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Journal of Drug Delivery and Therapeutics
Open Access to Pharmaceutical and Medical Research
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Open Access Full Text Article Research Article
Optimization and Characterization of Chlorthalidone Bilayer Tablets for Chronotherapeutic Pulsatile Drug Release
Moulindu Mondal ¹, Deepannita Roy Mukherjee ²*, Dona Biswas 3, Pinki Biswas 3, Saikat Santra 3
2 Department of Pharmacology, JRSET College of Pharmacy, Panchpota, Chakdah, Nadia–741222, West Bengal, India
3 Department of Pharmaceutics, JRSET College of Pharmacy, Panchpota, Chakdah, Nadia–741222, West Bengal, India
|
Article Info: _______________________________________________ Article History: Received 21 March 2026 Reviewed 07 May 2026 Accepted 31 May 2026 Published 15 June 2026 _______________________________________________ Cite this article as: For Correspondence: |
Abstract _______________________________________________________________________________________________________________ Pulsatile Drug Delivery System (PDDS) is defined as the rapid and transient release of drug molecules within a short time period immediately after a predetermined lag (off release) period. Blood pressure exhibits a well-documented circadian surge in the early morning hours — a window associated with peak cardiovascular morbidity. Chlorthalidone, a BCS Type-II thiazide-like diuretic with a plasma half-life of 40–60 hours, was selected as the model drug for a chronopharmacological pulsatile formulation. Nine bilayer press-coated tablet formulations (CHT-A through CHT-I) were prepared using Hydroxypropyl Methylcellulose K100M (HPMC) as the hydrophilic swelling polymer and Ethyl Cellulose (EC) as the hydrophobic rupturable membrane at varying weight ratios. Preformulation studies — including ATR-IR spectroscopy, Differential Scanning Calorimetry (DSC), and powder flow characterization — confirmed drug identity, thermal behaviour, and excipient compatibility. Scanning Electron Microscopy (SEM) was employed to characterize surface morphology. The core tablet exhibited a disintegration time of 185 seconds and 95.8% drug content. Formulation CHT-G (HPMC 150 mg: EC 250 mg) demonstrated the optimal 6-hour lag time followed by a burst release of 83.20% at hour 7. Korsmeyer-Peppas modelling (R² = 0.8545; n = 2.2082) identified super case-II swelling-controlled transport as the dominant release mechanism. The developed system offers a clinically promising chronopharmacological strategy for the management of morning-surge hypertension. Keywords: Pulsatile Drug Delivery; Chlorthalidone; Bilayer Tablet; HPMC; Ethyl Cellulose; DSC; SEM; Lag Time; Chronopharmacology; Hypertension. |
Chlorthalidone API was procured from Yarrow Chem Products. Mannitol, Microcrystalline Cellulose (MCC), Sodium Starch Glycolate (SSG), Magnesium Stearate, Talc, Lactose, and HPMC K100M were obtained from Lobe Chemie Pvt. Ltd., Mumbai. Croscarmellose Sodium (CCS) and Starch were sourced from Research-Lab Fine Chem Industries, Mumbai. Ethyl Cellulose (EC) was procured from HiMedia Laboratories. Methanol (AR grade) was used as a solvent in analytical studies. All materials were of pharmaceutical/analytical grade.
Table 1: List of Materials Used in the Study
|
S.No. |
Ingredient |
Category |
Manufacturer |
|
1 |
Chlorthalidone (Drug) |
API |
Yarrow Chem Products |
|
2 |
Mannitol |
Filler/Diluent |
Lobe Chemie Pvt. Ltd., Mumbai |
|
3 |
MCC |
Diluent/Binder |
Lobe Chemie Pvt. Ltd., Mumbai |
|
4 |
Sodium Starch Glycolate (SSG) |
Superdisintegrant |
Lobe Chemie Pvt. Ltd., Mumbai |
|
5 |
Croscarmellose Sodium (CCS) |
Superdisintegrant |
Research-Lab Fine Chem, Mumbai |
|
6 |
Magnesium Stearate |
Lubricant |
Lobe Chemie Pvt. Ltd., Mumbai |
|
7 |
Talc |
Glidant |
Lobe Chemie Pvt. Ltd., Mumbai |
|
8 |
Lactose |
Diluent |
Lobe Chemie Pvt. Ltd., Mumbai |
|
9 |
HPMC K100M |
Polymer (Coat) |
Lobe Chemie Pvt. Ltd., Mumbai |
|
10 |
Ethyl Cellulose |
Polymer (Coat) |
HiMedia Laboratories |
|
11 |
Methanol |
Solvent |
AR Grade |
Core tablets containing 10 mg of Chlorthalidone were prepared by the direct compression method²². All excipients listed in Table 2 were individually passed through sieve #60, accurately weighed, and blended uniformly in a closed polyethylene container for 30 minutes to ensure homogeneity²³. Magnesium stearate and talc were incorporated during the final 5 minutes of blending as lubricant and glidant, respectively²⁴. The prepared powder blend was evaluated for pre-compression parameters, including flow properties, prior to compression²⁵. The blend was then directly compressed using a 12-station rotary tablet punching machine fitted with 7 mm round flat-faced punches to obtain fast-dissolving core tablets²⁶.
Table 2: Composition of Core Tablet (per tablet)
|
S.No. |
Ingredient |
Quantity (mg) |
|
1 |
Chlorthalidone (API) |
10.0 |
|
2 |
Sodium Starch Glycolate |
9.3 |
|
3 |
Croscarmellose Sodium |
8.0 |
|
4 |
Microcrystalline Cellulose |
51.3 |
|
5 |
Mannitol |
24.0 |
|
6 |
Lactose |
13.3 |
|
7 |
Starch |
8.6 |
|
8 |
Magnesium Stearate |
1.6 |
|
9 |
Talc |
1.6 |
Nine formulations designated CHT-A through CHT-I were prepared using varying weight ratios of HPMC K100M (hydrophilic swelling layer) and Ethyl Cellulose (hydrophobic rupturable membrane)²⁷. The formulation code nomenclature — CHT (Chlorthalidone) followed by a letter suffix — reflects increasing HPMC content (CHT-A: pure EC → CHT-I: HPMC-rich; CHT-G represents the optimized 3:5 HPMC:EC ratio)²⁸. Coat materials were passed through sieve #24 and blended uniformly for 15 minutes²⁹. For each tablet, half of the coating blend was loaded into the die cavity, the pre-formed core tablet was manually centered, and the remaining coating material was added over the core³⁰. Final compression was performed using 11 mm round punches on a 12-station rotary tablet press to obtain press-coated bilayer tablets³¹. Table 3 presents the coating layer compositions of formulations CHT-A to CHT-I.
Table 3: Coating Layer Compositions for Formulations CHT-A to CHT-I
|
Code |
Polymer Ratio Description |
HPMC K100M (mg) |
Ethyl Cellulose (mg) |
|
CHT-A |
(EC only) |
0 |
400 |
|
CHT-B |
(HPMC only) |
400 |
0 |
|
CHT-C |
(1:1) |
200 |
200 |
|
CHT-D |
(3:1) |
300 |
100 |
|
CHT-E |
(1:3) |
100 |
300 |
|
CHT-F |
(5:3) |
250 |
150 |
|
CHT-G* |
(3:5 — OPTIMIZED) |
150 |
250 |
|
CHT-H |
(1:7) |
50 |
350 |
|
CHT-I |
(7:1) |
350 |
50 |
*CHT-G = Optimized formulation. HPMC:EC weight ratio = 150:250 (3:5).
Pure Chlorthalidone is a white to off-white, odorless, and tasteless crystalline powder, as shown in Figure 1. The melting point of the compound was found to be 227°C, which is in close agreement with the reported pharmacopoeial value. This result confirms the identity and purity of the drug, as outlined in Table 4.
Table 4: Identification Tests of Pure Chlorthalidone
|
S.No. |
Parameter |
Observation |
|
1 |
Colour |
White to off-white |
|
2 |
Odour |
Odourless |
|
3 |
Taste |
Tasteless |
|
4 |
Appearance |
Crystalline powder |
|
5 |
Melting Point |
227°C |
Chlorthalidone was found to be soluble in methanol, slightly soluble in ethanol, and insoluble in water, ether, and chloroform — consistent with its BCS Class II classification (low aqueous solubility, high permeability).
Sample |
Major Peaks (cm⁻¹) |
Functional Group Assignment |
Interpretation |
Pure Chlorthalidone (A) |
3418, 3327, 3248, 1650, 1458, 1383, 1167, 1076, 1017, 683 |
N–H stretching, C=O stretching, aromatic C=C/C–N stretching, S=O stretching, C–Cl stretching |
Characteristic peaks of Chlorthalidone confirming drug identity and structural integrity. |
Chlorthalidone–HPMC (1:1) (B) |
3248, 3214, 2361, 1659, 1560, 1383, 1338, 1019, 685 |
N–H stretching, C=O stretching, aromatic vibrations, S=O stretching, C–Cl stretching |
Characteristic drug peaks retained with minor shifts and intensity changes due to polymer presence; no evidence of chemical interaction. |
Chlorthalidone–EC (1:1) (C) |
3418, 3327, 3248, 2361, 1650, 1458, 1398, 1363, 1167, 1076, 1017, 683 |
N–H stretching, C=O stretching, aromatic vibrations, S=O stretching, C–Cl stretching |
Major drug peaks remained unchanged, indicating compatibility between Chlorthalidone and ethyl cellulose. |
Chlorthalidone with All Excipients (D) |
3429, 3301, 2922, 2854, 1734, 1604, 1512, 1262, 1178, 1017, 618 |
N–H stretching, C–H stretching, C=O stretching, aromatic vibrations, C–O stretching |
Presence of both drug and excipient peaks without disappearance of characteristic bands; indicates absence of significant drug–excipient interaction and good formulation compatibility. |
Figure 2. ATR-IR spectra of (a) pure Chlorthalidone, (b) Chlorthalidone-HPMC (1:1), (c) Chlorthalidone-EC (1:1), and (d) Chlorthalidone with all excipients.
The DSC thermogram of pure Chlorthalidone (Figure 3 a) exhibited a sharp endothermic peak at approximately 238°C, corresponding to the melting point of the crystalline drug. The sharp and intense peak confirms the crystalline nature and thermal stability of Chlorthalidone.
In the Chlorthalidone–HPMC physical mixture (Figure 3 b), the characteristic melting endotherm of
Chlorthalidone was retained with a slight shift toward a lower temperature (approximately 236°C). A broad endothermic event observed between 70–120°C can be attributed to the loss of absorbed moisture from HPMC. The preservation of the drug melting peak without the appearance of any new thermal events suggests the absence of significant interaction between Chlorthalidone and HPMC.
Similarly, the Chlorthalidone–EC physical mixture (Figure 3 c) showed the characteristic melting endotherm of Chlorthalidone at approximately 238°C with only a minor variation in peak intensity. A slight baseline deviation observed in the range of 100–150°C is associated with the polymeric characteristics of ethyl cellulose. No additional peaks or disappearance of characteristic drug peaks were observed, indicating good compatibility between Chlorthalidone and EC.
The retention of the characteristic melting endotherm of Chlorthalidone in both physical mixtures, along with only minor shifts in peak temperature and enthalpy values, indicates that no significant drug-excipient interactions occurred during mixing. These findings confirm the compatibility of Chlorthalidone with HPMC and EC, supporting their suitability for formulation development and indicating that there are no interactions or polymorphic conversions, as shown in Figure 3 and Table 6.
Figure 3: DSC thermograms of (a) pure Chlorthalidone, (b) Chlorthalidone-HPMC physical mixture (1:1), and (c) Chlorthalidone-EC physical mixture (1:1), showing characteristic melting endotherm and absence of drug-excipient interaction.
Table 6: DSC Parameters of Chlorthalidone and Physical Mixtures
|
Sample |
Onset Temperature (°C) |
Peak Temperature (°C) |
ΔH (J/g) |
|
Pure Chlorthalidone |
233.6 |
238.4 |
96.8 |
|
Chlorthalidone + HPMC (1:1) |
230.8 |
236.3 |
82.4 |
|
Chlorthalidone + EC (1:1) |
232.6 |
237.8 |
89.7 |
Note: ΔH values scaled to drug proportion. No new peaks or exotherms observed.
Figure 4 (A) (Pure Chlorthalidone): The SEM image of pure Chlorthalidone reveals well-defined, elongated rod-shaped crystals with smooth surfaces and sharp edges, indicating the crystalline nature of the drug. The uniform crystal habit and absence of surface irregularities suggest high crystallinity of the untreated drug material. Figure 4 (B) (Hydrated Matrix after Dissolution): The cross-sectional SEM image shows the formation of a distinct swollen polymeric layer surrounding the drug core. Numerous pores and channels are visible within the matrix, indicating penetration of dissolution medium and gradual erosion of the hydrated polymer network. The presence of the swollen HPMC layer demonstrates gel formation, which acts as a diffusion barrier and contributes to the controlled release of Chlorthalidone. The rupturable ethyl cellulose membrane remains partially intact around the hydrated core, supporting a membrane-controlled release mechanism. Figure 4 (C) (Optimized Formulation Surface): The surface morphology of the formulated tablet appears relatively smooth, compact, and homogeneous, with only a few minor surface imperfections. No visible drug crystals or phase separation are observed on the tablet surface, suggesting uniform dispersion of Chlorthalidone within the polymer matrix. The absence of cracks or large pores indicates good film-forming properties and effective compression characteristics of the formulation.
Figure 4: SEM micrographs: (a) Pure Chlorthalidone drug crystals (×500); (b) cross-section of optimized formulation CHT-G showing core, HPMC swelling layer, and EC rupturable outer membrane (×100); (c) coat surface of CHT-G at ×1000.
Core tablets met all pharmacopoeial and in-house specifications as summarized in Table 7. Hardness (4.2–4.5 kg/cm²) was appropriate for the subsequent press-coating step. Disintegration time (185 s; ~3 minutes) confirms rapid core disintegration once the coat ruptures. Drug content (95.8%) and friability (0.45%) are within IP 2010 limits.
Table 7: Post-Compression Parameters of Core Tablet
|
Weight (mg) |
Thickness (mm) |
Hardness (kg/cm²) |
Friability (%) |
Disintegration (s) |
Drug Content (%) |
|
150.7 ± 2.67 |
3.4 |
4.2–4.5 |
0.45 |
185 |
95.8 |
±SD and number of replicates (n) for Thickness, Hardness, Friability, Disintegration Time, and Drug Content per IP 2010 / USP standards.
All nine formulations exhibited a complete lag phase (0% drug release) during the first 2 hours in 0.1 N HCl. Following medium change to pH 6.8 buffer, drug release commenced at varying time points according to the HPMC:EC ratio (Table 8, Figure 5).
Table 8: Cumulative % Drug Release from Formulations CHT-A to CHT-I
|
Time (h) |
CHT-A |
CHT-B |
CHT-C |
CHT-D |
CHT-E |
CHT-F |
CHT-G* |
CHT-H |
CHT-I |
|
0 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
|
1 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
|
2 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
|
3 |
101.04 |
12.29 |
8.13 |
61.38 |
12.29 |
73.13 |
13.13 |
18.96 |
13.96 |
|
4 |
100.00 |
17.31 |
22.31 |
69.47 |
15.64 |
77.27 |
12.31 |
20.22 |
17.72 |
|
5 |
100.00 |
22.32 |
31.49 |
80.65 |
17.74 |
82.29 |
18.99 |
24.82 |
31.49 |
|
6 |
100.00 |
31.92 |
81.51 |
90.67 |
22.34 |
93.60 |
20.26 |
31.51 |
79.01 |
|
7 |
100.00 |
34.45 |
88.20 |
94.03 |
25.28 |
98.32 |
83.20 |
34.03 |
86.53 |
Kinetic analysis of CHT-G dissolution data revealed the Korsmeyer-Peppas model as the best fit (Figure 6, Table 9), with R² = 0.8545 and release exponent n = 2.2082, indicating super case-II transport (n > 1.0). Zero-order (R² = 0.6394), first-order (R² = 0.5078), and Higuchi (R² = 0.5581) models showed poor fit.
Table 9: Drug Release Kinetics Parameters-Optimized Formulation CHT-G
|
Kinetic Model |
R² |
Interpretation |
|
Zero Order |
0.6394 |
Poor fit |
|
First Order |
0.5078 |
Poor fit |
|
Higuchi |
0.5581 |
Poor fit |
|
Korsmeyer-Peppas |
0.8545 (n = 2.2082) |
Best fit — super case-II swelling/rupture transport (n = 2.2082 > 1.0) |
Figure 6: Kinetic release plots for optimized formulation CHT-G: (a) Zero-order; (b) First-order; (c) Higuchi; (d) Korsmeyer-Peppas-best fit model (R² = 0.8545).
4. DISCUSSION
The present study successfully developed and characterized a chronotherapeutic pulsatile drug delivery system of Chlorthalidone using bilayer press-coated tablets (CHT-A to CHT-I). The formulation strategy was designed to address the early morning surge in blood pressure, a period associated with an increased risk of adverse cardiovascular events such as myocardial infarction and stroke. By providing a predetermined lag phase followed by rapid drug release, the developed system aims to synchronize drug availability with the circadian rhythm of hypertension.
Preformulation studies confirmed the suitability of Chlorthalidone for incorporation into the pulsatile delivery system. The drug exhibited characteristic physicochemical properties consistent with reported literature values. ATR-IR spectroscopy demonstrated the retention of all major characteristic absorption bands of Chlorthalidone in the presence of HPMC, EC, and other formulation excipients, indicating the absence of significant chemical interactions. Similarly, DSC analysis revealed the preservation of the characteristic melting endotherm of Chlorthalidone with only minor shifts in peak temperature, confirming the thermal compatibility of the drug with the selected polymers. These findings indicate that the formulation components are compatible and unlikely to adversely affect drug stability during processing and storage.
SEM analysis provided valuable insight into the structural characteristics of the optimized formulation. The pure drug exhibited well-defined crystalline morphology, whereas the optimized tablet displayed a compact and homogeneous surface without visible drug crystals or major defects. The cross-sectional micrograph revealed a distinct multilayer structure comprising the drug core, swelling HPMC layer, and rupturable EC outer membrane. This architecture supports the proposed mechanism of pulsatile release, in which water penetration into the tablet causes swelling of HPMC, generating internal pressure that eventually ruptures the surrounding EC layer and triggers rapid drug release.
The dissolution profiles of formulations CHT-A through CHT-I clearly demonstrated the influence of polymer composition on lag time and drug release behavior. Formulation CHT-A, containing only ethyl cellulose (400 mg), exhibited premature drug release beginning at the third hour, indicating failure of the hydrophobic barrier to maintain the desired lag phase. The absence of a swelling polymer component prevented the generation of controlled internal pressure and resulted in rapid penetration of dissolution medium through the coating. Consequently, complete drug release was achieved much earlier than required for chronotherapeutic delivery. In contrast, formulation CHT-B, containing only HPMC K100M (400 mg), exhibited only 34.45% cumulative drug release after 7 h. The extensive swelling and gel-forming properties of HPMC produced a strong diffusion barrier that significantly retarded drug release and prevented the abrupt burst effect required for pulsatile therapy. These observations demonstrate that neither EC nor HPMC alone can provide an optimal pulsatile release profile.
A clear relationship between polymer ratio and drug release characteristics was observed among the intermediate formulations. Increasing the proportion of HPMC enhanced water uptake and swelling, thereby increasing the internal pressure generated within the coat. Excessive HPMC content led to early rupture and shorter lag times, as observed with CHT-D (300 mg HPMC:100 mg EC), which released 61.38% of drug by the third hour. Conversely, increasing the proportion of EC strengthened the hydrophobic barrier and delayed water penetration, resulting in prolonged lag times and slower release. Formulations containing high EC content, such as CHT-E and CHT-H, exhibited extended release retardation due to the greater resistance of the hydrophobic membrane to medium penetration. These results confirm that the lag phase and subsequent release pattern can be effectively modulated by adjusting the HPMC-to-EC ratio.
Among all formulations, CHT-G (HPMC 150 mg: EC 250 mg) exhibited the most desirable pulsatile release profile. The formulation maintained a lag phase for approximately 6 h, with only limited drug release during this period, followed by a rapid increase in drug release at the seventh hour. Such behavior is characteristic of a successful rupturable pulsatile system, where swelling-induced pressure gradually accumulates within the coating until mechanical failure of the EC membrane occurs. The abrupt release observed after the lag period demonstrates that the balance between the swelling force of HPMC and the mechanical resistance of EC was optimized in this formulation. The dissolution behavior of CHT-G closely matches the intended chronotherapeutic objective of delivering Chlorthalidone during the early morning hours following bedtime administration.
Drug release kinetic analysis further supported the proposed release mechanism. The Korsmeyer–Peppas model provided the best fit to the dissolution data of CHT-G (R² = 0.8545), whereas zero-order, first-order, and Higuchi models exhibited comparatively lower correlation coefficients. The release exponent (n = 2.2082) indicated super case-II transport, suggesting that drug release was governed predominantly by polymer relaxation, swelling, and pressure-induced membrane rupture rather than simple diffusion. This finding is consistent with the SEM observations and dissolution profile of the optimized formulation and confirms the suitability of the selected polymer combination for pulsatile drug delivery.
From a therapeutic perspective, the optimized formulation offers significant potential for chronotherapy of hypertension. Following bedtime administration, the approximately 6-hour lag phase would delay drug release until the early morning period, coinciding with the time of greatest cardiovascular risk. Once released, the fast-disintegrating core rapidly liberates Chlorthalidone, while the drug’s long elimination half-life helps maintain antihypertensive activity throughout the day. Therefore, the developed pulsatile system may improve therapeutic effectiveness, enhance patient compliance, and provide better protection against early morning cardiovascular events compared with conventional immediate-release formulations.
Overall, the study demonstrates that precise modulation of HPMC K100M and ethyl cellulose ratios can successfully control lag time and burst release behavior in press-coated tablets. The optimised formulation CHT-G achieved the optimal balance between swelling-pressure generation and membrane resistance, resulting in a pulsatile drug-delivery system capable of meeting the chronotherapeutic requirements of hypertension management.
5. CONCLUSION
A time-controlled pulsatile drug delivery system for Chlorthalidone was successfully developed, characterised, and optimised in the form of bilayer press-coated tablets designated CHT-A through CHT-I. The formulation employs HPMC K100M as a hydrophilic swelling layer and Ethyl Cellulose as a hydrophobic rupturable membrane, leveraging the swelling-pressure-driven rupture mechanism to achieve precisely timed drug release.
Comprehensive preformulation evaluation including melting point determination, ATR-IR spectroscopy, DSC thermal analysis, and SEM morphological characterization — confirmed drug identity (melting point 224°C), thermal stability (DSC endotherm at 238.4°C), crystalline purity, and excipient compatibility with both HPMC and EC, with no evidence of chemical interaction or polymorphic conversion. Core tablet evaluation demonstrated satisfactory fast-dissolving character (disintegration time 185 s) and adequate drug content (95.8%), with friability (0.45%) and weight variation within IP 2010 pharmacopoeial limits.
Among the nine formulations, CHT-G (HPMC 150 mg: EC 250 mg) was identified as the optimized formulation, exhibiting an approximately 6-hour lag phase (≤20.26% at hour 6) followed by a rapid burst release of 83.20% at hour 7. Drug release kinetics followed the Korsmeyer–Peppas model (R² = 0.8545; n = 2.2082), consistent with super case-II transport — a swelling-pressure-driven membrane rupture mechanism characteristic of rupturable bilayer press-coated systems. SEM cross-sectional analysis of CHT-G confirmed the three-layer architectural integrity of the bilayer press-coated system, with a clearly defined core, HPMC swelling layer, and EC outer membrane.
The developed CHT-G formulation presents a pharmacologically rational and patient-friendly chronopharmacological strategy for managing morning-surge hypertension: a single bedtime dose undergoes a 6-hour lag before delivering its antihypertensive payload precisely during the early morning cardiovascular high-risk window, without requiring an additional morning dose. Future studies should include in vivo pharmacokinetic validation in animal models, accelerated stability testing per ICH Q1A guidelines, and Phase I clinical pharmacokinetic assessment to confirm the chronotherapeutic benefit of CHT-G over conventional immediate-release Chlorthalidone tablets.
Conflict of Interest: The authors declare no potential conflict of interest concerning the contents, authorship, and/or publication of this article.
Author Contributions: All authors have equal contributions in the preparation of the manuscript and compilation.
Source of Support: Nil
Funding: The authors declared that this study has received no financial support.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data supporting this paper are available in the cited references.
Ethical approval: Not applicable.