Development, implementation and critique of a bioethics framework for pharmaceutical sponsors of human biomedical research

Pharmaceutical human biomedical research is a multi-dimensional endeavor that requires collaboration among many parties, including those who sponsor, conduct, participate in, or stand to benefit from the research. Human subjects' protections have been promulgated to ensure that the benefits of such research are accomplished with respect for and minimal risk to individual research participants, and with an overall sense of fairness. Although these protections are foundational to clinical research, most ethics guidance primarily highlights the responsibilities of investigators and ethics review boards. Currently, there is no published resource that comprehensively addresses bioethical responsibilities of industry sponsors; including their responsibilities to parties who are not research participants, but are, nevertheless key stakeholders in the endeavor. To fill this void, in 2010 Eli Lilly and Company instituted a Bioethics Framework for Human Biomedical Research. This paper describes how the framework was developed and implemented and provides a critique based on four years of experience. A companion article provides the actual document used by Eli Lilly and Company to guide ethical decisions regarding all phases of human clinical trials. While many of the concepts presented in this framework are not novel, compiling them in a manner that articulates the ethical responsibilities of a sponsor is novel. By utilizing this type of bioethics framework, we have been able to develop bioethics positions on various topics, provide research ethics consultations, and integrate bioethics into the daily operations of our human biomedical research. We hope that by sharing these companion papers we will stimulate discussion within and outside the biopharmaceutical industry for the benefit of the multiple parties involved in pharmaceutical human biomedical research.

Occurrence of pharmaceuticals and endocrine disrupting compounds in macroalgaes, bivalves, and fish from coastal areas in Europe

The occurrence and levels of PhACs, Endocrine Disrupting and related Compounds (EDCs) in seafood from potential contaminated areas in Europe has been studied. Macroalgae (Saccharina latissima and Laminaria digitata), bivalves (Mytilus galloprovincialis, Mytilus spp., Chamalea gallina and Crassostrea gigas) and fish (Liza aurata and Platichthys flesus) from Portugal, Spain, Italy, Netherlands, and Norway were analysed following 4 different analytical protocols depending on the organism and target group of contaminants. The results revealed the presence of 4 pharmaceutical compounds in macroalgae samples, 16 in bivalves and 10 in fish. To the best of our knowledge, this is the first time that PhACs have been detected in marine fish and in macroalgae. Besides, this is also the first time that dimetridazole, hydrochlorothiazide and tamsulosin have been detected in biota samples. The highest levels of PhACs corresponded to the psychiatric drug velanfaxine (up to 36.1 ng/g dry weight (dw)) and the antibiotic azithromycin (up to 13.3 ng/g dw) in bivalves from the Po delta (Italy). EDCs were not detected in macroalgae samples, however, the analysis revealed the presence of 10 EDCs in bivalves and 8 in fish. The highest levels corresponded to the organophosphorus flame retardant tris(2-butoxyethyl)phosphate (TBEP) reaching up to 98.4 ng/g dw in mullet fish from the Tagus estuary. Bivalves, in particular mussels, have shown to be good bioindicator organisms for PhACs and fish for EDCs. Taking into consideration the concentrations and frequencies of detection of PhACs and EDCs in the seafood samples analysed, a list of candidates' compounds for priorization in future studies has been proposed.

Eli Lilly and Company's bioethics framework for human biomedical research

Current ethics and good clinical practice guidelines address various aspects of pharmaceutical research and development, but do not comprehensively address the bioethical responsibilities of sponsors. To fill this void, in 2010 Eli Lilly and Company developed and implemented a Bioethics Framework for Human Biomedical Research to guide ethical decisions. (See our companion article that describes how the framework was developed and implemented and provides a critique of its usefulness and limitations.) This paper presents the actual framework that serves as a company resource for employee education and bioethics deliberations. The framework consists of four basic ethical principles and 13 essential elements for ethical human biomedical research and resides within the context of our company's mission, vision and values. For each component of the framework, we provide a high-level overview followed by a detailed description with cross-references to relevant well regarded guidance documents. The principles and guidance described should be familiar to those acquainted with research ethics. Therefore the novelty of the framework lies not in the foundational concepts presented as much as the attempt to specify and compile a sponsor's bioethical responsibilities to multiple stakeholders into one resource. When such a framework is employed, it can serve as a bioethical foundation to inform decisions and actions throughout clinical planning, trial design, study implementation and closeout, as well as to inform company positions on bioethical issues. The framework is, therefore, a useful tool for translating ethical aspirations into action - to help ensure pharmaceutical human biomedical research is conducted in a manner that aligns with consensus ethics principles, as well as a sponsor's core values.

Towards spatially smart abatement of human pharmaceuticals in surface waters: Defining impact of sewage treatment plants on susceptible functions

For human pharmaceuticals, sewage treatment plants (STPs) are a major point of entry to surface waters. The receiving waters provide vital functions. Modeling the impact of STPs on susceptible functions of the surface water system allows for a spatially smart implementation of abatement options at, or in the service area of, STPs. This study was performed on a nation-wide scale for the Netherlands. Point source emissions included were 345 Dutch STPs and nine rivers from neighboring countries. The Dutch surface waters were represented by 2511 surface water units. Modeling was performed for two extreme discharge conditions. Monitoring data of 7 locations along the rivers Rhine and Meuse fall mostly within the range of modeled concentrations. Half of the abstracted volumes of raw water for drinking water production, and a quarter of the Natura 2000 areas (European Union nature protection areas) hosted by the surface waters, are influenced by STPs at low discharge. The vast majority of the total impact of all Dutch STPs during both discharge conditions can be attributed to only 19% of the STPs with regard to the drinking water function, and to 39% of the STPs with regard to the Natura 2000 function. Attributing water treatment technologies to STPs as one of the possible measures to improve water quality and protect susceptible functions can be done in a spatially smart and cost-effective way, using consumption-based detailed hydrological and water quality modeling.

Ethnomedicinal uses of Edible Wild Fruits (EWFs) in Swat Valley, Northern Pakistan

ETHNOPHARMACOLOGICAL RELEVANCE

This study documents the ethno-pharmacological importance of Edible Wild Fruits (EWFs) resource in the wild floral emporium of Swat, Khyber Pakhtunkhwa Northern Pakistan. This is imitated in the great diversity of plants used for medicinal purposes as well as in their wide range of therapeutic applications.

METHODS

Ethnomedicinal data was collected through semi-structured and open ended interviews, questionnaires, field surveys and local gatherings. Use value (UV), Relative importance (RI), Relative frequency of citation (RFC), Informant consensus factor (ICF) and Family importance value (FIV) was calculated to elaborate the EWFs, their families, disease treated and significant fruit species based on use reports by informants.

RESULTS

A total of 47 species of EWFs belonging to 32 genera and 23 families were reported to be used in traditional medicines. Family Rosaceae dominated with 26% species followed by Moraceae (12%) and Rhamnaceae (10%), with mostly tree type of growth form (55%). The most consumed part of plants was fruit (72%) followed by leaves (21%). Decoction (26%) and unprocessed fruit (24%) were the major modes of crude drug preparation. The Informant consensus factor (ICF) of Joint/body aches was the highest followed by digestive disorders. Use value index of Vitis vinifera (3.8), being the highest, followed by Malus pumila (2) and Vitis parvifolia (2).

CONCLUSION

The tradition of using EWFs in treating ailments is a common practice among the tribal communities, depending on the socio-economic conditions of the people. The multiple uses of these EWFs suggest further investigation regarding phytochemical analysis and pharmaceutical applications.

On-demand drug delivery from local depots

Stimuli-responsive polymeric depots capable of on-demand release of therapeutics promise a substantial improvement in the treatment of many local diseases. These systems have the advantage of controlling local dosing so that payload is released at a time and with a dose chosen by a physician or patient, and the dose can be varied as disease progresses or healing occurs. Macroscale drug depot can be induced to release therapeutics through the action of physical stimuli such as ultrasound, electric and magnetic fields and light as well as through the addition of pharmacological stimuli such as nucleic acids and small molecules. In this review, we highlight recent advances in the development of polymeric systems engineered for releasing therapeutic molecules through physical and pharmacological stimulation.

The impact of pharmaceutical innovation on premature cancer mortality in Canada, 2000-2011

The premature cancer mortality rate has been declining in Canada, but there has been considerable variation in the rate of decline across cancer sites. I analyze the effect that pharmaceutical innovation had on premature cancer mortality in Canada during the period 2000-2011, by investigating whether the cancer sites that experienced more pharmaceutical innovation had larger declines in the premature mortality rate, controlling for changes in the incidence rate. Premature mortality before age 75 is significantly inversely related to the cumulative number of drugs registered at least 10 years earlier. Since mean utilization of drugs that have been marketed for less than 10 years is only one-sixth as great as mean utilization of drugs that have been marketed for at least a decade, it is not surprising that premature mortality is strongly inversely related only to the cumulative number of drugs that had been registered at least ten years earlier. Premature mortality before age 65 and 55 is also strongly inversely related to the cumulative number of drugs that had been registered at least ten years earlier. None of the estimates of the effect of incidence on mortality are statistically significant. Controlling for the cumulative number of drugs, the cumulative number of chemical subgroups does not have a statistically significant effect on premature mortality. This suggests that drugs (chemical substances) within the same class (chemical subgroup) are not therapeutically equivalent. During the period 2000-2011, the premature (before age 75) cancer mortality rate declined by about 9 %. The estimates imply that, in the absence of pharmaceutical innovation during the period 1985-1996, the premature cancer mortality rate would have increased about 12 % during the period 2000-2011. A substantial decline in the "competing risk" of death from cardiovascular disease could account for this. The estimates imply that pharmaceutical innovation during the period 1985-1996 reduced the number of years of potential life lost to cancer before age 75 in 2011 by 105,366. The cost per life-year before age 75 gained from previous pharmaceutical innovation is estimated to have been 2730 USD. Most of the previously-registered drugs were off-patent by 2011, but evidence suggests that, even if these drugs had been sold at branded rather than generic prices, the cost per life-year gained would have been below 11,000 USD, a figure well below even the lowest estimates of the value of a life-year gained. The largest reductions in premature mortality occur at least a decade after drugs are registered, when their utilization increases significantly. This suggests that, if Canada is to obtain substantial additional reductions in premature cancer mortality in the future (a decade or more from now) at a modest cost, pharmaceutical innovation (registration of new drugs) is needed today.

Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters

BACKGROUND

For the purpose of understanding the Food and Drug Administration's (FDA's) concerns regarding online promotion of prescription drugs advertised directly to consumers, this study examines notices of violations (NOVs) and warning letters issued by the FDA to pharmaceutical manufacturers.

METHODS

The FDA's warning letters and NOVs, which were issued to pharmaceutical companies over a 10-year period (2005 to 2014) regarding online promotional activities, were content-analyzed.

RESULTS

Six violation categories were identified: risk information, efficacy information, indication information, product labeling, material information issues, and approval issues. The results reveal that approximately 95% of the alleged violations were found on branded drug websites, in online paid advertisements, and in online videos. Of the total 179 violations, the majority of the alleged violations were concerned with the lack of risk information and/or misrepresentation of efficacy information, suggesting that achieving a fair balance of benefit versus risk information is a major problem with regard to the direct-to-consumer advertising (DTCA) of prescription drugs. In addition, the character space limitations of online platforms, eg, sponsored links on search engines, pose challenges for pharmaceutical marketers with regard to adequately communicating important drug information, such as indication information, risk information, and product labeling.

CONCLUSION

Presenting drug information in a fair and balanced manner remains a major problem. Industry guidance should consider addressing visibility and accessibility of information in the web environment to help pharmaceutical marketers meet the requirements for direct-to-consumer promotion and to protect consumers from misleading drug information. Promotion via social media warrants further attention, as pharmaceutical manufacturers have already begun actively establishing a social media presence, and the FDA has thus begun to keep tabs on social media promotions of prescription drugs.

Interpretation of cardiovascular outcome trials in type 2 diabetes needs a multiaxial approach

In cardiovascular (CV) diabetology a "one-size fits-all" approach needs caution as vasculopathy and CV manifestations in patients with type 2 diabetes (T2D) with short disease duration are different as compared to those with longer duration. This is of relevance when interpreting results of CV outcome trials as responses to any intervention aimed to reduce CV risk might be different in patients with established vasculopathy as compared to those without, where also the duration of the intervention may play a role. Additionally, the mode-of-action of the intervention and its assumed time to peak CV risk modulation need to be taken into account: an intervention with possibly immediate effects, like on blood pressure or other direct functional dynamic parameters such as endothelial function or renal hemodynamics, could likely provide a meaningful impact on CV outcomes over a shorter time span than interventions that primarily target pathways that work on atherosclerotic processes, organ-remodelling, or vessel integrity. We are now faced with CV outcome results to interpret from a plethora of outcomes trials in T2D, some of which are testing the CV risk modulation predominantly beyond glucose lowering, e.g., as is the case for several trials testing the newer therapy classes di-peptidyl peptidase-4 inhibitors, glucagon-like protein-1 receptor analogues and sodium glucose co-transporter-2 inhibitors, and this paper reviews the data that support a call for a multiaxial approach to interpret these results.

Influence of temperature on thyroid hormone signaling and endocrine disruptor action in Rana (Lithobates) catesbeiana tadpoles

Thyroid hormones (THs) are essential for normal growth, development, and metabolic control in vertebrates. Their absolute requirement during amphibian metamorphosis provides a powerful means to detect and assess the impact of environmental contaminants on TH signaling in the field and laboratory. As poikilotherms, frogs can experience considerable temperature fluctuations. Previous work demonstrated that low temperature prevents precocious TH-dependent induction of metamorphosis. However, a shift to a permissive higher temperature allows resumption of the induced metamorphic program regardless of whether or not TH remains. We investigated the impact of temperature on the TH-induced gene expression programs of premetamorphic Rana (Lithobates) catesbeiana tadpoles following a single injection of 10pmol/g body wet weight 3,3',5-triiodothyronine (T3). Abundance profiles of several T3-responsive mRNAs in liver, brain, lung, back skin, and tail fin were characterized under permissive (24°C), nonpermissive (5°C), or temperature shift (5-24°C) conditions. While responsiveness to T3 was retained to varying degrees at nonpermissive temperature, T3 modulation of thibz occurred in all tissues at 5°C suggesting an important role for this transcription factor in initiation of T3-dependent gene expression programs. Low temperature immersion of tadpoles in water containing 10nM T3 and the nonsteroidal anti-inflammatory drug, ibuprofen, or the antimicrobial agent, triclosan, perturbed some aspects of the gene expression programs of tail fin and back skin that was only evident upon temperature shift. Such temporal uncoupling of chemical exposure and resultant biological effects in developing frogs necessitates a careful evaluation of environmental temperature influence in environmental monitoring programs.

Occurrences of pharmaceuticals in drinking water sources of major river watersheds, China

Pharmaceuticals in drinking water sources (DWSs) have raised significant concerns for their persistent input and potential human health risks. Currently, little is known about the occurrence of pharmaceuticals in DWSs in China. In this study, a survey for multi-class pharmaceuticals in DWSs of five major river watersheds in China was conducted from 2012 to 2013. Samples were collected from 25 sampling sites in rivers and reservoirs. 135 pharmaceuticals were analyzed using solid-phase extraction and ultra-performance liquid chromatography tandem mass spectrometry. The results showed that a total of 70 pharmaceuticals were present in the samples, and the most frequently detected ones included sulfonamides, macrolides, antiepileptic drugs, anti-inflammatory drugs, and β-blockers, etc. Amongst these, maximum concentrations of lincomycin, sulfamethoxazole, acetaminophen and paraxanthine were between 44 ng/L and 134 ng/L, and those of metoprolol, diphenhydramine, venlafaxine, nalidixic acid and androstenedione were less than 1 ng/L. Concentrations of the two that were most persistent, DEET and carbamazepine, were 0.8-10.2 ng/L and 0.01-3.5 ng/L, respectively. Higher concentrations of cotinine were observed in warm season than in cold season, while concentrations of lincomycin were the opposite. In a causality analysis, the occurrence of pharmaceuticals in DWSs depends mainly on the detection limits of the methods, their usage and the persistence in the aquatic environment.

Linking the environmental loads to the fate of PPCPs in Beijing: Considering both the treated and untreated wastewater sources

The environmental loads of pharmaceutical and personal care products (PPCPs) in Beijing were estimated from direct discharge of untreated wastewater and WWTP treated effluent. The annual environmental loads of 15 PPCP components ranged from 16.3 kg (propranolol) to 9.85 tons (caffeine). A fugacity model was developed to successfully estimate the PPCP pollution based on the estimated environmental load. The modeled results approximated the observed PPCP concentrations in Beijing. The untreated wastewater contributed significantly to PPCP pollution in Beijing, ranging from 46% (propranolol) to 99% (caffeine). The total environmental burden of target PPCPs ranged from 0.90 kg (propranolol) to 536 kg (caffeine). Water is the most important media for the fate of PPCPs. Monte Carlo-based concentration distributions of PPCPs are consistent with the observed results. The most important way to reduce the PPCP pollution is to both improve wastewater collection rate and adopt deep treatment technologies.

A Time-Trend Economic Analysis of Cancer Drug Trials

BACKGROUND

Scientific advances have led to the discovery of novel treatments with high prices. The cost to publicly fund high-cost drugs may threaten the sustainability of drug budgets in different health care systems. In oncology, there are concerns that health-benefit gains are diminishing over time and that the economic evidence to support funding decisions is too limited.

METHODS

To assess the additional costs and benefits gained from oncology drugs over time, we used treatment protocols and efficacy results from U.S. Food and Drug Administration records to calculate cost-effectiveness ratios for drugs approved to treat first- and second-line metastatic or advanced breast, colorectal, and non-small cell lung cancer during the years 1994-2013. We assessed reimbursement recommendations reached by health technology assessment agencies in the U.K., Australia, and Canada.

RESULTS

Cost-effectiveness ratios were calculated for 50 drugs approved by the U.S. regulator. The more recent approvals were often based on surrogate efficacy outcomes and had extremely high costs, often triple the costs of drugs approved in previous years. Over time, the effectiveness gains have increased for some cancer indications; however, for other indications (non-small cell lung and second-line colorectal cancer), the magnitude of gains in effectiveness decreased. Reimbursement recommendations for drugs with the highest cost-effectiveness ratios were the most inconsistent.

CONCLUSION

Evaluation of the clinical benefits that oncology drugs offer as a function of their cost has become highly complex, and for some clinical indications, health benefits are diminishing over time. There is an urgent need for better economic evidence from oncology drug trials and systematic processes to inform funding decisions.

IMPLICATIONS FOR PRACTICE

High-cost oncology drugs may threaten the ability of health care systems to provide access to promising new drugs for patients. In order to make better drug-funding decisions and enable equitable access to breakthrough treatments, discussions in the oncology community should include economic evidence. This study summarizes the extra benefits and costs of newly approved drugs from pivotal trials during the postgenomic era of drug discovery. The reader will gain an appreciation of the need for economic evidence to make better drug-reimbursement decisions and the dynamics at play in today's oncology drug market.

Occurrence of selected pharmaceuticals at drinking water purification plants in Japan and implications for human health

The present study was performed to determine the occurrence of 64 pharmaceuticals and metabolites in source water and finished water at 6 drinking water purification plants and 2 industrial water purification plants across Japan. The analytical methods employed were sample concentration using solid-phase extraction cartridges and instrumental analysis by liquid chromatography with tandem mass spectrometry (LC-MS/MS), liquid chromatography with mass spectrometry (LC/MS), or trimethylsilyl derivatization followed by gas chromatography with mass spectrometry (GC/MS). Thirty-seven of the 64 target substances were detected in the source water samples. The maximum concentrations in the source water were mostly below 50 ng/L except for 13 substances. In particular, residual concentrations of iopamidol (contrast agent) exceeded 1000 ng/L at most facilities. Most of the residual pharmaceuticals and metabolites in the source water samples were removed in the course of conventional and/or advanced drinking water treatments, except for 7 pharmaceuticals and 1 metabolite, i.e., amantadine, carbamazepine, diclofenac, epinastine, fenofibrate, ibuprofen, iopamidol, and oseltamivir acid. The removal ratios of the advanced water treatment processes including ozonation and granular activated carbon filtration were typically much higher than those of the conventional treatment processes. The margins of exposure estimated by the ratio of daily minimum therapeutic dose to daily intake via drinking water were substantial, and therefore the pharmacological and physiological impacts of ingesting those residual substances via drinking water would be negligible.

Proteomics in pharmaceutical research and development

In the 20 years since its inception, the evolution of proteomics in pharmaceutical industry has mirrored the developments within academia and indeed other industries. From initial enthusiasm and subsequent disappointment in global protein expression profiling, pharma research saw the biggest impact when relating to more focused approaches, such as those exploring the interaction between proteins and drugs. Nowadays, proteomics technologies have been integrated in many areas of pharmaceutical R&D, ranging from the analysis of therapeutic proteins to the monitoring of clinical trials. Here, we review the development of proteomics in the drug discovery process, placing it in a historical context as well as reviewing the current status in light of the contributions to this special issue, which reflect some of the diverse demands of the drug and biomarker pipelines.

Method development and validation of arene substituted regioisomers in a pharmaceutical candidate by high temperature GC-FID

This paper describes the development and validation of a high temperature gas chromatography flame ionization detection (HTGC-FID) method for the purity evaluation of arene substituted regioisomers in a key starting material of a pharmaceutical candidate in Phase 3 studies. The chromatographic conditions of the method employ a (5%-phenyl)-methylpolysiloxane packed column (30m×0.25mm) at a constant flow of 1.0mLmin(-1) with a gradient temperature program from 150°C to 400°C with injector and detector temperatures of 300°C and 340°C, respectively. The calibration curve for the desired product (r=0.9999) was assessed for five points in the range from approximately 1.0μgmL(-1) to 40μgmL(-1). The precision (% RSD) of the method was calculated for six replicate injections and found to be 0.81%. The limits of detection and quantitation were determined to be 0.06 and 0.20μgmL(-1), respectively.

Transformation products of antibiotic and cytostatic drugs in the aquatic cycle that result from effluent treatment and abiotic/biotic reactions in the environment: an increasing challenge calling for higher emphasis on measures at the beginning of the pipe

Pharmaceuticals may undergo transformation into new products during almost all possible processes along their life-cycle. This could either take place in the natural water environment and/or during water treatment processes. Numerous studies that address the issue of such transformation products (TPs) have been published, describing selected aspects of TPs in the environment and their formation within effluent and water treatment processes. In order to exemplify the number and quality of information published on TPs, we selected 21 active pharmaceutical ingredients from the groups of antibiotics and antineoplastics, and assessed the knowledge about their TPs that has been published until the end of May 2012. The goal of this work was to demonstrate, that the quality of data on pharmaceutical TPs greatly differs in terms of the availability of chemical structures for each TP, rather than to provide an exhaustive database of available TPs. The aim was to point out the challenge going along with so many TPs formed under different treatment and environmental conditions. An extensive review in the form of a table showing the existing data on 158 TPs for 15 compounds, out of 21 investigated, was presented. Numerous TPs are the result of different treatments and environmental processes. However, also numerous different TPs may be formed within only one type of treatment, applied under sometimes even very similar treatment conditions and treatments times. In general, the growing number of elucidated TPs is rationalized by ineffective removal treatments. Our results demonstrate a severe risk of drowning in much unrelated and non-assessable data, both from a scientific and from a technical treatment-related point of view. Therefore, limiting the input of pharmaceuticals into effluents as well as improving their (bio) degradability and elimination behavior, instead of only relying on advanced effluent treatments, is urgently needed. Solutions that focus on this "beginning of the pipe" approach should minimize the adverse effects of parent compounds by reducing and formation of TPs and their entrance into the natural environment.

A review on emerging contaminants in wastewaters and the environment: current knowledge, understudied areas and recommendations for future monitoring

This review identifies understudied areas of emerging contaminant (EC) research in wastewaters and the environment, and recommends direction for future monitoring. Non-regulated trace organic ECs including pharmaceuticals, illicit drugs and personal care products are focused on due to ongoing policy initiatives and the expectant broadening of environmental legislation. These ECs are ubiquitous in the aquatic environment, mainly derived from the discharge of municipal wastewater effluents. Their presence is of concern due to the possible ecological impact (e.g., endocrine disruption) to biota within the environment. To better understand their fate in wastewaters and in the environment, a standardised approach to sampling is needed. This ensures representative data is attained and facilitates a better understanding of spatial and temporal trends of EC occurrence. During wastewater treatment, there is a lack of suspended particulate matter analysis due to further preparation requirements and a lack of good analytical approaches. This results in the under-reporting of several ECs entering wastewater treatment works (WwTWs) and the aquatic environment. Also, sludge can act as a concentrating medium for some chemicals during wastewater treatment. The majority of treated sludge is applied directly to agricultural land without analysis for ECs. As a result there is a paucity of information on the fate of ECs in soils and consequently, there has been no driver to investigate the toxicity to exposed terrestrial organisms. Therefore a more holistic approach to environmental monitoring is required, such that the fate and impact of ECs in all exposed environmental compartments are studied. The traditional analytical approach of applying targeted screening with low resolution mass spectrometry (e.g., triple quadrupoles) results in numerous chemicals such as transformation products going undetected. These can exhibit similar toxicity to the parent EC, demonstrating the necessity of using an integrated analytical approach which compliments targeted and non-targeted screening with biological assays to measure ecological impact. With respect to current toxicity testing protocols, failure to consider the enantiomeric distribution of chiral compounds found in the environment, and the possible toxicological differences between enantiomers is concerning. Such information is essential for the development of more accurate environmental risk assessment.

Development of a SPE-HPLC-MS/MS method for the determination of most prescribed pharmaceuticals and related metabolites in urban sewage samples

Based on regional prescription data several pharmaceuticals with variable amounts of prescription and corresponding metabolites were selected and analyzed in influent and effluent samples of the sewage treatment plant (STP) in Dresden, Germany. Pharmaceuticals of the following most prescribed therapeutic groups were chosen: antibiotics, antifungals, anticonvulsants, antipsychotics, antidepressants, and cardiovascular active compounds like beta blockers and angiotensin-converting enzyme inhibitors. To analyze the selected compounds, a multi-target method was developed and applied to 24-h composite wastewater samples for three single days in May and June 2014. The method was based on a cleanup of a sample with a volume of 1mL using solid phase extraction followed by a high performance liquid chromatography coupled to a tandem mass spectrometer. Analytes were separated in a 15min chromatographic separation and quantified using 23 Internal Standards and a calibration curve in 40-fold diluted blank urine. The limit of quantification varied between 50 and 200ng/L and for all analytes good accuracy and precision as well as linearity for the calibration curve with the correlation coefficient R(2) higher than 0.99 was reached. A total of 41 and 40 of the selected 55 analytes were detected and quantified in the influent and effluent samples of the studied STP, respectively. Valsartan was the compound with the highest maximum concentration in influent (27.1μg/L) and effluent (15.7μg/L). Furthermore, analytes like bezafibrate, candesartan, carbamazepine, gabapentin, metoprolol, levetiracetam, pregabalin and telmisartan as well as the metabolite O-desmethyl venlafaxine were detectable in influent and effluent samples, respectively, with a concentration higher than 1μg/L.

Monitoring simultaneous photocatalytic-ozonation of mixture of pharmaceuticals in the presence of immobilized TiO2 nanoparticles using MCR-ALS: Identification of intermediates and multi-response optimization approach

The present study has focused on the degradation of a mixture of three pharmaceuticals, i.e. methyldopa (MDP), nalidixic acid (NAD) and famotidine (FAM) which were quantified simultaneously during photocatalytic-ozonation process. The experiments were conducted in a semi-batch reactor where TiO2 nanoparticles (crystallites mean size 8nm) were immobilized on ceramic plates irradiated by UV-A light in the proximity of oxygen and/or ozone. The surface morphology and roughness of the bare and TiO2-coated ceramic plates were analyzed using scanning electron microscopy (SEM) and atomic force microscopy (AFM). An analytical methodology was successfully developed based on both recording ultraviolet-visible (UV-Vis) spectra during the degradation process and a data analysis using multivariate curve resolution with alternating least squares (MCR-ALS). This methodology enabled the researchers to obtain the concentration and spectral profiles of the chemical compounds which were involved in the process. A central composite design was used to study the effect of several factors on multiple responses namely MDP removal (Y1), NAD removal (Y2) and FAM removal (Y3) in the simultaneous photocatalytic-ozonation of these pharmaceuticals. A multi-response optimization procedure based on global desirability of the factors was used to simultaneously maximize Y1, Y2 and Y3. The results of the global desirability revealed that 8mg/L MAD, 8mg/L NAD, 8mg/L FAM, 6L/h ozone flow rate and a 30min-reaction time were the best conditions under which the optimized values of various responses were Y1=95.03%, Y2=84.93% and Y3=99.15%. Also, the intermediate products of pharmaceuticals generated in the photocatalytic-ozonation process were identified by gas chromatography coupled to mass spectrometry.

Evaluation of biological endpoints in crop plants after exposure to non-steroidal anti-inflammatory drugs (NSAIDs): implications for phytotoxicological assessment of novel contaminants

Human pharmaceuticals have been detected in the terrestrial environment at µg to mg kg(-1) concentrations. Repeated application of sewage sludge (biosolids) and increasing reclaimed wastewater use for irrigation could lead to accumulation of these novel contaminants in soil systems. Despite this, potential phytotoxicological effects on higher plants have rarely been evaluated. These studies aimed to test effects upon germination, development, growth and physiology of two crop plants, namely radish (Raphanus sativus Spakler 3) and lettuce (Lactuca sativa All Year Around), after exposure to different, but structurally related non-steroidal anti-inflammatory drugs (NSAIDs) at environmentally relevant concentrations. A range of biological endpoints comprising biomass, length, water content, specific root and shoot length, root to shoot ratio, daily progress of stages of cell elongation and organ emergence (primary root, hypocotyl elongation, cotyledon emergence, cotyledon opening, and no change), as well as photosynthetic measurements were evaluated. Compounds from the fenamic acid class were found to affect R. sativus root endpoints (root length and water content), while ibuprofen affected early root development of L. sativa. In general, phytotoxicological effects on root endpoints demonstrated that impacts upon higher plants are not only compound specific, but also differ between plant species. It was found that the usage of a wide range of biological endpoints (all simple, cost-effective and ecologically relevant) were beneficial in detecting differences in plant responses to NSAID exposure. Due to paucity and discrepancy within the few previously available phytotoxicological studies with pharmaceuticals, it is now essential to allocate time and resources to consider development of suitable chronic toxicity tests, and some suggestions regarding this are presented.

Multi-residue analysis of pharmaceuticals in wastewater by liquid chromatography-magnetic sector mass spectrometry: method quality assessment and application in a Belgian case study

Through systematic research a novel analytical method using solid-phase extraction (SPE) and liquid chromatography magnetic sector mass spectrometry was developed for the measurement of 43 pharmaceuticals in wastewater. A thorough method validation quantified the contribution of both the extraction recovery and matrix effects in the overall method process efficiency, and a detailed uncertainty analysis was performed to elaborate a quality labelling strategy to be used in data interpretation. Compounds for which a precise (relative standard deviation<20%) process efficiency between 60% and 140% was determined, were labelled as 'quantitative' whereas the results for other compounds should be interpreted as 'indicative'. Method application on influent and effluent samples of (i) a conventional active sludge system and (ii) a parallel membrane bioreactor/conventional active sludge wastewater treatment plant in Belgium revealed the occurrence of 22 pharmaceuticals. The anti-inflammatory drug diclofenac and the antidepressant venlafaxine were measured in the effluents at concentrations ranging from 0.5 to 1.8 μg L(-1) and 0.2 to 0.5 μg L(-1), respectively, which indicated to be of high potential environmental risk for the receiving river Dender, Belgium.

Elimination of polar micropollutants and anthropogenic markers by wastewater treatment in Beijing, China

Anthropogenic contamination of surface waters in Asia is on the increase. While polar organic contaminants are gradually recognized for their impacts on aquatic ecosystems in the Western World, less is known about the situation in Asia. In developing countries like China, water resources are particularly vulnerable. We investigated the occurrence, elimination, and per capita loads of a wide range of pharmaceuticals, household chemicals and pesticides in five Beijing WWTPs representative for megacities in China, and compare the efficiency of different treatment processes. Based on initial screening for 268 micropollutants using high-resolution mass spectrometry, 33 compounds were examined in detail. Pollutant concentrations in raw wastewater ranged from <0.02 μg L(-1) for pesticides to >20 μg L(-1) for caffeine and the contrast agent iopromide. Concentrations in the WWTP effluents were generally <1 μg L(-1), except for some pharmaceuticals, iopromide (1.2-18 μg L(-1)), caffeine (0.025-2.3 μg L(-1)), and the artificial sweetener sucralose (2.7-3.5 μg L(-1)). Elimination efficiencies varied greatly from <1% to close to 100%, with macrolides, some sulfonamides, metronidazole, iopromide, and 4-acetamidoantipyrine being the most persistent compounds. Total per capita loads of the investigated micropollutants were lower than in communal wastewater of Europe, amounting to 7.9-12.2 and 2.0-6.5 g d(-1)1000 inhabitants(-1) in the influents and effluents, respectively, with an average release of ∼100 kg d(-1) by the 11.4 million people and 2.3 million m(3) of wastewater treated per day. Since the wastewater effluents are often used for agricultural irrigation, residual organic pollutants pose a threat to food safety, the development of antibacterial resistance, and combined effects of micropollutants in the aquatic environment.

Validating pharmaceutical product claims: questions a formulary committee should ask

Claims, justifying the acceptance and placement of new products on health system formularies, are all too often presented in terms that are either unverifiable or only verifiable in a timeframe that is of no practical benefit to formulary committees. One solution is for formulary committees to request that (i) all predictive claims made should be capable of empirical testing and (ii) manufacturers in making submissions should be asked to submit a protocol that details how their claims are to be assessed. Evaluation of claims can provide not only a significant input to ongoing disease area and therapeutic reviews, but can also provide a needed link to comparative effectiveness research and value-based healthcare. This paper presents a set of protocol standards (PROST) together will questions that should be addressed in a protocol review.

Personalised dosing: Printing a dose of one's own medicine

Ink-jet printing is a versatile, precise and relatively inexpensive method of depositing small volumes of solutions with remarkable accuracy and repeatability. Although developed primarily as a technology for image reproduction, its areas of application have expanded significantly in recent years. It is particularly suited to the manufacture of low dose medicines or to short production runs and so offers a potential manufacturing solution for the paradigm of personalised medicines. This review discusses the technical and clinical aspects of ink-jet printing that must be considered in order for the technology to become widely adopted in the pharmaceutical arena and considers applications in the literature.

Characterization of trenbolone acetate and estradiol metabolite excretion profiles in implanted steers

Exogenous growth promoters have been used in US beef cattle production for over 50 yr. The environmental fate and transport of steroid growth promoters suggest potential for endocrine-disrupting effects among ecological receptors; however, the initial excretion of steroid metabolites from cattle administered growth promoters has not been well characterized. To better characterize excretion of trenbolone acetate and estrogen metabolites, steers were assigned to 1 of the following treatment groups: control, given no implant, or treatment, administered a combination implant (200 mg trenbolone acetate, 40 mg estradiol). Blood, urine, and fecal samples were collected over the course of 112 d following implantation. Samples were extracted and analyzed by liquid chromatography tandem mass spectrometry for trenbolone acetate and estrogen metabolites. In both urine and feces, 17α-trenbolone and 17α-estradiol were the predominant metabolites following implantation. Mean concentrations of 17α-trenbolone and 17α-estradiol in feces of implanted steers were 5.9 ± 0.37 ng/g and 2.7 ± 0.22 ng/g, respectively. A best-fit model is presented to predict 17α-trenbolone and 17α-estradiol excretion from steers receiving implants. The present study provides the first characterization of both trenbolone and estrogen metabolites in excreta from implanted cattle and will help provide estimates of steroid production from feedyards in the United States.

Obtaining process mass balances of pharmaceuticals and triclosan to determine their fate during wastewater treatment

To better understand pharmaceutical fate during wastewater treatment, analysis in both aqueous and particulate phases is needed. Reported herein is a multi-residue method for the determination of ten pharmaceutical drugs and the personal care product triclosan in wastewater matrices. Method quantitation limits ranged from 7.6 to 76.6 ng l(-1) for aqueous phases and from 7.0 to 96.7 ng g(-1) for particulate phases. The analytical method was applied to attain a complete process mass balance of a pilot-scale activated sludge plant (ASP) operated under controlled conditions. The mass balance (inclusive of aqueous and particulate concentrations at all sample points) was used to diagnose removal, revealing pharmaceuticals to be separable into three fate pathways: (a) biological degradation, (b) sorption onto activated sludge and (c) resistant to removal from the aqueous phase. These differences in fate behaviour explained a broad range of secondary removal observed (-8 to 99%). The ASP was also simultaneously compared to a full-scale trickling filter (TF) works whilst receiving the same influent wastewater. Performance of the ASP and TF was similar, achieving total pharmaceutical removals of 253 and 249 μg g(-1) biochemical oxygen demand (BOD) removed, respectively. This corresponded with reductions in total pharmaceutical load of 91 and 90% (ANOVA, p-value>0.05). Interestingly, despite low suspended solid concentrations final effluents of both the ASP and TF contained significant concentrations of some chemicals in the particulate phase. Individually, triclosan and the antibiotics ofloxacin and ciprofloxacin were within the particulate phase of effluents at concentrations ranging from 26 to 296 ng l(-1).

Cavitation technology - a greener processing technique for the generation of pharmaceutical nanoemulsions

Novel nanoemulsion-based drug delivery systems (DDS) have been proposed as alternative and effective approach for the delivery of various types of poorly water-soluble drugs in the last decade. This nanoformulation strategy significantly improves the cell uptake and bioavailability of numerous hydrophobic drugs by increasing their solubility and dissolution rate, maintaining drug concentration within the therapeutic range by controlling the drug release rate, and reducing systemic side effects by targeting to specific disease site, thus offering a better patient compliance. To date, cavitation technology has emerged to be an energy-efficient and promising technique to generate such nanoscale emulsions encapsulating a variety of highly potent pharmaceutical agents that are water-insoluble. The micro-turbulent implosions of cavitation bubbles tear-off primary giant oily emulsion droplets to nano-scale, spontaneously leading to the formation of highly uniform drug contained nanodroplets. A substantial body of recent literatures in the field of nanoemulsions suggests that cavitation is a facile, cost-reducing yet safer generation tool, remarkably highlighting its industrial commercial viability in the development of designing novel nanocarriers or enhancing the properties of existing pharmaceutical products. In this review, the fundamentals of nanoemulsion and the principles involved in their formation are presented. The underlying mechanisms in the generation of pharmaceutical nanoemulsion under acoustic field as well as the advantages of using cavitation compared to the conventional techniques are also highlighted. This review focuses on recent nanoemulsion-based DDS development and how cavitation through ultrasound and hydrodynamic means is useful to generate the pharmaceutical grade nanoemulsions including the complex double or submicron multiple emulsions.

Prediction of micropollutant elimination during ozonation of a hospital wastewater effluent

Determining optimal ozone doses for organic micropollutant elimination during wastewater ozonation is challenged by the presence of a large number of structurally diverse micropollutants for varying wastewater matrice compositions. A chemical kinetics approach based on ozone and hydroxyl radical (·OH) rate constant and measurements of ozone and ·OH exposures is proposed to predict the micropollutant elimination efficiency. To further test and validate the chemical kinetics approach, the elimination efficiency of 25 micropollutants present in a hospital wastewater effluent from a pilot-scale membrane bioreactor (MBR) were determined at pH 7.0 and 8.5 in bench-scale experiments with ozone alone and ozone combined with H2O2 as a function of DOC-normalized specific ozone doses (gO3/gDOC). Furthermore, ozone and ·OH exposures, ·OH yields, and ·OH consumption rates were determined. Consistent eliminations as a function of gO3/gDOC were observed for micropollutants with similar ozone and ·OH rate constants. They could be classified into five groups having characteristic elimination patterns. By increasing the pH from 7.0 to 8.5, the elimination levels increased for the amine-containing micropollutants due to the increased apparent second-order ozone rate constants while decreased for most micropollutants due to the diminished ozone or ·OH exposures. Increased ·OH quenching by effluent organic matter and carbonate with increasing pH was responsible for the lower ·OH exposures. Upon H2O2 addition, the elimination levels of the micropollutants slightly increased at pH 7 (<8%) while decreased considerably at pH 8.5 (up to 31%). The elimination efficiencies of the selected micropollutants could be predicted based on their ozone and ·OH rate constants (predicted or taken from literature) and the determined ozone and ·OH exposures. Reasonable agreements between the measured and predicted elimination levels were found, demonstrating that the proposed chemical kinetics method can be used for a generalized prediction of micropollutant elimination during wastewater ozonation. Out of 67 analyzed micropollutants, 56 were present in the tested hospital wastewater effluent. Two-thirds of the present micropollutants were found to be ozone-reactive and efficiently eliminated at low ozone doses (e.g., >80% for gO3/gDOC = 0.5).

Sublethal effects of the beta-blocker sotalol at environmentally relevant concentrations on the New Zealand mudsnail Potamopyrgus antipodarum

Monitoring sublethal effects of pharmaceuticals on nontarget species in aquatic environments has become an important topic in ecotoxicology, yet few studies have been conducted concerning the effects of beta-blockers on aquatic organisms. The present study investigated the effects of the beta-blocker sotalol (SOT) at 3 environmentally relevant concentrations on life-history traits of the New Zealand mudsnail Potamopyrgus antipodarum. Based on the pharmacodynamic properties of SOT, the authors hypothesized reduced numbers of embryos in the brood pouches, decelerated growth of adult snails, and smaller size of neonates, but no effect on mortality rates of adults. Contrary to the hypothesis, the total number of embryos was significantly higher after 56 d of exposure at nominal concentrations of 0.05 µg/L and 1.0 µg/L by 107% and 73%, respectively. No differences in embryo numbers were observed at earlier time-points. Therefore, the mode of action seems to be an extension of the reproductive period rather than an increase of the embryo production. Furthermore, our results indicate a hormetic dose-response relationship, because no effects were observed at the highest test-concentration (6.5 µg/L). Mortality, growth of adult snails, and neonate sizes were not affected by the beta-blocker. Given the strong influence on reproduction, the effects of sublethal concentrations of SOT and other beta-blockers deserve better consideration in ecotoxicological risk assessment.

Degradation of the anti-inflammatory drug ibuprofen by electro-peroxone process

Electro-peroxone (E-peroxone) treatment of the anti-inflammatory drug ibuprofen aqueous solution was investigated in this study. The E-peroxone process combined conventional ozonation with electrolysis processes, and used a carbon-polytetrafluorethylene cathode to electrochemically generate H2O2 from O2 in the sparged ozone generator effluent (O2 and O3 mixture). The in-situ generated H2O2 then reacted with the sparged O3 to produce aqueous •OH, which can in turn oxidize pollutants effectively in the bulk solution. The E-peroxone process overcomes several intrinsic limitations of conventional ozonation and electrolysis processes for pollutant degradation such as the selective oxidation with O3 and mass transfer limitations of pollutants to the electrodes, and thus significantly enhanced both ibuprofen degradation and total organic carbon (TOC) mineralization. Results show that ibuprofen could be completely degraded much more rapidly in the E-peroxone process (e.g., 5-15 min under all tested reaction conditions) than in ozonation (≥30 min) and electrolysis (several hours) processes. In addition, thanks to the powerful and non-selective oxidation capacity of •OH, toxic intermediates formed during ibuprofen degradation could be completely mineralized in the E-peroxone process. The E-peroxone effluent (2 h) thus exhibited much lower toxicity (5% inhibition of bioluminescence of Vibrio fisheri) than the ozonation and electrolysis effluents (22% and 88% inhibition, respectively). The results of this study indicate that the E-peroxone process may provide a promising technology for pharmaceutical wastewater treatment.

Emerging organic contaminants in vertical subsurface flow constructed wetlands: influence of media size, loading frequency and use of active aeration

Four side-by-side pilot-scale vertical flow (VF) constructed wetlands of different designs were evaluated for the removal of eight widely used emerging organic contaminants from municipal wastewater (i.e. ibuprofen, acetaminophen, diclofenac, tonalide, oxybenzone, triclosan, ethinylestradiol, bisphenol A). Three of the systems were free-draining, with one containing a gravel substrate (VGp), while the other two contained sand substrate (VS1p and VS2p). The fourth system had a saturated gravel substrate and active aeration supplied across the bottom of the bed (VAp). All beds were pulse-loaded on an hourly basis, except VS2p, which was pulse-loaded every 2h. Each system had a surface area of 6.2m(2), received a hydraulic loading rate of 95 mm/day and was planted with Phragmites australis. The beds received an organic loading rate of 7-16 gTOC/m(2)d. The sand-based VF (VS1p) performed significantly better (p<0.05) than the gravel-based wetland (VGp) both in the removal of conventional water quality parameters (TSS, TOC, NH4-N) and studied emerging organic contaminants except for diclofenac (85 ± 17% vs. 74 ± 15% average emerging organic contaminant removal for VS1p and VGp, respectively). Although loading frequency (hourly vs. bi-hourly) was not observed to affect the removal efficiency of the cited conventional water quality parameters, significantly lower removal efficiencies were found for tonalide and bisphenol A for the VF wetland that received bi-hourly dosing (VS2p) (higher volume per pulse), probably due to the more reducing conditions observed in that system. However, diclofenac was the only contaminant showing an opposite trend to the rest of the compounds, achieving higher elimination rates in the wetlands that exhibited less-oxidizing conditions (VS2p and VGp). The use of active aeration in the saturated gravel bed (VAp) generally improved the treatment performance compared to the free-draining gravel bed (VGp) and achieved a similar performance to the free-draining sand-based VF wetlands (VS1p).

Assessing potential modifications to the activated sludge process to improve simultaneous removal of a diverse range of micropollutants

It is proposed that wastewater treatment facilities meet legislated discharge limits for a range of micropollutants. However, the heterogeneity of these micropollutants in wastewaters make removal difficult to predict since their chemistry is so diverse. In this study, a range of organic and inorganic micropollutants known to be preferentially removed via different mechanisms were selected to challenge the activated sludge process (ASP) and determine its potential to achieve simultaneous micropollutant removal. At a fixed hydraulic retention time (HRT) of 8 h, the influence of an increase in solids retention time (SRT) on removal was evaluated. Maximum achievable micropollutant removal was recorded for all chemicals (estrogens, nonylphenolics and metals) at the highest SRT studied (27 days). Also, optimisation of HRT by extension to 24 h further augmented organic biodegradation. Most notable was the enhancement in removal of the considerably recalcitrant synthetic estrogen 17α-ethinylestradiol which increased to 65 ± 19%. Regression analysis indicates that this enhanced micropollutant behaviour is ostensibly related to the concomitant reduction in food: microorganism ratio. Interestingly, extended HRT also initiated nonylphenol biodegradation which has not been consistently observed previously in real wastewaters. However, extending HRT increased the solubilisation of particulate bound metals, increasing effluent aqueous metals concentrations (i.e., 0.45 μm filtered) by >100%. This is significant as only the aqueous metal phase is to be considered for environmental compliance. Consequently, identification of an optimum process condition for generic micropollutant removal is expected to favour a more integrated approach where upstream process unit optimisation (i.e., primary sedimentation) is demanded to reduce loading of the particle bound metal phase onto the ASP, thereby enabling longer HRT in the ASP to be considered for optimum removal of organic micropollutants.

Foregoing medicines in the former Soviet Union: changes between 2001 and 2010

Pharmaceutical costs dominate out-of-pocket payments in former Soviet countries, posing a severe threat to financial equity and access to health services. Nationally representative household survey data collected in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine were analysed to compare the level of population having to forego medicines in 2001 and 2010. Subgroup analysis was conducted to assess differences between populations of different economic status, and rural and urban populations. A substantial proportion of the population did forego medicines in 2010, from 29.2% in Belarus to 72.9% in Georgia. There was a decline in people foregoing medicines between 2001 and 2010; the greatest decline was seen in Moldova [rate ratio (RR)=0.67 (0.63; 0.71)] and Kyrgyzstan [RR=0.63 (0.60; 0.67)], while very little improvement took place in countries with a higher Gross National Income (GNI) per capita and greater GNI growth over the decade such as Armenia [RR=0.92 (0.87; 0.96)] and Georgia [RR=0.95 (0.92; 0.98)]. Wealthier, urban populations have benefited more than poorer, rural households in some countries. Countries experiencing the greatest improvement over the study period were those that have implemented policies such as price controls, expanded benefits packages, and encouragement of rational prescribing. Greater commitment to pharmaceutical reform is needed to ensure that people are not forced to forego medicines.

Biodegradation of sulfamethoxazole and other sulfonamides by Achromobacter denitrificans PR1

This study aimed to isolate and characterize a microbial culture able to degrade sulfonamides. Sulfamethoxazole (SMX)-degrading microorganisms were enriched from activated sludge and wastewater. The resultant mixed culture was composed of four bacterial strains, out of which only Achromobacter denitrificans PR1 could degrade SMX. This sulfonamide was used as sole source of carbon, nitrogen and energy with stoichiometric accumulation of 3-amino-5-methylisoxazole. Strain PR1 was able to remove SMX at a rate of 73.6 ± 9.6 μmol SMX/gcell dryweighth. This rate more than doubled when a supplement of amino acids or the other members of the mixed culture were added. Besides SMX, strain PR1 was able to degrade other sulfonamides with anti-microbial activity. Other environmental Achromobacter spp. could not degrade SMX, suggesting that this property is not broadly distributed in members of this genus. Further studies are needed to shed additional light on the genetics and enzymology of this process.

Environmental side effects of pharmaceutical cocktails: what we know and what we should know

Cocktails of pharmaceuticals are released in the environment after human consumption and due to the incomplete removal at the wastewater treatment plants. Pharmaceuticals are considered as contaminants of emerging concern and, a plethora of journal articles addressing their possible adverse effects have been published during the past 20 years. The emphasis during the early years of research within this field, was on the assessment of acute effects of pharmaceuticals applied singly, leading to results regarding their environmental risk, potentially not realistic or relevant to the actual environmental conditions. Only recently has the focus been shifted to chronic exposure and to the assessment of cocktail effects. To this end, this review provides an up-to-date compilation of 57 environmental and human toxicology studies published during 2000-2014 dealing with the adverse effects of pharmaceutical mixtures. The main challenges regarding the design of experiments and the analysis of the results regarding the effects of pharmaceutical mixtures to different biological systems are presented and discussed herein. The gaps of knowledge are critically reviewed highlighting specific future research needs and perspectives.

Mineralization of wastewater from the pharmaceutical industry containing chloride ions by UV photolysis of H2O2/Fe(II) and ultrasonic irradiation

The mineralization of pharmaceutical wastewater containing chloride ions using a UV/H2O2/Fe(II) process was studied. The addition of Fe(II) to the UV/H2O2 system did not improve the degradation efficiency due to inhibition of the photo-Fenton reaction, at acid pH, in the presence of chloride ions in these wastewaters. The increase of pH from 2 to 7 increased the degree of mineralization under UV photolysis of H2O2 because more HO radicals are available by HOCl dissociation reaction. Under the selected operation conditions ([H2O2]o = 11,500 ppm, [Fe(II)] = 0 ppm, [TOC]o = 125 ppm and pH = 7), 100% of TOC removal was attained in 120 min. A significant synergistic effect of combining photolysis (UV/H2O2) and sonolysis was observed. Sonophotolysis (UV/H2O2/ultrasound) technique significantly increased the degree of mineralization (100% TOC removal in 90 min using 6500 ppm H2O2) when compared with each individual process. Sonochemical reaction was favored by the presence of chloride ions since the concentration of contaminants at the gas-liquid interface increased. Free radicals reaction was the controlling mechanism in the UV/H2O2/ultrasound system. HO radicals were the main oxidative intermediate species in the process, although hydroperoxyl radicals (HO2) also played a role. The contribution of thermal-pyrolytic reaction (in gas-phase) to sonophotolysis process was negligible.

Acute toxicity of 8 antidepressants: what are their modes of action?

Currently, the hazard posed by pharmaceutical residues is a major concern of ecotoxicology. Most of the antidepressants belong to a family named the Cationic Amphipathic Drugs known to have specific interactions with cell membranes. The present study assessed the impact of eight antidepressants belonging to selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors by the combination of multi-approaches (in vivo, in vitro, in silico) and gives some insights on the mode of action for these molecules. Antidepressants were from the most to the least toxic compound for Daphnia magna: Sertraline (EC50=1.15 mg L(-1))>Clomipramine (2.74 mg L(-1))>Amitriptyline (4.82 mg L(-1))>Fluoxetine (5.91 mg L(-1))>Paroxetine (6.24 mg L(-1))>Mianserine (7.81 mg L(-1))>Citalopram (30.14 mg L(-1)) and Venlafaxine (141.28 mg L(-1)). These acute toxicities were found correlated to Log Kow coefficients (R=0.93, p<0.001) and to cytotoxicity assessed on abalone hemocytes through the neutral red uptake assay (R=0.96, p<0.001). If narcosis as mode of action is typically expected during acute ecotoxicity bioassays, we showed by molecular modeling that particular interactions can exist between antidepressants and phosphatidylcholine, a major component of cell membranes, leading to a more specific mode of action corresponding to a potential acidic hydrolysis of ester functions.

Assessment of cytotoxic and immunomodulatory properties of four antidepressants on primary cultures of abalone hemocytes (Haliotis tuberculata)

Pharmaceutical compounds like antidepressants found in surface waters raise concerns due to their potential toxicity on non-target aquatic organisms. This study aimed at investigating the in vitro cytotoxicity and immunomodulatory properties of four common antidepressants, namely Amitriptyline, Clomipramine, Citalopram and Paroxetine, on primary cultures of abalone hemocytes (Haliotis tuberculata), after 48 h-exposure. Effects on immunocompetence (phagocytosis, levels of reactive oxygen species, esterase activity and lysosomal membrane destabilization) were assessed. Results obtained by MTT assays revealed that acute toxicity is unlikely to occur in the environment since the LC50s of the four antidepressants are at the mg/L level. The different immunological endpoints displayed a biphasic response, with an increase at the lowest concentration (i.e. 1 μg/L) followed by a decrease at higher concentrations. Overall, Amitriptyline and Clomipramine, the two tricyclic antidepressants, had higher immunomodulatory capacities than the two selective serotonin reuptake inhibitors Citalopram and Paroxetine. Amitriptyline was the most potent and Citalopram the least potent drug in altering immune function in H. tuberculata.

Fate of diclofenac in municipal wastewater treatment plant - a review

Diclofenac (DCF) is a common anti-inflammatory pharmaceutical that is often detected in waste wasters, effluents and surface waters. Recently, DCF was included in the watch list of substances in EU that requires its environmental monitoring in the member states. DCF is also known to harmfully affect several environmental species already at concentrations of ≤ 1 μg/l. This review focuses on the occurrence and fate of DCF in conventional wastewater treatment processes. Research done in this area was gathered and analyzed in order to find out the possibilities to enhance DCF elimination during biological wastewater treatment. More precisely, human metabolism, concentrations in wastewater influents and effluents, elimination rates in the treatment train, roles of sorption and biotransformation mechanisms during the treatment as well as formation of transformation products are reported. Additionally, the effect of process configuration, i.e. conventional activated sludge (CAS), biological nutrient removal (BNR), membrane bioreactor (MBR) and attached-growth bioreactor, and process parameters, i.e. solids retention time (SRT) and hydraulic retention time (HRT) are presented. Generally, DCF is poorly biodegradable which often translates into low elimination rates during biological wastewater treatment. Only a minor portion is sorbed to sludge. MBR and attached-growth bioreactors may result in higher elimination of DCF over CAS or BNR. Long SRTs (>150 d) favor the DCF elimination due to sludge adaptation. Longer HRTs (>2-3d) could significantly increase the elimination of DCF during biological wastewater treatment. Bioaugmentation could be used to enhance DCF elimination, however, this requires more research on microbial communities that are able to degrade DCF. Also, further research is needed to gain more information about the deconjugation processes and biotic and abiotic transformation and the nature of transformation products.

The effect of pharmaceutical innovation on longevity, hospitalization and medical expenditure in Turkey, 1999-2010

We investigate the impact of pharmaceutical innovation on longevity, hospitalization and medical expenditure in Turkey during the period 1999-2010 using longitudinal, disease-level data. From 1999 to 2008, mean age at death increased by 3.6 years, from 63.0 to 66.6 years. We estimate that in the absence of any pharmaceutical innovation, mean age at death would have increased by only 0.6 years. Hence, pharmaceutical innovation is estimated to have increased mean age at death in Turkey by 3.0 years during the period 1999-2008. We also examine the effect of pharmaceutical innovation on hospital utilization. We estimate that pharmaceutical innovation has reduced the number of hospital days by approximately 1% per year. We use our estimates of the effect of pharmaceutical innovation on age at death, hospital utilization and pharmaceutical expenditure to assess the incremental cost-effectiveness of pharmaceutical innovation, i.e., the cost per life-year gained from the introduction of new drugs. The baseline estimate of the cost per life-year gained from pharmaceutical innovation is $2776. Even the latter figure is a very small fraction of leading economists' estimates of the value of (or consumers' willingness to pay for) a one-year increase in life expectancy.

Carbamazepine and its metabolites in wastewater: Analytical pitfalls and occurrence in Germany and Portugal

The occurrence of carbamazepine (CBZ) and its metabolites in German and Portuguese wastewater was investigated. A total of 46 samples from influent and effluent wastewater were analyzed by liquid-chromatography (LC) tandem mass spectrometry. The five metabolites 10,11-dihydro-10,11-dihydroxy-CBZ (DiOH-CBZ), 10,11-dihydro-10-hydroxy-CBZ (10-OH-CBZ), 10,11-epoxy-10,11-dihydro-CBZ, 2-hydroxy-CBZ and 3-hydroxy-CBZ were very persistent with little to no removal during wastewater treatment. The highest concentrations were found for CBZ, DiOH-CBZ, and 10-OH-CBZ, with up to 5.0, 4.8 and 1.1 μg/L, respectively. Furthermore, the related pharmaceutical oxcarbazepine and the metabolites 9-hydroxymethyl-10-carbamoylacridan, 1-hydroxy-CBZ (1-OH-CBZ) and 4-hydroxy-CBZ (4-OH-CBZ) were detected. Explicit care was taken to achieve a good chromatographic separation of the numerous isomers that were difficult to distinguish by mass spectrometry alone. A phenylether stationary phase provided the best separation. In combination with high resolution mass spectrometry and hydrogen-deuterium exchange, this LC column enabled us to identify 1-OH-CBZ and 4-OH-CBZ in wastewater for the first time.

Ecological implications of altered fish foraging after exposure to an antidepressant pharmaceutical

Pharmaceutical residues are increasingly detected in environmental and biological samples, some at levels known to adversely affect non-target organisms; however, less is known of how these organism-level effects relate to the ecology of aquatic systems. Foraging processes may be used as behavioral endpoints that link effects on individuals to the population and community levels, enabling risk assessment of environmental contaminants at larger ecological scales. In this study, we performed feeding trials using juvenile Eurasian perch (Perca fluviatilis) exposed to the selective serotonin reuptake inhibitor (SSRI) sertraline to test the hypothesis that sertraline alters foraging ecology of the fish in terms of their functional response. We found an exposure-dependent decrease in feeding with increasing sertraline concentrations. Further experiments revealed that feeding rates decrease at both low and high prey densities, indicating effects on both attack rate and handling time, respectively. Because the functional response can shape consumer-resource dynamics, such effects may alter the stability of predator-prey systems and consequently, community structure.

Chronic fluoxetine exposure alters movement and burrowing in adult freshwater mussels

The antidepressant fluoxetine is commonly found in aquatic fauna living near or downstream from point-sources of municipal waste effluent. Continuous release of fluoxetine results in increased effective exposure duration in surface waters, resulting in a chronic exposure for animals downstream, particularly in effluent dominated ecosystems. Fluoxetine is known to cause disruptions in reproductive behavior of freshwater mussels (order Unionoida), including stimulating release of gametes, parturition of glochidia (larvae), and changes in lure display and foot protrusion. However, the ecological relevance of these effects at environmental concentrations is unknown. We conducted a 67-d exposure of adult Lampsilis fasciola to fluoxetine concentrations of 0, 0.5, 2.5, and 22.3μg/L and assessed impacts on behavior (lateral movement, burrowing, and filtering) and metabolism (glycogen storage and respiration). Mussels treated with 2.5 and 22.3μg/L fluoxetine displayed mantle lures significantly (p<0.05) more than controls. Animals treated with 22.3μg/L fluoxetine were statistically more likely to have shorter time-to-movement, greater total movement, and initiate burrowing sooner than control animals. These observations suggest that increased activity of mussels exposed to fluoxetine may result in increased susceptibility to predators and may lead to a reduction in energy stores.

A systematic review of neuroprotective strategies after cardiac arrest: from bench to bedside (part II-comprehensive protection)

Neurocognitive deficits remain a significant source of morbidity in survivors of cardiac arrest. We conducted a literature review of treatment protocols designed to evaluate neurologic outcome and survival following global cerebral ischemia associated with cardiac arrest. The search was limited to investigational therapies that were implemented either during cardiopulmonary resuscitation or after return of spontaneous circulation in studies that included assessment of impact on neurologic outcome. Given that complex pathophysiology underlies global brain hypoxic ischemia following cardiac arrest, neuroprotective strategies targeting multiple stages of neuropathologic cascades should promise to improve survival and neurologic outcomes in cardiac arrest victims. In Part II of this review, we discuss several approaches that can provide comprehensive protection against global brain injury associated with cardiac arrest, by modulating multiple targets of neuropathologic cascades. Pharmaceutical approaches include adenosine and growth factors/hormones including brain-derived neurotrophic factor, insulin-like growth factor-1 and glycine-proline-glutamate, granulocyte colony stimulating factor and estrogen. Preclinical studies of these showed some benefit but were inconclusive in models of global brain injury involving systemic ischemia. Several medical gases that can mediate neuroprotection have been evaluated in experimental settings. These include hydrogen sulfide, hyperbaric oxygen and molecular hydrogen. Hyperbaric oxygen and molecular hydrogen showed promising results; however, further investigation is required prior to clinical application of these agents in cardiac arrest patients.

Shear-induced hydrodynamic cavitation as a tool for pharmaceutical micropollutants removal from urban wastewater

In this study, the removal of clofibric acid, ibuprofen, naproxen, ketoprofen, carbamazepine and diclofenac residues from wastewater, using a novel shear-induced cavitation generator has been systematically studied. The effects of temperature, cavitation time and H2O2 dose on removal efficiency were investigated. Optimisation (50°C; 15 min; 340 mg L(-1) of added H2O2) resulted in removal efficiencies of 47-86% in spiked deionised water samples. Treatment of actual wastewater effluents revealed that although matrix composition reduces removal efficiency, this effect can be compensated for by increasing H2O2 dose (3.4 g L(-1)) and prolonging cavitation time (30 min). Hydrodynamic cavitation has also been investigated as either a pre- or a post-treatment step to biological treatment. The results revealed a higher overall removal efficiency of recalcitrant diclofenac and carbamazepine, when hydrodynamic cavitation was used prior to as compared to post biological treatment i.e., 54% and 67% as compared to 39% and 56%, respectively. This is an important finding since diclofenac is considered as a priority substance to be included in the EU Water Framework Directive.

The drugs don't sell: DIY heart health and the over-the-counter statin experience

This paper draws on a study of over-the-counter statins to provide a critical account of the figure of the 'pharmaceutical consumer' as a key actor in the pharmaceuticalisation literature. A low dose statin, promising to reduce cardiovascular risk, was reclassified to allow sale in pharmacies in the UK in 2004. We analysed professional and policy debates about the new product, promotional and sales information, and interviews with consumers and potential consumers conducted between 2008 and 2011, to consider the different consumer identities invoked by these diverse actors. While policymakers constructed an image of 'the citizen-consumer' who would take responsibility for heart health through exercising the choice to purchase a drug that was effectively rationed on the NHS and medical professionals raised concerns about 'a flawed consumer' who was likely to misuse the product, both these groups assumed that there would be a market for the drug. By contrast, those who bought the product or potentially fell within its target market might appear as 'health consumers', seeking out and paying for different food and lifestyle products and services, including those targeting high cholesterol. However, they were reluctant 'pharmaceutical consumers' who either preferred to take medication on the advice of a doctor, or sought to minimize medicine use. In comparison to previous studies, our analysis builds understanding of individual consumers in a market, rather than collective action for access to drugs (or, less commonly, compensation for adverse effects). Where some theories of pharmaceuticalisation have presented consumers as creating pressure for expanding markets, our data suggests that sociologists should be cautious about assuming there will be demand for new pharmaceutical products, especially those aimed at prevention or asymptomatic conditions, even in burgeoning health markets.

Effects of triclocarban, N,N-diethyl-meta-toluamide, and a mixture of pharmaceuticals and personal care products on fathead minnows (Pimephales promelas)

Pharmaceuticals and personal care products (PPCPs) have been detected widely in aquatic ecosystems, but little is known about their mechanisms of toxicity. We exposed adult fathead minnows (Pimephales promelas) for 48 h to triclocarban (1.4 µg/L), N,N-diethyl-meta-toluamide (DEET; 0.6 µg/L), or a mixture of PPCPs consisting of atenolol (1.5 µg/L), caffeine (0.25 µg/L), diphenhydramine (0.1 µg/L), gemfibrozil (1.5 µg/L), ibuprofen (0.4 µg/L), naproxen (1.6 µg/L), triclosan (2.3 µg/L), progesterone (0.2 µg/L), triclocarban (1.4 µg/L), and DEET (0.6 µg/L). Quantitative real-time polymerase chain reaction revealed an upregulation in vitellogenin (vtg) in livers of females and males exposed to triclocarban. Also, an upregulation of hepatic lipoprotein lipase (lpl) and a downregulation of androgen receptor (ar) and steroidogenic acute regulatory protein (star) were observed in testes. The group treated with DEET only showed a significant decrease in ar in females. In contrast, the PPCP mixture downregulated vtg in females and males and expression of estrogen receptor alpha (erα), star, and thyroid hormone receptor alpha 1 (thra1) in testes. The authors' results show that the molecular estrogenic effects of triclocarban are eliminated (males) or reversed (females) when dosed in conjunction with several other PPCP, once again demonstrating that results from single exposures could be vastly different from those observed with mixtures. Environ Toxicol Chem 2014;33:910-919. © 2013 SETAC.

In vitro effects of the nonsteroidal anti-inflammatory drug, ibuprofen, on the immune parameters of the colonial ascidian Botryllus schlosseri

In this study, in vitro effects of ibuprofen (IBU) on the immune parameters of the colonial ascidian Botryllus schlosseri were evaluated. Haemocytes were exposed for 1h to 0 (control), 100 and 1000 μg IBU/L and the effects on haemocyte viability and morphology (shape factor), lysosomal membrane stability (Neutral Red Retention Assay), phagocytic activity, apoptosis (TUNEL reaction), hydrolytic (acid phosphatase) and oxidative (phenoloxidase and peroxidase) enzyme activities were evaluated. The exposure of haemocytes to IBU did not affect significantly their viability, but increased the percentage of cells with round shape. IBU caused a significant reduction in both phagocytic activity and lysosomal membrane stability. The percentage of haemocytes positive to TUNEL reaction (indicative of DNA fragmentation) increased significantly after IBU exposure. Significant decreases in the percentage of haemocytes positive to acid phosphatase were recorded at 1000 μg/L of IBU. Conversely, no significant variations were recorded in the percentage of haemocytes positive to phenoloxidase and peroxidase. Results obtained indicate that exposure of ascidian haemocytes to IBU induces marked alterations in cell functionality. Immunomarkers measured in this study are sensitive, rapid and reproducible. However, their responsiveness and biological relevance will need to be verified for in vivo exposure.

The impact of pharmaceutical innovation on longevity and medical expenditure in France, 2000-2009

Longitudinal, disease-level data are used to analyze the impact of pharmaceutical innovation on longevity (mean age at death) and medical expenditure in France during the period 2000-2009. The estimates imply that pharmaceutical innovation increased mean age at death by 0.29 years (3.43 months) during this period-about one-fifth of the total increase in longevity. This estimate is smaller than those obtained in previous studies of Germany and the U.S., but the rate of adoption of new drugs was lower in France. Longevity is much more strongly related to the number of drugs than it is to the number of drug classes. Pharmaceutical innovation during 2000-2009 is estimated to have increased per capita pharmaceutical expenditure by $125 (26%) in 2009, but most (87%) of this increase was offset by a reduction in hospital expenditure. The baseline estimate of the cost per life-year gained from pharmaceutical innovation in France during 2000-2009 is about $8100. This estimate is fairly close to the mean of estimates obtained ($10,800) from U.S., German, and Australian studies.