Forced degradation studies of medroxyprogesterone acetate injectable suspensions (150 mg/ml) with implementation of HPLC, mass spectrometry, and QSAR techniques

Medroxyprogesterone acetate (MPA) injectable products are a key commodity for reproductive health and are available in the global market from a variety of manufacturing sources. Depending on the climatic zone conditions of the destination country for product use, MPA injectables are at risk of exposure to adverse transport and storage conditions. Analytical methods are available that quantify impurity levels in MPA and MPA injectable products, but minimal information is publicly available on the source of impurity and degradation product generation or the safety risk of these compounds. Forced degradation studies were conducted on MPA and MPA injectables to gain a better understanding of potential sources of impurities and degradation products. Furthermore, QSAR analysis was conducted to assess the toxicity risk of known impurities. More impurities were generated under acidic, basic, light, and oxidative forced degradation conditions relative to thermal degradation, however thermal exposure is the most likely adverse condition to be experienced by these products. Even if impurities are present in MPA injectables, QSAR analysis found that known impurities for MPA are apparently no more of a safety risk than MPA.

Local pathology and systemic serum bupivacaine after subcutaneous delivery of slow-releasing bupivacaine microspheres

BACKGROUND

Prolonged local anesthesia, particularly desirable to minimize acute and chronic postoperative pain, has been provided by microspheres that slowly release bupivacaine (MS-Bup). In this study, we report on the systemic drug concentrations and the local dermatopathology that occur after subcutaneous injection of MS-Bup.

METHODS

Rats (approximately 300 g) were injected under the dorsolumbar skin with MS-Bup containing 40 mg of bupivacaine (base) or with 0.4 mL of 0.5% bupivacaine-HCl (BupHCl; 1.78 mg bupivacaine). Blood was drawn, under sevoflurane anesthesia, at 10 minutes to 144 hours, and the serum analyzed for total bupivacaine by liquid chromatography-tandem mass spectrometry. In different animals, skin punch biopsies (4 mm) were taken at 1, 3, 7, 14, and 30 days after the same drug injections, sectioned at 5 μm, and stained with hematoxylin-eosin. Samples from skin injected with BupHCl, with MS-Bup suspended in carboxymethyl cellulose (MS-Bup.CMC), or in methyl cellulose (MS-Bup.MC) were compared with their respective drug-free controls (placebos).

RESULTS

Serum bupivacaine reached a maximal average value (n = 8) of 194.9 ng/mL at 8 hours after injection of MS-Bup (95% upper prediction limit = 230.2 ng/mL), compared with the maximal average (n = 6) serum level of 374.9 ng/mL (95% prediction limit = 470.6 ng/mL) at 30 minutes after injection of BupHCl. Serum bupivacaine decreased to undetectable levels (<3.23 ng/mL) at 8 hours after BupHCl and was detectable at approximately 20% of the maximal value at 144 hours after MS-Bup injection. BupHCl injection resulted in moderate lymphocytic infiltration of skeletal muscle at 1 and 3 days. MS-Bup.CMC and placebo-CMC caused extensive infiltration of macrophages, lymphocytes, and some neutrophils at 1 to 7 days, whereas MS-Bup.MC and placebo-MC caused only mild inflammation.

CONCLUSIONS

Subcutaneous administration of microspheres releasing bupivacaine results in lower blood levels lasting for much longer times than those from bupivacaine solution.

Risk of non-AIDS-defining events among HIV-infected patients not yet on antiretroviral therapy

OBJECTIVES

Certain non-AIDS-related diseases have been associated with immunodeficiency and HIV RNA levels in HIV-infected patients on combination antiretroviral therapy (cART). We aimed to investigate these associations in patients not yet on cART, when potential antiretroviral-drug-related effects are absent and variation in RNA levels is greater.

METHODS

Associations between, on the one hand, time-updated CD4 counts and plasma HIV RNA and, on the other hand, a composite non-AIDS-related endpoint, including major cardiovascular diseases, liver fibrosis/cirrhosis, and non-AIDS-related malignancies, were studied with multivariate Poisson regression models in 12 800 patients diagnosed with HIV infection from 1998 onwards while not yet treated with cART.

RESULTS

During 18 646 person-years of follow-up, 203 non-AIDS-related events occurred. Compared with a CD4 count ≥ 500 cells/μL, adjusted relative risks (RRs) for the composite endpoint were 4.71 [95% confidence interval (CI) 2.98-7.45] for a CD4 count < 200 cells/μL, 2.06 (95% CI 1.38-3.06) for a CD4 count of 200-349 cells/μL, and 1.19 (95% CI 0.82-1.74) for a CD4 count of 350-499 cells/μL. There was no evidence for an independent association with HIV RNA. Other important covariates were age [RR 1.40 (95% CI 1.31-1.49) per 5 years older], hepatitis B virus coinfection [RR 5.66 (95% CI 3.87-8.28)] and hepatitis C virus coinfection [RR 9.26 (95% CI 6.04-14.2)].

CONCLUSIONS

In persons not yet receiving cART, a more severe degree of immunodeficiency rather than higher HIV RNA levels appears to be associated with an increased risk of our composite non-AIDS-related endpoint. Larger studies are needed to address these associations for individual non-AIDS-related events.

Fighting a losing battle: eating-related distress of men with advanced cancer and their female partners. A mixed-methods study

BACKGROUND

Anorexia/cachexia is a frequent complication of advanced cancer with poorly understood psychosocial impact or eating-related distress (ERD) on both patients and family members. To assist palliative care practitioners manage this important psychosocial aspect of care, we aimed to discover and describe elements of ERD, focusing on male patients with advanced cancer and their female partners.

METHODS

Nineteen male patients and their partners were systematically investigated by (1) focus group interviews and data analysis inspired by Grounded Theory, and (2) a comparative survey with categorical questions.

RESULTS

For patients, eating-related distress was characterised by obstruction to eating, poor and capricious appetite, a disconnection of oral intake and ability to gain weight, and continuous efforts to eat. Partners expressed feelings of deep concern, frustration, and insufficiency in their loving and innovative efforts to prepare appealing food. Partners were more concerned about patients' weight loss than patients themselves (P =0.002). Patients felt more pressure to eat from partners than they estimated (P =0.007).

CONCLUSION

Anorexia/cachexia of male cancer patients affects the cooking at home, a couple's daily eating routines, and their spousal relationship. Identification of ERD may trigger targeted psychosocial interventions.

[Nursing science courses at the University of Basel/Switzerland. Concept, guidelines, curriculum and evaluation of study results]

Since 2000 the University of Basel offers the first Bachelor-Master's education in nursing science in Switzerland. The structure, content, faculty and students of this BSN-MSN curriculum are described. An evaluation study on the basis of quantitative and qualitative data drawn from students (n = 50) and alumni, respectively (n = 15), assesses strengths and weaknesses of this new education.

Traumatic memories of relatives regarding brain death, request for organ donation and interactions with professionals in the ICU

Little is known about the memories of relatives after they have been confronted with the brain death of a loved one and the request for organ donation. We conducted this study, guided by Grounded Theory, to explore relatives' experiences, their interactions with health care providers and what influenced their memories. We interviewed 40 relatives (31 consenting to and 9 refusing organ donation) of 33 brain-dead individuals. Relatives described their experiences as a difficult process composed of several stages spanning from the initial encounter to the final decision about donation. Long-term memories of bereaved relatives were influenced by the characteristics of their decision-making style (clear vs. ambivalent) and the perceived quality of the interaction with professionals on the intensive care unit. Organ-focused behavior of professionals and an ambivalent decision-making style of relatives appear to be risk factors for traumatic memories.

[Developing and establishing an expanded and more comprehensive HIV/AIDS nursing practice]

Developing and establishing an advanced nursing practice is an essential step toward future-oriented nursing care. An action research process was initiated to establish advanced nursing practice at the HIV clinic of the outpatient department at the University Hospital Basel with the goal to offer advanced nursing care to patients. Participatory action research allows generating knowledge about a social system while at the same time tempts to promote social change. The most important goal is to constantly analyse, improve, and evaluate nursing care for patients and family caregivers. Advanced nursing practice in HIV/AIDS is based on solid knowledge regarding the illness and current therapies. Central concepts are caring, clinical experiences, evidence based practice, and patient preferences. Through a systematic step-by-step process, the nurses at the HIV clinic are being better educated and more experienced in these concepts. An essential aspect of advanced nursing practice is the specialization of each nurse in a self selected topic within HIV/AIDS care. These nurses now offer new services such as medication management and adherence support, health maintenance and prevention, and symptom management. This ongoing process of learning while establishing advanced nursing practice in HIV/AIDS, enables the nurses to face future changes in health care in a proactive way.

Emotional and physical demands on caregivers in home care to the elderly in Switzerland and their relationship to nursing home admission

BACKGROUND

Planning the home care of growing numbers of old, dependent people must include the caregivers' burden.

METHODS

A convenience sample of 129 caregivers of elderly patients with multiple diagnoses was interviewed about the caregiving context, burden, caregivers' tolerance of patients' troublesome behaviours and physical symptoms, mutuality and feelings of closeness between caregiver and patient. Continued maintenance of home care was assessed by a follow-up telephone call.

RESULTS

Caregivers were mainly spouses (67%) and female (73%), and the mean duration of care was 5.5 years. In five activities of daily living (ADL) 50-69% of the patients needed full help. Caregivers reported predominantly negative effects of caregiving on their physical and mental health, rest and sleep, leisure time and social life, problems with patients' symptoms and behaviours and little or no conversing (51%) or exchanging feelings with patients (71%). PREDICTIVE MODELS: Contributors to variance were for burden (35%), impact of care on caregivers' mental health, social relations and leisure time, patients' gender, accumulation of patients' symptoms and behaviours; for caregivers' tolerance toward patients' symptoms and behaviours (17%) caregivers' physical health, patients' level of confusion, feelings of mutuality; for mutuality (22%) and for closeness (19%) caregivers' mental health, patients' accumulation of symptoms and behaviours. Within 23 months 19% of the patients had been institutionalized. Factors giving a higher likelihood of institutionalization were: being male, caregiver was not a partner, and less closeness between caregiver and patient.

CONCLUSION

Caregiving of older persons has bio-psychosocial ramifications for caregivers. Closeness between caregiver and patient seems to be a key factor in determination of the long-term outcome.

[Visions for the future--nursing as a profession in German-speaking Swiss health care]

Social, scholarly, and technical changes and changes in health politics have a lasting influence on the nursing profession. The development of nursing science programs can be seen in this context and institutions, which offer educational programs for nurses, have to orient them toward the new demands of the profession. Up to now in the German-speaking realm, published data, which describe the changes the nursing profession can expect, have not been available, nor have possible future fields of activity of nursing been examined. In order to close this gap, a group of opinion leaders and experts in nursing in German-speaking Switzerland were studied. Eighty-one people were surveyed by means of a questionnaire, and ten people were interviewed in-depth. The results reflect the visions and perspectives of the nursing profession of the future in German-speaking Switzerland. The expectation is that nursing should deal increasingly with sociopolitical changes and that the main issues of nursing with regard to type of client and locations where care is given will change. A re-orientation toward strengthening professional identity is called for in the following areas: involvement in determining and shaping decisions in politics and health politics; taking entrepreneurial initiatives; building clinical practice on caring, patient preferences, and evidence; making professional training and continuing education clinically-oriented as well as the development and the establishment of nursing science. Through a re-orientation, nursing should be better able to meet the challenges, which it faces because of health and social problems in the population. A great discrepancy exists between the expectations for nursing in the future and present reality. The challenge will be to see whether it will be possible to close the gap between visions and reality by means of training, continuing education, and changes in clinical practice.

A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission

BACKGROUND

In-home preventive visits with multidimensional geriatric assessments can delay the onset of disabilities in older people.

METHODS

This was a stratified randomized trial. There were 791 participants, community-dwelling people in Bern, Switzerland, older than 75 years. The participants' risk status was based on 6 baseline predictors of functional deterioration. The intervention consisted of annual multidimensional assessments and quarterly follow-up in-home visits by 3 public health nurses (nurses A, B, and C), who, in collaboration with geriatricians, evaluated problems, gave recommendations, facilitated adherence with recommendations, and provided health education. Each nurse was responsible for conducting the home visits in 1 ZIP code area.

RESULTS

After 3 years, surviving participants at low baseline risk in the intervention group were less dependent in instrumental activities of daily living (ADL) compared with controls (odds ratio, 0.6; 95% confidence interval, 0.3-1.0; P = .04). Among subjects at high baseline risk, there were no favorable intervention effects on ADL and an unfavorable increase in nursing home admissions (P= .02). Despite the similar health status of subjects, nurse C identified fewer problems in the subjects who were visited compared with those assessed by nurses A and B. Subgroup analysis revealed that among low-risk subjects visited by nurses A and B, the intervention had favorable effects on instrumental ADL (P = .005) and basic ADL (P = .009), reduced nursing home admissions (P = .004), and resulted in net cost savings in the third year (US $1403 per person per year). Among low-risk subjects visited by nurse C, the intervention had no favorable effects.

CONCLUSIONS

These data suggest that this intervention can reduce disabilities among elderly people at low risk but not among those at high risk for functional impairment, and that these effects are likely related to the home visitor's performance in conducting the visits.

[Psychosocial nursing diagnosis: an interpretative-phenomenological perspective]

Nursing diagnoses and other nomenclatures of this kind belong to the category of technological knowledge, developed for the sake of domination (Scheler 1974-1928). Nomenclatures can be used as base for the recording of nursing services. However, the body of knowledge represented by nursing diagnoses cannot serve the profession as a foundation for clinical decision making nor as inspiration for professional conversations with patients. Selected psycho-social nursing diagnoses are critiqued by comparing them with the description of a patient's illness experiences.

[Foot reflexology massage: a clinical study]

The aim of the study was to investigate the possible usefulness of foot reflexology on the recovery after a surgical intervention. 130 patients participated in the study. They underwent abdominal surgery under full anesthesia for different, but exclusively gynecological reasons. Foot reflexology investigated in this study was applied only for a few days for each patient. The following parameters were recorded: the subjective, self-assessed, general condition, pain intensity, movement of the bowels, micturition and sleep, beginning on the day before operation until day 10. Two other treatments served as controls, a simple massage of the foot or a personal conversation. The simple massage turned out to be a relaxing, positive experience, whereas foot reflexology had various effects, some of them were even negative. The conclusion was that foot reflexology is not recommended for acute, abdominal postsurgical situations in gynecology because it can occasionally trigger abdominal pain. This project is one of the few studies planned, conducted and performed by the nursing staff.

[Foot reflexology: an intervention study]

The study's goal was to test if foot reflexology (FR) affects well-being, voiding, bowel movements, pain and/or sleep in women who underwent an abdominal operation. 130 subjects were randomized into three groups. For five days they were exposed to 15 minutes of FR, foot/leg massage (FM) or talking respectively. Results show that women in the FR group were more able to void without problems, after the indwelling catheter had been removed, than did women in the comparison groups. There was also a tendency in the FR-group for the indwelling catheter to be removed earlier than in the other groups. In comparison, the FR-subjects slept worse than the others. FM showed significant results in subjective measurements of well-being, pain and sleep.

[A nursing intervention study in interdisciplinary cooperation: challenges and problem solving strategies]

Doing a nursing intervention study in two hospitals in collaboration with physicians challenged all participating parties. The course of the study was influenced and partially changed by unforeseen problems. This article presents organizational perspectives on carrying through an intervention study while daily patient care is taking place and discusses specific issues of collaborating with physicians and nurses. Problem solving strategies and consequences from experiences with this study are presented.

[Nursing as an art in practice and science]

This paper relies on the assumption that care and science are practices in MacIntyre's sense. Every practice can be carried out on different skill levels. Both practices, care and science are intricately linked to each other. Practice on the first three levels described by Dreyfus & Benner is theory driven, while the works of experienced and expert practitioners can be compared to art. Works from care and science are used to illustrate works of art, but also, for comparing and contrasting the competent and expert practices.

Learning About Another Culture: Project and Curricular Reflections

Over the past two years, an innovative collaborative project in the care of Ethiopian Jews who immigrated to Israel has been carried out. In this project, both students and faculty joined in activities of research and practice through a clinic at a trailer court that houses 96 Ethiopian immigrant families. This project brought about several favorable changes: a) Health of the underprivileged and underserved was enhanced through bi-weekly services provided to the poor and sick trailer court inhabitants; b) An educational program for learning in a cross-cultural community setting was developed. This curricula advanced recognition of the growing cultural and racial diversity of both individual and family lifestyles, as well as allowed for learning events that are based on substantive contact with, or participation by, persons at health risk; c) An educational milieu that fosters the use of research-based interventions was developed. This article describes the cross-cultural educational project which was designed as a pilot for a new baccalaureate program in nursing, and critiques it based on the criteria of the five major concepts--primacy of the teacher-student relationship, social responsibility, centrality of caring, interpretive stance and theoretical pluralism, proposed by the promoters of the "curriculum revolution."

[Body image and the experience of illness--experience of women with breast cancer]

This phenomenological study aimed at problematizing the living body as experienced by American women who suffered from breast cancer and underwent chemotherapy. Forty-eight interviews were collected from 18 women over a period of six months for another study. A secondary analysis was performed. It centered on the following three questions: 1. How do bodily changes impact on the women's embodied self-understanding? 2. How does bodily subjection to medical treatments illuminate professional and self's relationships to the body? and 3. What kind of knowledge about the body and the illness do the women express?

RESULTS

1. Central in the patients' accounts were experiences of "I cannot" (any more) or "I can" (again). 2. Illness and bodily subjection to medical interventions influenced the women's relationship with their body. Five different patterns of "I"-body-relationships are described. They varied between "I"-body-oneness and "I"-body distance. 3. The women expressed varying levels of knowledge as they talked about bodily experiences and the illness. Vernacular concepts, medical concepts and complex medical knowledge were expressed. The paper emphasizes the existential importance of "I can" or "I cannot" experiences.

[Practical experience as a source of learning]

This paper describes Benner's model of skill acquisition (1984) in nursing and additional work of Benner to a German readership. Emphasis is put on learning from practice by "knowing the patient" through "paradigm cases" and by "telling stories". Benner's work provides a model which allows to distinguish between different levels of competence and enables professionals to describe expert clinical practice in a language which is conductive to learning from experience. Suggestions are given as to how learning from experience may be promoted. Thought is given to the way in which experiential learning in nursing practice might be promoted in our situation. Benner's model offers a language which is capable of expressing the difference between levels of competence and which can describe examples of "mastery" which one might want to follow.