Strategies
Examine design
On this multicentre, double-blind, parallel-group efficacy and security examine, symptomatic adults inside three days of signs onset with a constructive fast SARS-CoV-2 antigen check have been randomized to obtain NONS or placebo. Nasal SARS-CoV-2 RNA presence was confirmed by a constructive reverse transcription polymerase chain response (RT-PCR) screening swab check (outcomes weren’t accessible till post-randomization).
Topics self-administered nitric oxide nasal spray or placebo two sprays per nostril; 0·45 mL/dose six instances a day, a minimum of two to a few hours aside whereas awake for seven remedy days (Day one to Day eight [end of treatment (EOT)]). All individuals obtained commonplace supportive care in accordance with newest tips issued by Ministry of Well being and Household Welfare from the Authorities of India, which included antipyretics for the remedy of fever and ache, antitussives for cough, and satisfactory hydration/vitamin.
The protocol obtained approval from every Investigator’s web site Institutional Ethics Committee (IEC). The trial was carried out in accordance with the Good Medical Apply (GCP), ideas of the Declaration of Helsinki, and all relevant nationwide and native regulatory necessities. The trial was initiated with 20 scientific websites throughout India; 15 websites enrolled topics within the examine from 10 August 2021 to 25 January 2022. A low incidence of COVID-19 infections and different precedence research prevented recruitment in 5 websites. A abstract of the important thing protocol amendments primarily based on dialogue with the regulatory authority Drug Controller Common of India (DCGI) is described within the Desk S1 (Supplementary Materials; Appendix).
Members
Eligible grownup women and men (aged 18–70 years) with gentle COVID-19 signs and a constructive nasal fast antigen check for SARS-CoV-2 have been enrolled into the examine no matter their vaccination standing. Gentle signs of COVID-19 included fever, cough, sore throat, malaise, headache, nasal congestion, muscle ache, gastrointestinal signs, lack of style or scent with out shortness of breath or dyspnea. The utmost permitted distinction within the time of onset of signs and the time of remedy was ≤ 72 hours. Blood oxygen saturation (SpO2) > 94 % and respiratory charge < 24 breaths/min have been additionally enrolment criterion.
For girls to be enrolled, proof of post-menopause, or a damaging pre-treatment urine being pregnant check (for pre-menopausal topics) was required. Girls of child-bearing age (feminine or male with feminine companion of child-bearing age) agreed to take efficient contraceptive measures (together with hormonal contraception, barrier strategies or abstinence) along with his/her companion throughout the examine interval and for a minimum of seven days following the EOT. All exclusion standards and prohibited drugs are listed in Desk S2 (Appendix).
Assessing COVID-19-Associated Signs in Outpatient Grownup and Adolescent Topics in Medical Trials of Medicine and Organic Merchandise for COVID-19 Prevention or Therapy Steerage for Business.
Written consent was obtained from all individuals.
Randomisation and masking
300 and 6 eligible individuals have been deliberate to be randomised in a 1:1 ratio to obtain NONS or matching an identical placebo nasal spray utilizing a computer-generated randomisation scheme (Desk S3, Appendix). Blinding of the remedy allocation was achieved through the use of remedy kits recognized by a numeric code; remedy allocation was primarily based on equipment numbers. An information security monitoring board reviewed the trial and examine knowledge.
Procedures
An in depth scientific historical past, bodily examination, vaccination standing, important indicators, SpO2 (measured non-invasively by Rad-57 Sign Extraction Pulse CO-Oximeter; Masimo Worldwide, US), 12-lead ECG, chest x-ray, blood (chemistries and haematology)/urine collections for laboratory analysis and eligibility evaluation have been carried out after acquiring knowledgeable consent (Desk S2, Appendix). Speedy Antigen Check (Meril Diagnostics Pvt. Ltd, sensitivity 96·6%, specificity 100%) for COVID-19 was carried out as a part of the screening evaluation by educated web site personnel. Topics with a damaging COVID-19 antigen end result have been thought of a display failure. Topics with a constructive COVID-19 antigen end result have been randomized. Swabs from each nostrils have been additionally taken for quantitative and qualitative RT-PCR assessments at baseline previous to remedy by educated web site personnel. The quantitative virus RNA was assessed at a central laboratory (Metropolis, Mumbai). Assay knowledge are introduced in items of SARS-CoV-2 genome equal copies per mL log10 values. An entire description of the assay technique is supplied in Desk S2 (Appendix).
Members have been randomized into one of many two remedy teams, provided a blinded examine remedy 25 mL nasal spray bottle, and instructed on the right way to self-administer every dose. The NONS and placebo spray bottles have been an identical in look (form and measurement [round], color [white], with a 22mm tapered white nasal tip actuator coated by a transparent mud cap), scent and style. NONS contained two NO producing components, gelling agent (hypromellose, [HPMC]), preservative (benzalkonium chloride 0·01%) in regular saline (0·9% sodium chloride). The placebo contained preservative (benzalkonium chloride 0·01%) in regular saline. In vitro antiviral exercise of NONS and placebo are described in Desk S4 (Appendix). Commonplace supportive care was supplied to all topics throughout the examine.
A minimal frequent consequence measure set for COVID-19 scientific analysis.
COVID-19 associated signs scores have been obtained utilizing the affected person reported outcomes (PRO) US-FDA signs questionnaire format. Methemoglobin (MetHb; Pulse CO-Oximeter) was measured in a subgroup of topics.
On Day two (≤ 24 hours on remedy), Day 4 (72 h on remedy), and Day eight (seven days on remedy; EOT) examine web site procedures included AE assessment, concomitant remedy assessment, examine remedy compliance assessment, nasal swabs for RT-PCR, SpO2, MetHb, important indicators and investigator’s WHO CPS rating; Day three (48 h on remedy) nasal swab for RT-PCR; Day 4 included a chest x-ray or CT scan (investigator’s discretion); Day eight additionally included a bodily examination, 12-lead ECG and blood/urine laboratory evaluations.
Any topics having a damaging baseline qualitative RT-PCR swab end result have been withdrawn from the examine as soon as the end result was accessible (inside at some point submit randomisation). For topics having a damaging qualitative RT-PCR (RT-PCR damaging) end result at Day 4, no RT-PCR assessments have been accomplished on Day eight.
The final topic contact was on Day 19 ± two days (with commonplace of care continued), or any time between Day eight and Day 19 if the topic’s COVID-19 symptom standing and RT-PCR end result turned damaging. The contact was both a telephonic go to or web site go to. Concomitant drugs, AEs and WHO CPS scores have been recorded. For topics who have been RT-PCR constructive on Day eight, a nasal swab from each nostrils was collected each two to a few days till their qualitative RT-PCR evaluation turned damaging or examine finish reached. Topics have been requested on Day one (baseline), Day two, Day 4, Day 8 (EOT), and their final day in regards to the complete variety of instant contacts (a minimum of eight hours of shut each day contact) that had turn out to be contaminated with COVID-19 (check confirmed). The whole variety of instant contacts with signs suggestive of COVID-19 an infection was captured.
Efficacy outcomes
The first goal and endpoint have been set to exhibit the power of NONS to scale back SARS-CoV-2 RNA quickly and considerably, utilizing the change from baseline in log viral RNA by EOT measured by quantitative RT-PCR. The secondary aims and endpoints have been centered on scientific and viricidal enchancment assist measures, together with the proportion of topics with damaging conversion of SARS-CoV 2 RT-PCR on Day two, three, 4, and eight; time required to realize a RT-PCR damaging standing; proportion of sufferers attaining a two level change in WHO CPS Rating on Day two, 4, eight and 19; proportion of topics requiring oxygen use or hospitalization for the remedy of COVID-19 by Day 19 and alter from baseline in COVID-19 associated signs at Day two, three, 4, eight and 19.
Security outcomes
Security and tolerability of NO nasal spray remedy (secondary endpoints) included the quantity and kinds of AEs and severe antagonistic occasions (SAEs). An AE was outlined as any unfavourable and unintended signal (together with an irregular laboratory discovering), symptom or illness (new or exacerbated) related to the usage of the examine drug, whether or not or not associated to the examine drug. An SAE included any untoward medical incidence that resulted in a loss of life; was life-threatening; required a hospitalization or prolongation of an current hospitalization; resulted in incapacity/incapacity or was an vital medical occasion which will have jeopardized the topic or required medical/surgical intervention to forestall one of many different outcomes beforehand listed.
Change from baseline in important indicators, ECG parameters, SpO2, MetHb, laboratory (chemistry, hematology, and urine) valuations and bodily examinations at EOT and/or the examine finish (Day 19) have been additionally decided.
Statistical evaluation
Major and secondary efficacy analyses have been carried out on knowledge from topics who had been randomized, obtained a minimum of one dose of examine remedy, had non-missing baseline measurements (excluded 58 topics with damaging RT-PCR at screening and 35 with damaging RT-PCR as much as at some point post-randomisation) and a minimum of one post-baseline efficacy measurement for the first efficacy variable (modified intent-to-treat [mITT] inhabitants). The regulatory authority, DCGI, really useful evaluation be centered on these prone to sickness development, i.e., excessive danger inhabitants. The excessive danger inhabitants was outlined as topics that have been unvaccinated, age ≥ 45 years or who had comorbidities. Analyses was additionally carried out within the unvaccinated and mITT populations. The per protocol (PP) inhabitants included all topics who have been randomized, obtained a minimum of one dose of examine remedy, accomplished the examine, and didn’t have any main protocol deviations. The excessive danger PP inhabitants evaluation carried out was supportive. Main protocol deviations have been mentioned and determined on the blinded knowledge assessment assembly earlier than the database lock.
- Pajon R
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The secondary efficacy evaluation included the proportion of topics with damaging conversion of SARS-CoV 2 RT PCR on Day two, 4 or eight primarily based on qualitative RT-PCR constructive/damaging outcomes. The time to occasion, a damaging SARS-CoV2 RT-PCR (conversion) end result, was analysed utilizing the Kaplan-Meier technique and log-rank. The proportion of sufferers attaining a 2-point change in WHO CPS rating on Day two, 4, eight and thru 19 (examine finish), and proportion of topics requiring hospitalization or oxygen use have been analysed utilizing the chi-square check or Fisher’s actual check. An exploratory analysis was carried out on the proportion of the instant examine topics’ contacts changing into contaminated with COVID-19 (i.e., % of contacts per analysis Day/remedy group for signs or SARS-CoV-2 constructive check).
Security analyses have been carried out on all randomized topics who had obtained a minimum of one dose of examine drug (security inhabitants).
The statistical and analytical plans for this examine are described within the protocol and statistical evaluation plan (SAP). All analyses have been carried out utilizing SAS® software program V 9·4. Datasets have been ready utilizing headings from Medical Knowledge Interchange Commonplace Consortium (CDISC) Evaluation Knowledge Mannequin (ADaM). The SAP was ready previous to remaining examine knowledge evaluation. Any modification to the evaluation plan was up to date within the SAP. Generally, all knowledge have been summarized with descriptive statistics (variety of topics, imply, and commonplace deviation, minimal, median and most) for steady endpoints, and frequency and proportion for categorical endpoints. Another abstract statistics are described on a person foundation.
Pattern measurement willpower
- Winchester S
- John S
- Jabbar Ok
- Isaac J
The AUC estimate was the most effective accessible knowledge, albeit utilized to a barely longer SARS-CoV-2 evaluation interval used on this examine (finish of remedy). As AUC just isn’t simply interpretable
Assessing COVID-19-Associated Signs in Outpatient Grownup and Adolescent Topics in Medical Trials of Medicine and Organic Merchandise for COVID-19 Prevention or Therapy Steerage for Business.
and thought of proportional to the imply change in viral RNA from baseline, the first endpoint centered on the imply change from baseline evaluation. The present trial assumed a standardised impact measurement of 0⋅5; 128 to 172 evaluable topics (64 to 86 topics per arm) would supply an influence of 80% to 90% with two-sided significance stage of 5%. For the secondary endpoint (RT-PCR conversion), assuming an RT-PCR conversion of 40% within the placebo group by EOT, 194 to 260 topics (97 to 130 topics in every arm) would supply an influence of 80 to 90% at two-sided significance stage of 5%, to detect a remedy distinction of 20% in proportion of topics attaining RT-PCR conversion. Assuming a dropout charge of 15%, 306 complete topics (153 topics per arm) was the enrollment goal.
Topics utilizing ≤ 80% of their complete anticipated doses of examine remedy over the remedy interval have been thought of non-compliant. The trial is registered with Medical Trials Registry India with identifier: CTRI/2021/08/035432.
Function of the funding supply: Glenmark Prescribed drugs Restricted is the sponsor of the examine.
Outcomes
Determine 1NONS Examine Trial Disposition.
The variety of topics finishing the trial was comparable between the NONS and placebo teams, 118 topics/NONS and 122 topics/Placebo, respectively. Eight topics didn’t full the examine. The commonest purpose for discontinuation was withdrawal by the topic [six (2·0%), followed by one (0·3%) each due to physician’s decision and a pregnancy]. The mITT inhabitants analyses included 207 topics (N = 105 in NONS; N = 102 in placebo, with all topics having a constructive RT-PCR worth at screening and as much as at some point submit randomization (35 further topics excluded from the first analyses for a damaging RT-PCR), excessive danger mITT inhabitants analyses included 133 topics (N = 64 analysed in NONS; N = 69 in placebo). The unvaccinated mITT inhabitants analyses included 90 topics (N = 44 analysed in NONS; N =46 in placebo).
Desk 1Traits of the sufferers at baseline (security inhabitants).
Percentages have been primarily based on the overall variety of topics in every remedy.
Efficacy
The excessive danger mITT grownup inhabitants analyses outcomes are the first focus of the report, with different inhabitants and sensitivity outcomes introduced within the Appendix.
Viral SARS-CoV-2 RNA discount
SARS-CoV-2 RNA (imply [SD]) log10 copies/mL have been diminished from 6·96 [1·51] (screening) to five·86 [1·51] and 5·09 [1·93] within the NONS group at Day two (≤ 24 hours) and Day three (48 hours) on remedy, respectively. Imply viral RNA log10 copies/mL have been diminished from 7·16 [1·53] (screening) to six·71 [1·56] and 5·98 [1·70] within the placebo group at Day 2 and Day 3 on remedy, respectively (Desk S6, Appendix).
After adjustment for baseline by MMRM, the imply viral RNA change from baseline was -1·20 [93·7% reduction (original anti-log scale)] and -1·98 [99·0% reduction] log10 copies/mL within the NONS group at Day 2 and Day 3 on remedy, respectively. The adjusted change from baseline in viral RNA log10 copies/mL at Day two and Day three on remedy with NONS have been statistically superior to the change in placebo with a imply remedy distinction [SE] of -0·82 [0·260] (6⋅6 fold enchancment); 95% CI -1·33, -0·31 (p = 0·002) and -0·87 [0·270] (7⋅4 fold enchancment); 95% CI -1·61, -0·12 (p = 0·022), respectively.
Desk 2Imply SARS-CoV-2 viral load (log10 copies per mL) change from baseline by day 8 in grownup COVID-19 contaminated sufferers (mITT excessive danger inhabitants: MMRM).
CFB = Change from baseline.
Imply change from baseline in viral load log values by Day eight (7 days of remedy) was analysed by MMRM. The distinction LSM(SE) between teams was calculated for NONS vs placebo (NONS-placebo). Sufferers have been required to have a constructive RT-PCR at Day one (screening) and Day two (≤ 24 submit randomisation). The 95% confidence interval (CI) for the LSM imply distinction between teams was calculated for NONS minus placebo. p-values have been calculated for the comparability of remedy teams with remedy as major impact and by contemplating go to, baseline worth, danger issue (excessive danger sure/no), and remedy by go to interplay as covariates.
Desk 3Normalized AUC SARS-CoV-2 viral load (log10 copies per mL) change from baseline by day 8 in grownup COVID-19 contaminated sufferers (mITT excessive danger inhabitants: MMRM).
AUC = normalized space below the curve.
Distinction LSM(SE) between teams was calculated for NONS vs placebo (NONS-placebo) by MMRM. Sufferers have been required to have a constructive RT-PCR at Day one (screening) and Day two (≤ 24 submit randomisation). The 95% confidence interval (CI) for the LSM imply distinction between teams was calculated for NONS minus placebo. p-values have been calculated for the comparability of remedy teams with remedy as major impact and by contemplating go to, baseline worth, danger issue (excessive danger sure/no), and remedy by go to interplay as covariates. Imply [SD] NONS baseline SARS-CoV-2 viral load was 6·96 [1·506] log10 copies/mL, and seven·16 [1·532] log10 copies/mL within the placebo group.
Extent and rapidity of virologic restoration
Determine 2Kaplan–Meier curve for time to damaging conversion of SARS-CoV 2 RT PCR (mITT excessive danger inhabitants).
Medical standing enchancment – investigator decided
Determine 3Proportion of grownup COVID-19 contaminated sufferers with ≥2 level scientific standing enchancment in WHO development scale rating (mITT excessive danger inhabitants).
Hospitalizations required for the remedy of COVID-19
No grownup COVID-19 contaminated affected person within the examine required hospitalization (or supplemental oxygen) for the remedy of COVID-19 by examine finish.
Rapid contacts with sufferers changing into contaminated with COVID-19
Determine 4Trial sufferers’ instant contacts reporting testing COVID-19 constructive and instant contacts having COVID-19 signs (mITT excessive danger inhabitants).
Security
Desk 4Abstract of grownup COVID-19 contaminated sufferers with antagonistic occasions by remedy group (security inhabitants).
Antagonistic occasion phrases have been coded utilizing MedDRA model 23·0 or newest. At every stage of summarization a topic was counted as soon as if the topic reported a number of occasions in a given stage of summarization. Percentages have been primarily based on the overall variety of topics in security inhabitants in every remedy. y is the overall variety of occasions in security inhabitants in every remedy.
Determine 5Methemoglobin ranges with NONS remedy at every go to day in grownup COVID-19 sufferers.
Dialogue
- McCarthy Ok
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- et al.
,
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- et al.
- Motozono C
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,
- Hirabara S
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The excessive danger inhabitants (outlined as unvaccinated, ≥ 45 years of age, or had a number of comorbidities within the current examine), demonstrated a profound SARS-CoV-2 RNA burden discount of 93·7% at 24 hours and 99·0% at 48 h with NONS. NONS had a fast impact of viral RNA discount, i.e., a 7⋅4 fold better viral RNA discount in comparison with placebo at 48 h of remedy. Clinically, that is putting in that our sufferers had excessive baseline viral RNA concentrations (107 copies/mL) related to presumably the very best danger for added sickness development.
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- et al.
- Weinreich D
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- Norton T
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An oral mixture antiviral remedy (ritonavir [100 mg]-boosted nirmatrelvir [300 mg] twice each day, demonstrated a -0⋅9 log10 copies/mL better decline than placebo in nasopharyngeal viral RNA by Day 5). We hypothesize the smaller than anticipated remedy distinction within the present trial is because of the usage of an lively placebo, carried out throughout a morphing SARS-CoV-2 VOC panorama, in topics additionally had free entry to hydroxychloroquine and azithromycin publicly throughout the trial; though use of hydrochloroquine was exclusionary). Our examine included individuals with vaccine breakthrough (46⋅1%), demonstrating the lack of vaccination to prevention infections throughout an outbreak of the Delta VOC (58% of individuals) or mixed Omicron/Delta VOCs (42% of individuals).
A considerably better proportion of excessive danger COVID-19 contaminated topics receiving NONS had no measurable SARS-CoV-2 RNA (RT-PCR damaging) by the tip of remedy (82·8% of NONS topics vs 66·7% of placebo; remedy distinction 16⋅1%, 95% CI 0·2, 32·1; p = 0·046). NONS topics have been 35·4 % extra more likely to obtain RT-PCR damaging standing 4 days sooner (72 h on remedy) than the placebo group (Day 8), which is predicted to lead to vital sickness burden discount and be clinically related to sufferers, clinicians, employers, insurers and governments. To our data no different outpatient antiviral therapies have as rapidly produced this damaging RT-PCR conversion. Clinically, extra topics receiving NONS have been asymptomatic with no detectable SARS-CoV-2 RNA, primarily based on the investigators’ WHO Medical Development Scale rating (two or extra level discount), close to the tip of the examine in comparison with placebo (Day 16 remedy distinction 12·6%, 95% CI 0·1, 25·1; p = 0·038).
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- Reiner Giorgio
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Others have advised {that a} shorter time to elimination of viral RNA will cut back the time of potential infectivity.
NONS quickly works inside the nostril to inactivate SARS-CoV-2 to probably shorten the length of a person’s infectivity, scientific an infection trajectory and virus transmissibility (per adhoc evaluation).
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,
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Clinically, the usage of NONS is predicted to lead to much less use of medical sources, much less lack of productiveness and days absence from work, and the upkeep of high quality of life (bodily, psychological and social; to be assessed in additional Section III trials). NONS use just isn’t anticipated to be related to the event of drug resistance or systemic drug-drug interactions, in contrast to these related to different anti-SARS-CoV-2 therapies. An extra good thing about NONS is its exercise in opposition to a broad spectrum of respiratory pathogens, together with influenza.
Utah State College Institute for Antiviral Analysis.Virucidal assay in opposition to Influenza A, HRV-14, and RSV. Report 2021-098. June 25, 2021 [data on file].
- Hirabara S
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Pattern measurement will proceed to extend considerably to satisfy this goal if used as a major endpoint. Quite we consider smaller samples sizes centered on the discount of RNA and pace to a damaging RT-PCR can equate to efficacy. At present permitted therapies have usually demonstrated efficacy by a discount of hospitalisation and deaths which has been related to an accelerated clearance of nasal viral RNA. Antivirals unable to realize a discount in viral RNA are usually not permitted by regulatory authorities or present in remedy tips. The placebo nasal spray used within the examine contained a preservative (benzalkonium chloride). Knowledge suggests regular saline and benzalkonium chloride have virucidal exercise.
SaNOtize examine report – management check of NONS formulation in opposition to H1N1 [2021, data on file].
The smaller than anticipated clinically vital impact measurement, primarily based on the pattern measurement calculation, was possible impacted by means of an lively placebo.
The exceptional security profile could also be useful if used within the aged, youngsters, immunocompromised and pregnant/breastfeeding ladies. The numerous discount in SARS-CoV-2 accompanied by an early virological treatment and symptomatic enchancment (investigator decided) with nitric oxide nasal spray demonstrated on this examine assist the usage of NONS for remedy of COVID-19 sufferers in these prone to sickness development.
Contributors
MT, WW, RK, AP, SR, KM, and CM have been concerned within the design or group of the trial, or each. SW, YPT, and SJ supplied the optimum strategies for nasal swab approach and laboratory PCR technique analyses. SK, AK, CRJ, RG, SN, RR, NB, AG, VP, DA, AN, VR, SK, ZP, and SB educated the examine workers and applied the strategies for recruitment the examine individuals, pattern collections, knowledge assortment and assessed the affect of remedy on the examine individuals. RK and AP have been concerned in knowledge administration. WW oversaw the technology and analyses of the information. WW, MT, RK, KM and CM analysed the information. KM and SW wrote the primary draft of the manuscript. All authors contributed to the ultimate model of the paper. MT, WW, RK, KM, SW, YPT, CM and SJ had full entry to all the information within the examine and had remaining duty for the choice to submit the manuscript for publication.
Acknowledgements
We want to thank Gilly Regev, PhD for her contribution to the examine protocol and content material. We want to thank Dr Hrishikesh Kulkarni, Dr Vinayak Sapakal, Sanjay Jankar, Dinesh Singh, Yashodhan Warke, Yogesh Gadage, Roshan Extra, Shubhangi Kalamkar, Dr Urmila Gupta, Sagar Borle, Reshma Extra, Prafulla Shetty, Harshani Sawant, Sunil Jagdale, Nikhil Khanwilkar, Nandakumar Thakur, Manali Mokal, Pankaj Khaire, Poonam Jadhav and Shraddha Nagpure for monitoring, knowledge administration, programming, and knowledge assessment. We want to thank the examine individuals, web site analysis workers, web site scientific workers, central laboratory, and knowledge security monitoring board. We sincerely thank the reviewers for his or her feedback and options which improved the standard of the paper.