organs of mice and rats are applicable to in vivo or ex vivo imaging, opening completely new avenues for many researchers. Advances in fluorescent labeling of pathogens and infected cells, as well as improved small animal models for human pathogens, led to the increased application of in vivo imaging in infectious diseases research in recent years. Here, we review the latest literature on intravital or ex vivo imaging of viral and bacterial infections and critically discuss requirements, benefits and drawbacks of applied animal models, labeling strategies, and imaged organs.

Gamma scintigraphy and biodistribution of (99m)Tc-cefotaxime sodium in preclinical models of bacterial infection and sterile inflammation.

(99m)Tc-cefotaxime sodium ((99m)Tc-CEF) was developed and standardized under varying conditions of reducing and antioxidant agent concentration, pH, radioactivity dose, and reducing agent type. Labeling studies were performed by changing the selected parameters one by one, and optimum labeling conditions were determined. After observing the conditions for maximum labeling efficiency and stability, lyophilized freeze dry kits were prepared accordingly. Simple method for radiolabeling of CEF with (99m)Tc has been developed and standardized. Labeling efficiency of (99m)Tc-CEF was assessed by both radio thin-layer chromatography and radio high-performance liquid chromatography and found higher than 90%. The labeled compound was found to be stable in saline and human serum up to 24 h. Two different freeze dry kits were developed and evaluated. Based on the data obtained from this study, both products were stable for 6 months with high labeling efficiency. The prepared cold kit was found sterile and pyrogen free. The bacterial infection and sterile inflammation imaging capacity of (99m)Tc-CEF was evaluated. Based on the in vivo studies, (99m)Tc-CEF has higher uptake in infected and inflamed thigh muscle than healthy thigh muscle.

Recent advances of semiconducting polymer nanoparticles in in vivo molecular imaging

Semiconducting polymer nanoparticles (SPNs) emerge as attractive molecular imaging nanoagents in living animals because of their excellent optical properties including large absorption coefficients, tunable optical properties and controllable dimensions, high photostability, and the use of organic and biologically inert components without toxic metals. This review summarizes the recent advances of these new organic nanoparticles in in vivo molecular imaging. The in vivo biocompatibility of SPNs is discussed first in details, followed by examples of their applications ranging from sentinel lymph node mapping and tumor imaging to long-term cell tracking, to drug toxicity and bacterial infection imaging for fluorescence, bioluminescence, chemiluminescence and photoacoustic imaging in living animals. The utility of SPNs for designing smart activatable probes for real-time in vivo imaging is also discussed.

Infection Imaging With 18F-FDS and First-in-Human Evaluation

PurposeThe noninvasive imaging of bacterial infections is critical in order to reduce mortality and morbidity caused by these diseases. The recently reported 18F-FDS (18F-2-fluorodeoxy sorbitol) as a PET (positron emission tomography) tracer can be used to image Enterobacteriaceae-specific infections and provides a potential alternative to this problem compared with other probes for imaging infections. In this study, automatic synthesis, validation of 18F-FDS and a first-in-human study were performed and discussed. MethodsA multifunctional synthesis module was employed for the radiosynthesis of 18F-FDG (18F-2-fluorodeoxy glucose) and 18F-FDS starting from 18F ion using two-pot three-step fully automated reactions. The behavior of 18F-FDS as an in vivo imaging probe for infections was evaluated in an Escherichia coli mouse infection model. The first detailed pharmacokinetic and biodistribution parameters were obtained from healthy human volunteers. ResultsThe uptake of 18F-FDS in an E. coli mouse-myositis infection model was easily differentiated from other organs and normal muscle. Intensive lesion uptake declined after antibiotic treatment. In the pilot human study, no adverse effects due to 18F-FDS were observed up to 24h post-injection. The radiotracer was rapidly cleared from the circulation and excreted mainly through the urinary system. ConclusionWe conclude that 18F-FDS PET holds great potential for appropriate and effective for the imaging of bacterial infections in vivo. These preliminary results indicate that further clinical studies are warranted.

Visualizing and quantifying Pseudomonas aeruginosa infection in the hindbrain ventricle of zebrafish using confocal laser scanning microscopy

Pseudomonas aeruginosa colonizes surfaces using a stepwise process that involves several phases, including attachment, production of exopolysaccharides, formation of microcolonies and the eventual development of biofilms. This process has been extensively characterized in vitro using both light and electron microscopic techniques. However, our ability to visualize this process in situ at the site of infection has been limited by the nature of the vertebrate models available. The optically clear zebrafish (Danio rerio) is an emerging model well suited for imaging bacterial infections. In this study, we infected the hindbrain ventricle of 54h post-fertilization zebrafish with P. aeruginosa PAO1 and visualized and quantified microcolony formation using confocal laser scanning microscopy and image analyses. In comparison to wildtype PAO1, infection with a P. aeruginosa mutant deficient in the ability to produce the exopolysaccharide Psl caused less zebrafish mortality and fewer, smaller microcolonies per zebrafish at both 18h and 29h post-infection. The work presented here demonstrates reproducible in situ visualization and quantification methods for determining the extent of P. aeruginosa infection in a vertebrate model. We demonstrate how this model system can be manipulated to understand the effect of virulence factors on pathogenicity. Furthermore, this model can be adapted to study biofilm formation in situ, thereby extending our understanding of how bacterial persistence leads to chronic infections.

Targeted imaging of bacterial infections: advances, hurdles and hopes.

Bacterial infections represent an increasing problem in modern health care, in particular due to ageing populations and accumulating bacterial resistance to antibiotics. Diagnosis is rarely straightforward and consequently treatment is often delayed or indefinite. Therefore, novel tools that can be clinically implemented are urgently needed to accurately and swiftly diagnose infections. Especially, the direct imaging of infections is an attractive option. The challenge of specifically imaging bacterial infections in vivo can be met by targeting bacteria with an imaging agent. Here we review the current status of targeted imaging of bacterial infections, and we discuss advantages and disadvantages of the different approaches. Indeed, significant progress has been made in this field and the clinical implementation of targeted imaging of bacterial infections seems highly feasible. This was recently highlighted by the use of so-called smart activatable probes and a fluorescently labelled derivative of the antibiotic vancomycin. A major challenge remains the selection of the best imaging probes, and we therefore present a set of target selection criteria for clinical implementation of targeted bacterial imaging. Altogether, we conclude that the spectrum of potential applications for targeted bacterial imaging is enormous, ranging from fundamental research on infectious diseases to diagnostic and therapeutic applications.

Development of a Hybrid Tracer for SPECT and Optical Imaging of Bacterial Infections

In trauma and orthopedic surgery, infection of implants has a major impact on the outcome for patients. Infections may develop either during the initial implantation or during the lifetime of an implant. Both infections, as well as aseptic loosening of the implant, are reasons for revision of the implants. Therefore, discrimination between aseptic-mechanical-loosening and septic-bacterial-loosening of implants is critical during selection of a patient-tailored treatment policy. Specific detection and visualization of infections is a challenge because it is difficult to discriminate infections from inflammation. An imaging tracer that facilitates bacterial identification in a pre- and intraoperative setting may aid the workup for patients suspicious of bacterial infections. In this study we evaluated an antimicrobial peptide conjugated to a hybrid label, which contains both a radioisotope and a fluorescent dye. After synthesis of DTPA-Cy5-UBI29-41 and-when necessary-radiolabeling with (111)In (yield 96.3 ± 2.7%), in vitro binding to various bacterial strains was evaluated using radioactivity counting and confocal fluorescence microscopy. Intramuscular bacterial infections (S. aureus or K. pneumoniae) were also visualized in vivo using a combined nuclear and fluorescence imaging system. The indium-111 was chosen as label as it has a well-defined coordination chemistry, and in pilot studies labeling DTPA-Cy5-UBI29-41 with technetium-99m, we encountered damage to the Cy5 dye after the reduction with SnCl2. As a reference, we used the validated tracer (99m)Tc-UBI29-41. Fast renal excretion of (111)In-DTPA-Cy5-UBI29-41 was observed. Target to nontarget (T/NT) ratios were highest at 2 h post injection: radioactivity counting yielded T/NT ratios of 2.82 ± 0.32 for S. aureus and 2.37 ± 0.05 for K. pneumoniae. Comparable T/NT ratios with fluorescence imaging of 2.38 ± 0.09 for S. aureus and 3.55 ± 0.31 for K. pneumoniae were calculated. Ex vivo confocal microscopy of excised infected tissues showed specific binding of the tracer to bacteria. Using a combination of nuclear and fluorescence imaging techniques, the hybrid antimicrobial peptide conjugate DTPA-Cy5-UBI29-41 was shown to specifically accumulate in bacterial infections. This hybrid tracer may facilitate integration of noninvasive identification of infections and their extent as well as real-time fluorescence guidance during surgical resection of infected areas.

Label-Free Imaging and Spectroscopic Analysis of Intracellular Bacterial Infections

Staphylococcus aureus is one of the most frequent human pathogens that can also act as a facultative intracellular pathogen causing infections that are extremely difficult to treat. Only little is known about the pathogen's intracellular adaptation strategies to escape the host's response. Here, we present an advanced Raman-based imaging approach providing high quality false-color images to specifically identify intracellular S. aureus and to localize them exactly in three dimensions within endothelial cells. At the same time unprecedented insights into the metabolic characteristics of the pathogen are provided in a label-free and nondestructive manner. The spectral information reveals that the intracellular bacteria are in the exponential growth phase with a reduced replication rate and biochemically different from extracellular bacteria proving their adaptation to the host's conditions. This powerful biophotonic analysis tool paves the way for further mechanistic studies of difficult-to-investigate infection processes.

PET Imaging of Bacterial Infections with Fluorine‐18‐Labeled Maltohexaose

AbstractA positron emission tomography (PET) tracer composed of 18F‐labeled maltohexaose (MH18F) can image bacteria in vivo with a sensitivity and specificity that are orders of magnitude higher than those of fluorodeoxyglucose (18FDG). MH18F can detect early‐stage infections composed of as few as 105 E. coli colony‐forming units (CFUs), and can identify drug resistance in bacteria in vivo. MH18F has the potential to improve the diagnosis of bacterial infections given its unique combination of high specificity and sensitivity for bacteria.

PET imaging of bacterial infections with fluorine-18-labeled maltohexaose.

A positron emission tomography (PET) tracer composed of (18)F-labeled maltohexaose (MH(18)F) can image bacteria in vivo with a sensitivity and specificity that are orders of magnitude higher than those of fluorodeoxyglucose ((18)FDG). MH(18)F can detect early-stage infections composed of as few as 10(5) E. coli colony-forming units (CFUs), and can identify drug resistance in bacteria in vivo. MH(18)F has the potential to improve the diagnosis of bacterial infections given its unique combination of high specificity and sensitivity for bacteria.

Synthesis of [¹⁸F]-labelled maltose derivatives as PET tracers for imaging bacterial infection.

To develop novel positron emission tomography (PET) agents for visualization and therapy monitoring of bacterial infections. It is known that maltose and maltodextrins are energy sources for bacteria. Hence, (18)F-labelled maltose derivatives could be a valuable tool for imaging bacterial infections. We have developed methods to synthesize 4-O-(α-D-glucopyranosyl)-6-deoxy-6-[(18)F]fluoro-D-glucopyranoside (6-[(18)F]fluoromaltose) and 4-O-(α-D-glucopyranosyl)-1-deoxy-1-[(18)F]fluoro-D-glucopyranoside (1-[(18)F]fluoromaltose) as bacterial infection PET imaging agents. 6-[(18)F]fluoromaltose was prepared from precursor 1,2,3-tri-O-acetyl-4-O-(2',3',-di-O-acetyl-4',6'-benzylidene-α-D-glucopyranosyl)-6-deoxy-6-nosyl-D-glucopranoside (5). The synthesis involved the radio-fluorination of 5 followed by acidic and basic hydrolysis to give 6-[(18)F]fluoromaltose. In an analogous procedure, 1-[(18)F]fluoromaltose was synthesized from 2,3, 6-tri-O-acetyl-4-O-(2',3',4',6-tetra-O-acetyl-α-D-glucopyranosyl)-1-deoxy-1-O-triflyl-D-glucopranoside (9). Stability of 6-[(18)F]fluoromaltose in phosphate-buffered saline (PBS) and human and mouse serum at 37 °C was determined. Escherichia coli uptake of 6-[(18)F]fluoromaltose was examined. A reliable synthesis of 1- and 6-[(18)F]fluoromaltose has been accomplished with 4-6 and 5-8% radiochemical yields, respectively (decay-corrected with 95 % radiochemical purity). 6-[(18)F]fluoromaltose was sufficiently stable over the time span needed for PET studies (∼96% intact compound after 1-h and ∼65% after 2-h incubation in serum). Bacterial uptake experiments indicated that E. coli transports 6-[(18)F]fluoromaltose. Competition assays showed that the uptake of 6-[(18)F]fluoromaltose was completely blocked by co-incubation with 1 mM of the natural substrate maltose. We have successfully synthesized 1- and 6-[(18)F]fluoromaltose via direct fluorination of appropriate protected maltose precursors. Bacterial uptake experiments in E. coli and stability studies suggest a possible application of 6-[(18)F]fluoromaltose as a new PET imaging agent for visualization and monitoring of bacterial infections.

Investigation of 6-[¹⁸F]-fluoromaltose as a novel PET tracer for imaging bacterial infection.

Despite advances in the field of nuclear medicine, the imaging of bacterial infections has remained a challenge. The existing reagents suffer from poor sensitivity and specificity. In this study we investigate the potential of a novel PET (positron emission tomography) tracer that overcomes these limitations.Methods6-[18F]-fluoromaltose was synthesized. Its behavior in vitro was evaluated in bacterial and mammalian cultures. Detailed pharmacokinetic and biodistribution profiles for the tracer were obtained from a murine model.Results6-[18F]-fluoromaltose is taken up by multiple strains of pathogenic bacteria. It is not taken up by mammalian cancer cell lines. 6-[18F]-fluoromaltose is retained in infected muscles in a murine model of bacterial myositis. It does not accumulate in inflamed tissue.ConclusionWe have shown that 6-[18F]-fluoromaltose can be used to image bacterial infection in vivo with high specificity. We believe that this class of agents will have a significant impact on the clinical management of patients.