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Abstract

A major worldwide health problem, multidrug-resistant tuberculosis (MDR-TB) reflects resistance to at least isoniazid and rifampicin, the first-line anti-TB treatments. Various elements cause this syndrome, including inadequate or incomplete treatment adherence, antibiotic abuse, and direct transmission of resistant Mycobacterium tuberculosis strains. Worldwide, MDR-TB presents a major difficulty for efficient tuberculosis control initiatives. Often, the clinical presentation of MDR-TB is indistinguishable from that of drug-sensitive tuberculosis. Common symptoms are chronic cough, fever, night sweats, tiredness, chest discomfort, and notable weight loss. These symptoms might impair the quality of life, postpone diagnosis, and make prompt treatment start more difficult. Compared to drug-sensitive TB, MDR-TB treatment is noticeably more complicated. It incorporates second-line anti-TB medications, which frequently have longer treatment durations (18–24 months), more adverse effects, and inferior efficacy. Novel regimens like the BPALM regimen and bedaquiline-based therapies are examples of recent developments that have showed promise in shortening treatment durations and enhananc. In order to address MDR-TB, this review highlights the urgent need for improved diagnosis methods, better treatment regimen adherence, and all-encompassing international policies. Governments, medical professionals, and communities must work together to solve this changing health catastrophe and lessen the global burden of MDR-TB.

Keywords

MDR-TB, Bedaquiline (BDQ), Linezolid (LZD), Pretomanid, Moxifloxacin, Drug resistance mechanism, new drug regimen.

Introduction

Multidrug-resistant tuberculosis (MDR-TB) continues to be one of the biggest challenges in the fight against TB worldwide. In the past, treating MDR-TB meant putting patients through long, gruelling regimens that could last up to 20 months. These treatments often relied on injectable drugs and strong antibiotics, which not only caused serious side effects like hearing loss and kidney damage but also made it very hard for patients to complete their treatment. Many ended up dropping out mid-way, leading to further drug resistance and spreading of the disease. Clearly, the older approach wasn’t working well, especially in countries where healthcare resources are limited. The complexity, cost, and toxicity of these regimens created a huge burden—not just on patients, but on healthcare systems too. Thankfully, things are starting to change for the better. With the development of newer, more effective oral drugs like bedaquiline, delamanid, pretomanid, and linezolid—and even some repurposed ones like clofazimine—we now have options that are shorter, safer, and easier for patients to stick with. One major breakthrough is the BPaLM regimen, a six-month, all-oral combination therapy that has been introduced under India’s National TB Elimination Program. It’s showing promising results with fewer side effects and better treatment success. The World Health Organization has updated its guidelines to support shorter, all-oral treatments in many cases, which is a big step forward. However, some promising drugs still need stronger evidence before they can be widely recommended. Also, as definitions of drug resistance continue to evolve—with XDR-TB now including resistance to key oral drugs like bedaquiline and linezolid—it's more important than ever to personalize treatment plans. With continued research, smarter drug use, and a strong focus on patient-centered care, we have a real chance of turning the tide against MDR-TB.

2. Epidemiology

2.1 World: Overview

Though studies published from the developing world suggested that drug resistance was a potential problem. it was the emergence of MDR-TB  in USA in the 1990s which attracted the attention. The problem of drug-resistant tuberculosis (TB) is a serious global concern, as shown in a WHO and IUATLD report based on data collected between 1994 and 1997. This large-scale study looked at 35 countries and found that resistance to key TB medicines existed in every single one—clearly showing that this is not just a local issue but a worldwide challenge. The extent of resistance varied widely, from as low as 5.3% in New Zealand to a staggering 100% in a region of Russia. On average, about 36% of TB cases showed some level of drug resistance. Among patients who had already been treated for TB, around 4.4% were resistant to all four of the main TB drugs. Multidrug-resistant TB (MDR-TB), which is harder and more expensive to treat, was also a major concern—with the percentage of MDR-TB cases ranging from 0% in Kenya to over 54% in Latvia. These numbers highlight several "hot spots" where MDR-TB is alarmingly common, posing a serious threat to public health and making it harder for countries to control the spread of the disease.  When looking at global drug-resistant TB trends, it's clear that the earlier WHO-IUATLD survey from 1994 to 1997 had some important limitations. It didn’t track how resistance changed over time, and in major high-burden countries like China, India, and Russia, the data often came from just one region—so it didn’t reflect the full national picture. To get a better understanding, the survey was expanded between 1996 and 1999 to include 58 different locations worldwide. Among newly diagnosed TB patients, resistance to at least one first-line drug varied widely—from just 1.7% in Uruguay to nearly 37% in Estonia, with the middle range (median) being around 10.7%. While the overall global rate of multidrug-resistant TB (MDR-TB) among new cases was relatively low at 1%, some areas had alarmingly high numbers. Estonia topped the list with 14.1%, followed closely by parts of China (Henan and Zhejiang provinces), Latvia, regions in Russia like Ivanovo and Tomsk, and even Iran. On the bright side, countries like France and the United States showed a decline in MDR-TB, pointing to the success of their control efforts. But in Estonia, the situation worsened, with MDR-TB cases rising from 11.7% in 1994 to 18.1% in 1998. Bringing all this global data together—including findings from 64 countries and estimates from 72 more—it’s believed that around 273,000 new cases of MDR-TB occurred worldwide in the year 2000, making up about 3.2% of all new TB infections that year.

2.2 India: Overview

An analysis of tuberculosis (TB) trends in India between 1975 and 2000 reveals a consistently high burden of the disease, particularly in the decades leading up to the 21st century. According to estimates from the World Health Organization (WHO), the prevalence of all forms of TB in India was approximately 506 cases per 100,000 population in 1995, which declined to around 280 per 100,000 by 2007, suggesting an average annual reduction of about 6% in the years following major TB control interventions. These changes indicate some progress in TB control toward the end of the 1990s, although the disease remained widespread throughout the study period (WHO, 2010). In 2000, estimates from the Tuberculosis Research Centre (TRC) indicated approximately 3.8 million smear-positive pulmonary TB cases, 3.9 million smear-negative cases, and 0.8 million extra-pulmonary cases nationwide, reflecting the massive scale of TB in India at the time (Kolappan et al., 2006). A significant turning point was the introduction of the Revised National Tuberculosis Control Programme (RNTCP) in 1997, under which an annual decline in prevalence of around 5.6% was observed in subsequent years (WHO, 2010). Though standardized surveillance and reporting were limited in the earlier decades (1975–1990), trends strongly suggest that India carried one of the highest TB burdens globally during that era. Despite the limitations in early data, these findings emphasize both the historical severity of the TB epidemic in India and the beginning of meaningful progress by the end of the 20th century. Prevalence of MDR-TB among previously treated patients has been observed to be higher. In a study conducted at a referral tuberculosis hospital in Amargadh, Gujarat28, multidrug resistance in previously treated cases was observed to increase.

 

Table I. Prevalence of multidrug resistant M. tuberculosis isolates among new cases in India

Place

Study period No. of isolated tested resistance to isoniazid

And rifampicin with or without resistance

to other drug

Gujarat28

1983-86

570

0

North Arcot district29

1985-89

2779

1.6

Pondicherry region29

1985-91

2127

0.7

Bangalore30

1980s

436

1.1

Bangalore31

1985-86

588

1.4

Kolar31

1987-89

292

3.4

Jaipur33

1988-91

1009

0.8

Tamil Nadu state35

1997

384

3.4

Composite North Arcot district*43

1999

282

2.8

Composite Raichur district†43

1999

278

2.5

Resistance to antituberculosis drugs arises from spontaneous chromosomal mutations in M. tuberculosis, which occur at predictable but unrelated rates. This means resistance to one drug usually does not imply resistance to another. For example, the chance of developing resistance to both isoniazid (1 in 10?) and rifampicin (1 in 10?) simultaneously is about 1 in 10¹?, which is extremely rare. Even in severe TB cases, such a high number of bacilli is unlikely. This forms the scientific basis of combination therapy in TB treatment. Mutations in specific drug target genes are the main cause of multidrug resistance. The molecular mechanisms of drug resistance as they are currently understood are listed in Table II.

Table-2 Biologic and Molecular Basis of Drug Resistance

Drug

Gene(S) Involved in Drug Resistance

Isoniazid

Enoyl acp reductase (inhA), Catalase-peroxidase (katG)

Alkyl hydroperoxide reductase (ahpC), Oxidative stress regulator (oxyR)

Rifampicin

RNA polymerase subunit B (rpoB)

Pyrazinamide

Pyrazinamidase  (pncA)

Streptomycin

Ribosomal protein subunit 12 (rpsL),16s ribosomal RNA (rrs)

Aminoglycoside phosphotransferase gene (strA)

Ethambutol

Arabinosyl transferase (emb A,B and C)

3.Causes of Multidrug-Resistant Tuberculosis (MDR-TB)

Multidrug-Resistant Tuberculosis (MDR-TB) is a significant global health challenge caused by Mycobacterium tuberculosis strains resistant to at least isoniazid and rifampicin, the two most potent first-line anti-TB drugs. The emergence of MDR-TB is multifactorial, involving treatment-related issues, patient behavior, healthcare system failures, transmission dynamics, biological mechanisms, and socioeconomic factors. Below is a detailed exploration of these causes, supported by credible references.

3.1Treatment-Related Causes

Incomplete Treatment: MDR-TB often develops when patients fail to complete their prescribed TB treatment regimens. Premature discontinuation allows Mycobacterium tuberculosis to survive and adapt, leading to drug resistance. Factors contributing to incomplete treatment include side effects, lack of access to healthcare, and patient non-compliance.

Improper Dosage: Incorrect dosages, whether due to prescribing errors or patient misunderstanding, can weaken the efficacy of anti-TB drugs. Suboptimal drug levels in the bloodstream create an environment for bacteria to develop resistance.

Substandard Medications: The use of low-quality or counterfeit drugs, often prevalent in resource-limited settings, results in ineffective treatment and fosters resistance.

3.2 Patient Behaviour and Adherence

Non-Adherence to Treatment: Lengthy and complex treatment regimens, often lasting months, lead to patients skipping doses or abandoning treatment altogether. This non-adherence is a major driver of resistance.

Lack of Awareness: Many patients are unaware of the importance of completing their treatment. Misconceptions about TB and its treatment contribute to interruptions in therapy.

3.3 Healthcare System Failures

Delayed or Incorrect Diagnosis: Misdiagnosis or delayed identification of TB can result in inappropriate treatment regimens, increasing the likelihood of resistance.

Inadequate Follow-Up: Insufficient monitoring of patients during and after treatment allows incomplete treatment to go unnoticed, leading to resistance.

Resource Limitations: In many low-income countries, healthcare systems lack access to second-line TB drugs and advanced diagnostic tools, hindering effective management of MDR-TB.

3.4Transmission of Resistant Strains

Direct Transmission: MDR-TB can spread directly from an infected individual to others through airborne droplets. This is particularly common in crowded or poorly ventilated environments, such as prisons and hospitals.

Close-Contact Scenarios: Overcrowded living conditions and inadequate infection control measures increase the risk of transmission of resistant strains.

3.5 Biological and Genetic Factors

Spontaneous Genetic Mutations: Mycobacterium tuberculosis can develop resistance through genetic mutations. These mutations occur naturally but are amplified by improper treatment practices.

Selective Pressure: Exposure to suboptimal drug concentrations creates selective pressure, allowing resistant bacteria to thrive while susceptible strains are eliminated.

3.6 Socioeconomic and Environmental Factors

Poverty and Malnutrition: Poor living conditions and inadequate nutrition weaken the immune system, making individuals more susceptible to TB infections and subsequent drug resistance.

Stigma and Discrimination: Social stigma surrounding TB often discourages patients from seeking timely diagnosis and treatment, contributing to the development of resistance.

4.Diagnosis of MDR-TB

Modern method

For quick drug-susceptibility testing of M. tuberculosis, radiometric techniques have been developed57–59. The 7H12 medium containing palmitic acid labeled with radioactive carbon (14C-palmitic acid) is used as an inoculant in the BACTEC-460 (BectonDickinson) radiometric procedure. The emission of radioactive carbon dioxide (14CO2), a sign of bacterial development, occurs as the mycobacteria break down these fatty acids. By substituting the BACTEC approach for the traditional Lowenstein-Jensen culture, the proportions method has been altered. Sensitivity findings with this change will be accessible in 10 days57,58. A quick and non-radioactive way to detect and test for M. tuberculosis susceptibility is the Becton-Dickinson mycobacteria growth indicator tube (MGIT) system59,60. In order to identify mycobacterial growth, the MGIT system uses an oxygen-sensitive fluorescent chemical that is housed in a silicone plug at the tube's bottom. A sample of mycobacteria is added to the medium, and as the bacteria grow, they use the oxygen and the chemical fluoresces. A UV transilluminator is used to detect the fluorescence that is so created. Comparable outcomes were obtained using the proportions method60 and the BACTEC in studies that used both direct clinical samples and cultured. By classifying and comparing isolates of M. tuberculosis, restriction fragment length polymorphism (RFLP) patterns have made it easier to understand the genetic epidemiology of TB61. Using this method, the cultivated bacilli's DNA is retrieved. The element is cleaved at base pair 461 by a restriction endonuclease like PvuII. Following electrophoresis on an agarose gel, DNA fragments are separated, transferred to a membrane (Southern blotting), hybridized, and detected using a labeled DNA probe. To construct the fingerprint, each mycobacterial isolate's DNA is represented as a set of bands on an X-ray film. The amount of insertion sequences and their separation from one another determine the banding pattern that represents the quantity and location of copies of IS6110, a 1361 base pair insertion sequence, within the chromosomes.

Advancements in Treatment: Mechanism of New Drugs for MDR-TB

Multidrug-Resistant Tuberculosis (MDR-TB) has long posed a challenge to global health due to its resistance to first-line anti-TB drugs. However, recent advancements in treatment regimens, particularly the BPaLM regimen, have revolutionized the management of MDR-TB. This section delves into the mechanisms of action of the drugs in the BPaLM regimen, their clinical significance, and their potential to transform MDR-TB treatment outcomes.

1. Overview of the BPaLM Regimen

The BPaLM regimen is a six-month, all-oral treatment protocol comprising Bedaquiline, Pretomanid, Linezolid, and Moxifloxacin. It has been endorsed by the World Health Organization (WHO) for eligible MDR-TB patients due to its shorter duration, higher efficacy, and reduced toxicity compared to traditional regimens.

2. Mechanism of Action of Key Drugs

Drug

Mechanism of action

Clinical significance

Bedaquiline

Inhibits ATP synthase, disrupting energy production in Mycobacterium tuberculosis.

Targets dormant bacteria, crucial for reducing relapse rates.

Pretomanid

Inhibits mycolic acid synthesis, essential for bacterial cell wall integrity.

Effective against both replicating and non-replicating TB bacteria.

Linezolid

Inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit.

Demonstrates strong activity against drug-resistant strains.

Moxifloxacin

Inhibits DNA gyrase, preventing bacterial DNA replication.

Broad-spectrum activity, enhancing the regimen's overall efficacy.

3. Advantages of the BPaLM Regimen

Shorter Duration: Reduces treatment time from 9–20 months to just six months, improving patient adherence.

Higher Efficacy: Clinical trials, such as the TB-PRACTECAL and ZeNix studies, have shown success rates exceeding 90%.

Reduced Toxicity: Eliminates the need for injectable drugs, minimizing severe side effects like hearing loss.

4. Challenges and Future Directions

Accessibility: Ensuring the availability of BPaLM in resource-limited settings remains a challenge.

Resistance Monitoring: Continuous surveillance is required to prevent the emergence of resistance to these new drugs.

Cost-Effectiveness: Studies indicate that BPaLM is cost-saving compared to traditional regimens, but affordability for low-income countries must be prioritized. Clinical Outcomes and Efficacy of MDR-TB Regimens

Clinical Outcomes and Efficacy of MDR-TB Regimens

1. Overview of Clinical Trials on New MDR-TB Regimens

Over the past decade, multiple clinical trials have evaluated the efficacy of novel MDR-TB treatment regimens. Notably, the TB-PRACTECAL trial and the ZeNix trial have provided strong evidence supporting shorter, all-oral regimens.

TB-Practecal Trial

Conducted by Médecins Sans Frontières (MSF), this trial compared the new BPaLM regimen (Bedaquiline, Pretomanid, Linezolid, Moxifloxacin) to conventional MDR-TB treatments. The trial demonstrated 90% treatment success rates in patients receiving BPaLM, significantly higher than the 50-60% success rates observed in standard regimens.

ZeNix Trial

This study focused on optimizing Linezolid dosage within the BPaLM regimen to minimize side effects while maintaining efficacy. The findings suggested that a lower dose of Linezolid (600mg vs. 1200mg daily) significantly reduced adverse events such as neuropathy and myelosuppression, without compromising treatment success.

2. Success Rates and Treatment Outcomes

Treatment Regimen

Treatment Duration

Success Rate

Adverse Effects

Traditional MDR-TB Regimen

18-24 months

50-60%

High toxicity, hearing loss, liver damage

Short-Course BPaLM Regimen

6 months

-90%

Reduced toxicity, improved adherence

Modified ZeNix BPaLM (Lower Linezolid Dose)

6months

-88%

Fewer neurological side effects

Key Takeaways

Shortened six-month regimens significantly improve patient compliance compared to traditional treatments. Higher cure rates (~90%) with BPaLM and its variations make them more effective alternatives to older regimens. Optimizing Linezolid dosage is critical for reducing side effects while maintaining efficacy.

3. Side Effects and Toxicity Analysis

While the BPaLM regimen offers substantial advantages, side effects—particularly those related to Linezolid—remain an area of concern.

Major Adverse Events Observed in BPaLM and ZeNix Trials

Linezolid-associated neuropathy: Tingling or numbness in extremities due to prolonged exposure to high doses.

Myelosuppression: Suppressed bone marrow activity, leading to reduced white blood cell count.

Mild gastrointestinal issues: Nausea, diarrhea, and fatigue, though less severe compared to conventional regimens.

Strategies to Minimize Toxicity

Lowering Linezolid dosage from 1200mg to 600mg reduces neuropathy while preserving therapeutic benefits.

Regular monitoring of patients for early signs of toxicity to adjust regimens accordingly.

Potential replacements for Linezolid are under investigation, aiming to develop safer alternatives.

CONCLUSION

Multidrug-Resistant Tuberculosis (MDR-TB) continues to pose a significant challenge to global health, particularly in regions with limited access to advanced healthcare facilities. This review has explored the multifactorial causes of MDR-TB, emphasizing the crucial role of treatment adherence, accurate diagnosis, and robust healthcare infrastructure in mitigating the spread of resistant strains. The emergence of novel treatment regimens, such as the BPaLM regimen, marks a significant milestone in MDR-TB management, offering shorter treatment durations, improved efficacy, and better patient adherence compared to traditional regimens. Clinical trials, including TB-PRACTECAL and ZeNix, have demonstrated the promise of these regimens in transforming patient outcomes while highlighting the need for continued monitoring to prevent drug resistance. Global efforts to combat MDR-TB must prioritize equitable access to advanced diagnostics and novel regimens, particularly in resource-constrained settings. Strengthening public health policies, fostering international collaboration, and addressing socioeconomic barriers are imperative for the successful implementation of these strategies. Additionally, continued research is essential to optimize current therapies, develop safer alternatives, and enhance diagnostic tools to ensure early detection and effective management of resistant strains. In conclusion, the fight against MDR-TB requires a comprehensive, patient-centered approach involving healthcare providers, policymakers, researchers, and communities. By aligning innovative treatments with public health strategies, the global community can make significant strides toward eliminating MDR-TB and reducing its burden. Achieving this goal will not only save lives but also contribute to a healthier, more resilient wor

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  38. Raviglione, M. C., & Smith, I. M. (2007). XDR tuberculosis—implications for global public health. New England Journal of Medicine, 356(7), 656–659. https://doi.org/10.1056/NEJMp068273
  39. Migliori, G. B., Ortmann, J., Girardi, E., Besozzi, G., Lange, C., Cirillo, D., & Raviglione, M. C. (2007). Extensively drug-resistant tuberculosis, Italy and Germany. Emerging Infectious Diseases, 13(5), 780–782. https://doi.org/10.3201/eid1305.061390
  40. Mitnick, C., Bayona, J., Palacios, E., Shin, S., Furin, J., Alcantara, F., ... & Farmer, P. (2003). Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. New England Journal of Medicine, 348(2), 119–128. https://doi.org/10.1056/NEJMoa022928
  41. Nathanson, E., Lambregts-van Weezenbeek, C., Rich, M. L., Gupta, R., Bayona, J., Blondal, K., ... & Espinal, M. (2006). Multidrug-resistant tuberculosis management in resource-limited settings. Emerging Infectious Diseases, 12(9), 1389–1397. https://doi.org/10.3201/eid1209.051618
  42. Goble, M., Iseman, M. D., Madsen, L. A., Waite, D., Ackerson, L., & Horsburgh, C. R. (1993). Treatment of 171 patients with pulmonary tuberculosis resistant to isoniazid and rifampin. New England Journal of Medicine, 328(8), 527–532. https://doi.org/10.1056/NEJM199302253280803
  43. Farmer, P., Bayona, J., Becerra, M., Furin, J., Henry, C., Hiatt, H., ... & Kim, J. Y. (1997). The dilemma of MDR-TB in the global era. International Journal of Tuberculosis and Lung Disease, 1(9), 749–759.
  44. Iseman, M. D., & Madsen, L. A. (1989). Drug-resistant tuberculosis. Clinical Chest Medicine, 10(3), 341–353.
  45. David, H. L. (1980). Probability distribution of drug-resistant mutants in unselected populations of Mycobacterium tuberculosis. Applied and Environmental Microbiology, 39(5), 1056–1058. https://doi.org/10.1128/aem.39.5.1056-1058.1980
  46. Mitchison, D. A. (1979). Basic mechanisms of chemotherapy. Chest, 76(6 Suppl), 771–781S. https://doi.org/10.1378/chest.76.6_supplement.771
  47. Canetti, G., Froman, S., Grosset, J., Hauduroy, P., Langerova, M., Mahler, H. T., ... & Sula, L. (1968). Mycobacteria: Laboratory methods for testing drug sensitivity and resistance. Bulletin of the World Health Organization, 38(5), 829–853.
  48. Crofton, J., & Mitchison, D. A. (1968). Streptomycin resistance in pulmonary tuberculosis. British Medical Journal, 1(5589), 849–853. https://doi.org/10.1136/bmj.1.5589.84.

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  41. Nathanson, E., Lambregts-van Weezenbeek, C., Rich, M. L., Gupta, R., Bayona, J., Blondal, K., ... & Espinal, M. (2006). Multidrug-resistant tuberculosis management in resource-limited settings. Emerging Infectious Diseases, 12(9), 1389–1397. https://doi.org/10.3201/eid1209.051618
  42. Goble, M., Iseman, M. D., Madsen, L. A., Waite, D., Ackerson, L., & Horsburgh, C. R. (1993). Treatment of 171 patients with pulmonary tuberculosis resistant to isoniazid and rifampin. New England Journal of Medicine, 328(8), 527–532. https://doi.org/10.1056/NEJM199302253280803
  43. Farmer, P., Bayona, J., Becerra, M., Furin, J., Henry, C., Hiatt, H., ... & Kim, J. Y. (1997). The dilemma of MDR-TB in the global era. International Journal of Tuberculosis and Lung Disease, 1(9), 749–759.
  44. Iseman, M. D., & Madsen, L. A. (1989). Drug-resistant tuberculosis. Clinical Chest Medicine, 10(3), 341–353.
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  46. Mitchison, D. A. (1979). Basic mechanisms of chemotherapy. Chest, 76(6 Suppl), 771–781S. https://doi.org/10.1378/chest.76.6_supplement.771
  47. Canetti, G., Froman, S., Grosset, J., Hauduroy, P., Langerova, M., Mahler, H. T., ... & Sula, L. (1968). Mycobacteria: Laboratory methods for testing drug sensitivity and resistance. Bulletin of the World Health Organization, 38(5), 829–853.
  48. Crofton, J., & Mitchison, D. A. (1968). Streptomycin resistance in pulmonary tuberculosis. British Medical Journal, 1(5589), 849–853. https://doi.org/10.1136/bmj.1.5589.84.

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Shubham Kumar
Corresponding author

SAGE UNIVERSITY BHOPAL.

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Abhishek Shrivastava
Co-author

SAGE UNIVERSITY BHOPAL.

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Dr.Jitendra Banweer
Co-author

SAGE UNIVERSITY BHOPAL.

Shubham Kumar*, Abhishek Shrivastava, Dr. Jitendra Banweer, A Review on New Drug Regimens in the Treatment of Multidrug-Resistant Tuberculosis, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 4, 3224-3235 https://doi.org/10.5281/zenodo.15287098

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