Formulation and evaluation of controlled release matrices of ketoprofen and influence of different co-excipients on the release mechanism

The present work reports the study of different controlled release formulations of ketoprofen, which is a non-steroidal anti-inflammatory drug (NSAID) and like other NSAIDs requires large and frequent daily doses, resulting in severe side effects and non-compliance. To avoid these problems, controlled release matrices were developed using different grades of ethylcellulose polymer with a drug-polymer ratio of 10:3 by the direct compression method. The effect on drug release of partial replacement of lactose by different co-excipients, HPMC K100 M, starch and CMC, was also studied. The tablets were tested for their drug content, weight variation, friability, hardness, thickness and diameter, all these physical properties being within the USP range. The release profile of all formulations containing polymer and co-excipients was compared with a formulation developed without polymer and co-excipients. After a 24-hour release study, it was concluded that formulations containing different grades of ethylcellulose polymer showed prolonged release for 6-18 hours, but the formulation containing the polymer Ethocel standard FP 7 Premium without co-excipient showed controlled release for 24 hours. DSC and FT-IR studies were performed to investigate any incompatibility between drug, polymer and co-excipient but no interaction was found. Different kinetic models were used, such as first order equation, zero order equation, Higuachi equation, Hixon Crowel's equation and Korsmeyer-Peppas to study the release mechanism. The formulations containing co-excipients showed an enhanced release rate.

A rare case of an aberrant anterior mitral valve chord resulting in severe mitral regurgitation

A 49 year old female presented with severe dyspnoea due to mitral regurgitation. Echocardiography revealed an aberrant mitral valve chord causing severe mitral regurgitation. The aberrant chord extended between the anterior mitral valve leaflet (AMVL) and the atrial septum causing AMVL prolapse. Resection of the aberrant chord and correction of the AMVL using synthetic Gore-Tex sutures was performed. The patient made an uneventful recovery with post-op echocardiography demonstrating normal mitral valve function.

Craniosynostosis: early recognition prevents fatal complications

BACKGROUND

Craniosynostosis is the premature fusion of cranial vault sutures. The overall incidence is 3-5/10,000 live births. With multiple craniosynostoses, brain growth may be impeded by the unyielding skull. Most cases of single suture involvement can be treated with linear excision of suture. Involvement of multiple sutures or skull has usually required combined efforts of neurosurgeons and craniofacial surgeons.

METHODS

On the basis of visible skull deformity all patients were admitted in the Department of Neurosurgery, Liaquat University Hospital, Jamshoro, Pakistan. Patients were examined for signs of raised ICP and other congenital deformities. The records of patients were maintained till follow up.

RESULTS

Twenty-seven children were included in this study from 2002 to 2009. Age range was 1-6 years, boys were 18 (66.6%), and girls were 9 (33.3%). The common suture affected was coronal 12 (44.4%). Two children with craniostenosis belonged to same family, and all presented with suture involvement. Three (11.1%) deaths occurred due to hypothermia (1), and blood loss (2).

CONCLUSION

Early diagnosis, expert surgical techniques and per- and postoperative care for bleeding and temperature regulation prevent mortality and morbidity.

Understanding hypertrophic cardiomyopathy: implications of diagnosis for the patient and family

Hypertrophic cardiomyopathy (HCM) may be a challenging condition for an internist. The algorithm for work-up and treatment is fairly straight forward when the presentation is classic. However, in the real world, subtle and moderate forms of the disease occur more commonly. We analyse, step by step, diagnosis and management of a patient with mild HCM and review the literature on pertinent questions regarding diagnosis, risk stratification, treatment options and implications for patient's lifestyle and for his family.

Scintimammography in conjunction with ultrasonography for local breast cancer recurrence in post-mastectomy breast

The aim of this study was to compare the usefulness of (99)Tc(m)-methoxy-isobutyl-isonitrile (MIBI) scintimammography and ultrasonography, alone and in combination, for the detection of chest wall recurrence in the post-mastectomy breast. A total of 41 consecutive post-mastectomy patients (mean age 46.6 years; median age 45 years) with clinical suspicion of breast cancer recurrence were evaluated. For scintimammography all patients received a 740-900 MBq iv injection of (99)Tc(m)-MIBI; planar images were taken 5-10 min post-injection followed by supine single photon emission CT. Breast ultrasonography was performed in each patient using a 7.5 MHz transducer. Both MIBI uptake and ultrasound findings were documented using standard protocols. All patients had fine needle aspiration cytology biopsy (FNAC), core biopsy or excision biopsy for final tissue diagnosis. Of the 41 patients, 24 had true positive signs of local breast cancer recurrence upon ultrasonography, 10 were diagnosed as true negatives, a sensitivity of 86%, specificity 77%, positive predictive value (PPV) 89%, negative predictive value (NPV) 71% and accuracy 83% (p = 0.001). By comparison, scintimammography findings were found to be true positive in 25 patients and true negative in 12 patients - sensitivity 89%, specificity 92%, PPV 96%, NPV 80% and accuracy 90% (p = 0.001). Using a combination of these two modalities, the combined sensitivity was 100%, specificity 77%, PPV 90%, NPV 100% and accuracy 93%. The high NPV of the two studies in combination implies a potential use of this approach to exclude recurrent disease in patients with a low initial index of suspicion and/or when histology is indeterminate.

Cardiac ischaemia and rhythm disturbances during elective colonoscopy

BACKGROUND

The number of colonoscopic procedures continues to rise rapidly. With widespread adoption of colonoscopy based bowel screening programmes, this rising trend is set to continue.

AIMS

This study aimed to identify whether elective colonoscopy could provoke cardiac rhythm disturbances and/or myocardial ischaemia, as evidenced by 12 lead Holter ECG recordings and troponin I (cTnI) changes.

MATERIALS AND METHODS

Patients were stratified into three groups based on the presence of cardiac disease or cardiovascular risk factors. They underwent real time 12 lead Holter monitoring before, during and after colonoscopy. Bloods were taken for pre- and post-procedure cTnI estimation.

RESULTS

Holter ECG recordings of the three groups showed a high incidence of new but silent ischaemic and arrhythmic ECG changes during the colonoscopy in patients with documented but stable heart disease and to a lesser extent in those patients with one or more risk factors for heart disease. Three patients had high cTnI concentrations both before and after colonoscopy. Two patients with known heart disease died within 30 days of colonoscopy.

CONCLUSIONS

This study demonstrates for the first time the occurrence of potentially clinically significant ST-T wave changes and rhythm disturbances during elective colonoscopy in patients with known heart disease and to a lesser extent in those patients with a known cardiovascular risk profile.

Burden of Haemophilus influenzae type b disease in Pakistani children

Estimates of the burden of Haemophilus influenzae type b (Hib) in children in Pakistan are limited. A prospective surveillance was set up in 8 sentinel sites in Karachi and Hyderabad in January 2004. A total of 1481 children aged < 5 years underwent lumbar puncture for suspected acute bacterial meningitis. Specimens from 237 (16.0%) children met the criteria for probable bacterial meningitis, and Hib was detected in 45 of them (19.0%). The minimum detected incidence of Hib meningitis in the Hyderabad area was 7.6 per 100 000 in children < 5 years of age, and 38.1 per 100 000 children < 1 year. Hib vaccination is justified for inclusion in Pakistan's expanded programme of immunization.

Hematopoietic stem cell transplantation in Oman

Hematopoietic SCT (HSCT) is an integral part of the management of patients with hematologic disorders. The Sultanate of Oman, with a population of 2.3 million, has an HSCT program based in the Sultan Qaboos University (SQU) hospital. Initiated in 1995, this two-bed unit continues to be the only program in the country. Between June 1995 and August 2006, a total of 128 patients underwent HSCT in this center, averaging about 10-12 transplants per year. The median age of these patients was 11 years (2 months to 45 years). Hematologic malignancies (49%) and inherited disorders (42%) constituted the major transplant indications, whereas BM failure accounted for the remaining. The majority of transplants carried out so far have been HLA-matched sibling-donor allogeneic HSCTs. Among the inherited disorders, homozygous beta-thalassemia and primary immunodeficiency are important transplant indications in this center. The approximate cost of an uncomplicated transplant in this center is US$50,000. The success of this program has now led to the initiation of a new and larger HSCT complex to provide the opportunity for more patients to benefit from this treatment modality within the country.

Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled Type 2 diabetes in East London

AIMS

To determine the prevalence and reasons for refusal to commence insulin in Bangladeshi patients with Type 2 diabetes.

METHODS

A survey of 212 Bangladeshi patients seen in a hospital diabetes unit, with poor glycaemic control (HbA(1c)>or= 8.0%) on maximum oral glucose-lowering therapy, in whom insulin was deemed necessary. Patients who refused insulin were invited to attend focus groups. Data were analysed by thematic content analysis using the constant comparative method.

RESULTS

Of 212 patients offered insulin, 122 (57.5%) commenced insulin immediately, 47 (22.1%) started insulin within 6 months and 43 (20.3%) refused to commence insulin despite repeated counselling. Thirty-six (83.7%) of those who refused insulin agreed to participate in focus groups. Reasons for insulin refusal included: disease severity--perceptions that requirement for insulin was an indicator of a more serious stage of their condition; insulin leading to premature death--common suggestion that commencing insulin led to early death; loss of control--including fear of hypoglycaemia, weight gain, loss of independence and reliance on others to give insulin or look for signs of hypoglycaemia; lack of perception of benefits--poor perception of the benefits of improved glycaemic control on quality of life and cardiovascular risk; needle anxiety--a significant proportion of subjects conveyed concern over frequent injections.

CONCLUSIONS

Insulin refusal is common in Bangladeshi subjects with Type 2 diabetes and poor glycaemic control. A number of factors contribute to this, and methods to overcome the barriers to insulin therapy need to be sought.

Rule base system for identification of patients with specific critical care syndromes: The "sniffer" for acute lung injury

Early detection of specific critical care syndromes, such as sepsis or acute lung injury (ALI)is essential for timely implementation of evidence based therapies. Using a near-real time copy of the electronic medical records ("ICU data mart") we developed and validated custom electronic alert (ALI"sniffer") in a cohort of 485 critically ill medical patients. Compared with the gold standard of prospective screening, ALI "sniffer" demonstrated good sensitivity, 93% (95% CI 90 to 95) and specificity, 90% (95% CI 87 to 92). It is not known if the bedside implementation of ALI "sniffer" will improve the adherence to evidence-based therapies and outcome of patients with ALI.

Outcome of Pregnancy in Renal Allograft Recipients: SIUT Experience

The course of pregnancy and its outcome was studied in renal allograft recipients. Between November 1985 and November 2005, a total of 1481 renal transplants were carried out at the Sindh Institute of Urology and Transplantation (SIUT); among them were 348 females, with 73 potential females for pregnancy. All patients received cyclosporine and prednisolone, with 82% also receiving azathioprine and 4 patients mycophenolate mofetil as a third immunosuppressant drug. We evaluated incidence of hypertension, diabetes, pre-eclampsia, urinary tract infection (UTI), rejection during pregnancy and during 3 months' postdelivery as well as outcomes of pregnancy. Among 73 potential candidates, 31 had 47 pregnancies, after an average of 31 months (8-86 months). Of 31 subjects, 21 subjects were hypertensive on one or two drugs prior to conception. A rise in blood pressure during pregnancy was noticed in 7 patients. Albuminuria from trace to 3+ appeared in 13 patients and glycosuria in one other. Blood sugar levels remained within normal range in all subjects. UTIs occurred during pregnancy in 7 patients. Among 47 pregnancies, 9 had abortions (7 spontaneous, 2 therapeutic) and 6 had preterm deliveries. The others were full-term deliveries: 12 via a lower segment caesarean section and 20 were normal vaginal deliveries. Average birth weight was 4.8 lbs. At an average follow-up of 38 months the serum creatinine values ranged from 0.94 to 2.3 mg %. One patient developed acute irreversible graft dysfunction soon after delivery. Our study demonstrated that pregnancy did not reduce renal graft survival, but newborns are at greater risk of premature birth and low birth weight.

Experimental study on a large animal model of a new thermoablation technique

BACKGROUND

A novel technique of thermoablation, using a microtube to deliver pulses of hot water vapour, was tested on a large animal model in order to evaluate its efficacy and potential adverse effects.

MATERIALS AND METHODS

The medical device consisted of a microtube extension connected to a hydropneumatic pump. Pulses of pure water were injected though the microtube where they were heated and delivered as vapour into the target zone. The method was tested on the liver of 12 healthy pigs, either during open surgery or percutaneously under ultrasounds.

RESULTS

The technique was efficient and well-tolerated by the animals. Large volumes of necrotic tissue were created in a significantly short time compared to concurrent thermoablative techniques.

CONCLUSION

Anticipating human application, this experimental study demonstrated a safe and efficient innovative thermoablation technique. The first human applications have been successfully performed and will be reported soon.

Routine database registration of biological therapy increases the reporting of adverse events twentyfold in clinical practice. First results from the Danish Database (DANBIO)

OBJECTIVE

To present from the Danish Database for Biological Therapies in Rheumatology (DANBIO) the frequencies and types of adverse events as well as risk factors during treatment with biological agents in clinical practice.

METHODS

Adverse events during the first 2 years of clinical use of biological agents in Denmark were reported to the nationwide DANBIO and compared to the mandatory reports to the Danish Medicines Agency.

RESULTS

Almost 90% of the patients treated with biological agents were registered in the DANBIO, and the database picked up 20 times as many adverse events as the Danish Medicines Agency. Infections and hypersensitivity reactions were the most prevalent adverse events. Age, disease duration, and previous number of disease-modifying anti-rheumatic drugs (DMARDS) were found to be risk factors for bacterial infections.

CONCLUSION

A routine-based Danish database for biological therapies covers approximately 90% of patients and improves the reporting of adverse events.

Ethnic differences in patient perceptions of heart failure and treatment: the West Birmingham heart failure project

OBJECTIVE

To investigate further the hypothesis that ethnic groups would have different levels of knowledge and perceptions of congestive heart failure (CHF) and treatments for this condition, a cross sectional survey was conducted of patients who were attending the heart failure clinics in two teaching hospitals of Birmingham, UK, that serve a multiethnic population.

METHODS

103 patients with CHF (66 men, 37 women) were surveyed by standard questionnaire: 42 were white, 34 Indo-Asian, 22 Afro-Caribbean, and 5 Oriental.

RESULTS

When asked about their beliefs about control of one's health, 22 (64.7%) of Indo-Asians felt that God/fate controlled their health. The majority of white patients tended to believe that the greatest factor influencing their health was the doctor (15 (35.7%)). Of the total study cohort, only 68 (66%) of patients were aware of their primary diagnosis of heart failure; the majority of Indo-Asians (21 (61.8%)) were not aware of their diagnosis. Half of Indo-Asians (17 (50%)) felt that heart failure was not severe, in contrast to 40.9% (n = 9) of Afro-Caribbeans and only 19.1% (n = 8) of white patients. Of the study cohort, 38 (36.9%) were taking their drugs because their doctor told them to, a response most common among the Indo-Asians. The majority of Indo-Asians (22 (64.7%)) and Afro-Caribbeans (14 (63.6%)) stated that they did not have, or did not know whether they had enough, information about their drug. The corresponding figure for white patients was 21.4% (n = 9). When asked whether they took their medication regularly as prescribed, 7 (31.8%) of Afro-Caribbeans reported that they did not take their drugs regularly.

CONCLUSIONS

Our study has highlighted deficiencies in the knowledge of CHF among patients from ethnic minority groups, as well as deficiencies in the information being given to these patients. There is a clear need to invest more in patient education for CHF, with special emphasis on certain high risk subgroups.

Alpha-1 antitrypsin deficiency in emphysema

Human plasma contains a number of proteinase inhibitors which together form 10% of the total plasma proteins. Serine proteases are a group of closely related proteolytic enzymes, with serine in their active site. These play a key role in coagulation, fibrinolysin, kinin and complement activation. Serine protease inhibitors or "serpins" are specific inhibitors which control the activities of these enzymes. Among the serine protease inhibitors. Alpha-1 antitrypsin (alpha1 ATD) is found in highest concentration in plasma. It is the major physiologic inhibitor for neutrophil elastase. It has control over the elastase mediated degradation of elastic tissue in the lung. Alpha1ATD deficiency is a common genetic disorder and potentially lethal disease predominantly found in North European population--where the incidence is one in 2500; worldwide figures suggest that one in 6000 people have classic alpha1ATD. In cases of deficiency, antielastase activity is reduced in the lungs which results in increased elastin breakdown and development of emphysema. Cigarette smoking contributes to destructive changes in emphysema by suppressing the proteinase inhibitory activity of human serum and by inducing certain bronchoalveolar changes. Prevalence and severity of asthma increases in persons with abnormal alpha1ATD phenotype.

Comparison between clinical and radiologic outcome measures after reconstruction of acetabular fractures

OBJECTIVES

To compare clinical and radiologic outcome measures in patients after reconstruction of acetabular fractures and to investigate whether an objective radiologic outcome could be used as a proxy for a clinical outcome.

DESIGN

Follow-up survey with retrospective analysis of consecutive case records.

PATIENTS AND INTERVENTION

Over a ten-year period, 201 consecutive patients had open reduction and internal fixation of acetabular fractures performed by a single surgeon. The outcome measures on 166 fractures were available for analysis when the twenty-six patients who were lost to follow-up and the fourteen patients who had salvage total hip replacement were excluded.

MAIN OUTCOME MEASUREMENTS

The assessment of patients was performed by one of two independent assessors, who used the Merle d'Aubigné (1954) clinical outcome score and a radiologic score of degenerative hip disease (Matta, 1994).

RESULTS

Although the overall correlation between the clinical and radiologic outcome grades was good (r = 0.63, p < 0.001), their agreement (i.e., the prediction of a specific clinical outcome by a corresponding radiologic one) was poor (Kappa = 0.24). The authors found that the clinical scoring system was difficult to apply specifically to acetabular trauma in 29 percent of fractures because of complications related to associated injuries. When the individual Merle d'Aubigné scores for pain, range of motion, and walking were correlated with the radiologic score, it was found that the walking score had a significant association with the radiologic score and the pain and range of movement scores.

CONCLUSIONS

The Merle d'Aubigné score has shortcomings as an outcome measure for acetabular fractures. Our aim to use a radiologic outcome as a proxy for this clinical grading system was not realized, but we propose that the patient's walking ability could be used as an objective local outcome measurement.

Daytime sleepiness and other sleep disorders in Parkinson's disease

BACKGROUND

PD is associated with a variety of sleep problems. The dopamine agonists (DA) pramipexole and ropinirole were recently implicated in causing "sleep attacks" and motor vehicle accidents.

METHODS

In order to determine the overall rate of subjective sleep problems in PD and to determine if any factors, including specific medications, correlate with sleep pathology, the authors surveyed consecutive patients with PD seen over a 3-month period in a Movement Disorders Clinic. The authors collected demographic and medication data, and the patients completed the Epworth Sleepiness Scale (ESS), questions assessing the presence of restless legs syndrome (RLS), a modified National Sleep Foundation sleep survey, and specific questions regarding falling asleep while driving.

RESULTS

A total of 320 patients completed the questionnaire. The authors eliminated 17, six for incomplete data and 11 for having a primary diagnosis other than PD. The mean age of the remaining 303 patients was 67.1 +/- 10.7 years, and the mean duration of PD was 9.1 +/- 5.7 years. The ESS scores averaged 11.1 +/- 5.9, and in 50.2% of patients the score was abnormally high (>10). Stepwise regression analysis found that sleepiness correlated with longer duration of PD (p < 0.001), more advanced PD (p < 0.004), male sex (p < 0.001), and the use of any DA (p < 0.003). The soporific effects of the three most common DA (pramipexole, ropinirole, and pergolide) were similar. Falling asleep while driving was reported by 63/279 (22.6%) of current drivers and correlated with higher ESS scores (p < 0.05). Other sleep disorders, including RLS, were also frequently reported.

CONCLUSION

Daytime sleepiness is common in PD and correlates with more advanced and longer duration of PD, and male sex. The DA were also independently associated with daytime sleepiness, but in this group, no single DA was more culpable than the others.

The influence of additives on the spreading coefficient and adhesion of a film coating formulation to a model tablet surface

The surface energies of film coating formulations based on hydroxypropyl methylcellulose and containing microcrystalline cellulose, lactose and Tween 20, respectively, have been assessed. The approach taken allowed the components of the surface energy, in terms of the Lifshitz-van der Waals and the acid-base contributions, to be determined. Spreading coefficients of these coating formulations were determined on a model tablet surface whose surface energy had been similarly characterised. The determined spreading coefficients were high and positive indicating that spreading and wetting would not be a controlling factor in the formation of an adequate film coat. The adhesion of the coats to the core was measured and showed that the inclusion of additives influenced the adhesion of the film. Maximum adhesion was obtained when microcrystalline cellulose was included in the coating formulation that presumably allowed a strong interaction with the same component in the tablet core. Adhesion was enhanced when the tablet cores were made at a higher compaction force. Atomising air pressure had little influence on the adhesion.

Catheter ablation in patients with multiple and unstable ventricular tachycardias after myocardial infarction: short ablation lines guided by reentry circuit isthmuses and sinus rhythm mapping

BACKGROUND

Extensive lines of radiofrequency (RF) lesions through infarct (MI) can ablate multiple and unstable ventricular tachycardias (VTs). Methods for guiding ablation that minimize unnecessary RF applications are needed. This study assesses the feasibility of guiding RF line placement by mapping to identify a reentry circuit isthmus.

METHODS AND RESULTS

Catheter mapping and ablation were performed in 40 patients (MI location: inferior, 28; anterior, 7; and both, 5) with an electroanatomic mapping system to measure the infarct region and ablation lines. The initial line was placed in the MI region either through a circuit isthmus identified from entrainment mapping or a target identified from pace mapping. A total of 143 VTs (42 stable, 101 unstable) were induced. An isthmus was identified in 25 patients (63%; 5 with only stable VTs, 5 with only unstable VTs, and 15 with both VTs). Inducible VTs were abolished or modified in 100% of patients when the RF line included an isthmus compared with 53% when RF had to be guided by pace mapping (P=0.0002); those with an isthmus identified received shorter ablation lines (4.9+/-2.4 versus 7.4+/-4.3 cm total length, P=0.02). During follow-up, spontaneous VT decreased markedly regardless of whether an isthmus was identified. VT stability and number of morphologies did not influence outcome.

CONCLUSIONS

A 4- to 5-cm line of RF lesions abolishes all inducible VTs in more than 50% of patients. Less ablation is required if a reentry circuit isthmus is identified even when multiple and unstable VTs are present.