Exploring measurement tools to optimise hospital physician distribution

INTRODUCTION

Equitable healthcare delivery is essential and requires resources to be distributed, which include assets and healthcare workers. To date, there is no gold standard for measuring the correct number of physicians to meet healthcare needs. This rapid review aims to explore measurement tools employed to optimise the distribution of hospital physicians, with a focus on ensuring fair resource allocation for equitable healthcare delivery.

MATERIALS AND METHODS

A literature search was performed across PubMed, EMBASE, Emerald Insight and grey literature sources. The key terms used in the search include 'distribution', 'method', and 'physician', focusing on research articles published in English from 2002 to 2022 that described methods or tools to measure hospital-based physicians' distribution. Relevant articles were selected through a two-level screening process and critically appraised. The primary outcome is the measurement tools used to assess the distribution of hospital-based physicians. Study characteristics, tool advantages and limitations were also extracted. The extracted data were synthesised narratively.

RESULTS

Out of 7,199 identified articles, 13 met the inclusion criteria. Among the selected articles, 12 were from Asia and one from Africa. The review identified eight measurement tools: Gini coefficients and Lorenz curve, Robin Hood index, Theil index, concentration index, Workload Indicator of Staffing Need method, spatial autocorrelation analysis, mixed integer linear programming model and cohortcomponent model. These tools rely on fundamental data concerning population and physician numbers to generate outputs. Additionally, five studies employed a combination of these tools to gain a comprehensive understanding of physician distribution dynamics.

CONCLUSION

Measurement tools can be used to assess physician distribution according to population needs. Nevertheless, each tool has its own merits and limitations, underscoring the importance of employing a combination of tools. The choice of measuring tool should be tailored to the specific context and research objectives.

Comparing various cut-offs of aspartate aminotransferase-to-platelet ratio index (APRI) in liver cirrhosis diagnosis among hepatitis C patients in Malaysia

INTRODUCTION

A major challenge in providing hepatitis C virus (HCV) treatment at primary healthcare clinics is the lack of radiological facilities to guide the decision making of liver cirrhosis (LC). This study aimed to compare the performance of three commonly used cut-offs of the aspartate aminotransferase-to-platelet ratio index (APRI) in diagnosing LC among hepatitis C patients in Malaysia.

METHODS

This cross-sectional study was based on the data collected from the Hepatitis C Elimination through Access to Diagnostics (HEAD-Start) study in 25 primary healthcare clinics across three regions of Malaysia. The findings of biochemical tests were used to calculate the APRI for each study participant. Transient elastography was used as a standard reference for the diagnosis of cirrhosis. The area under the receiver operating curve (AUROC) was used to determine the discriminative ability of APRI in both HCV mono-infected and HCV/HIV co-infected patients. The diagnostic performance of APRI at three different cutoffs (>1.0, ≥1.5 and >2.0) were also evaluated.

RESULTS

This study included 867 HCV-RNA-positive patients, 158 (16.1%) were co-infected with HIV. For the HCV mono-infected patients, the sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) for the cut-off of >1.0 were 61.8%, 88.7%, 73.8% and 81.9%, and for the cut-off of ≥1.5, 45.6%, 97.0%, 88.7% and 77.6%, respectively. A much lower sensitivity (29.9%) was observed for the cut-off of >2.0. The diagnostic accuracy of APRI at the cut-off of ≥1.5 in the HCV/HIV co-infected patients was relatively suboptimal.

CONCLUSION

APRI, with a cut-off of ≥1.5, can more accurately predict LC among hepatitis C patients in Malaysia. However, additional physical examination and laboratory assessment are likely to be required to support the diagnosis, especially in those with HCV/HIV co-infection.

Erratum to "Fragmentation dynamics of single agglomerate-to-wall impaction" [Powder Technology 378 (2021) 561-575, DOI: 10.1016/j.powtec.2020.10.021]

[This corrects the article PMC8724865.].

Pharmacokinetics/pharmacodynamics of antipseudomonal bacteriophage therapy in rats: a proof-of-concept study

OBJECTIVES

Pan-drug-resistant (PDR) Pseudomonas aeruginosa is one of the three top-priority pathogens identified by the WHO, and bacteriophages have been investigated as an alternative therapy. However, knowledge on the pharmacokinetics/pharmacodynamics (PK/PD) of phage therapy is sparse, limiting its clinical applications. This study aimed to evaluate the PK/PD of the antipseudomonal phage øPEV20 in vivo following intravenous administration.

METHODS

Healthy Sprague-Dawley rats were given øPEV20 as a single intravenous bolus of ~6, 9 and 11-log₁₀PFU/rat. Arterial blood was sampled over 72 h. At 72 h, the animals were killed and multiple tissues were harvested for biodistribution studies. A PK model was developed using the importance sampling algorithm and deterministic simulations with a PD model were performed.

RESULTS

A three-compartment model with non-linear clearance described the exposure of øPEV20 in blood. Model evaluation indicated that the model was robust and parameter estimates were accurate. The median (standard error) values of model-predicted PK parameters for V_C, V_P1, V_P2, Q₁, Q₂, V_m and K_m were 111 mL/rat (8.5%), 128 mL/rat (4.97%), 180 mL/rat (4.59%), 30.4 mL/h/rat (19.2%), 538 mL/h/rat (4.97%), 4.39 × 10¹⁰ PFU/h/rat (10.2%) and 1.64 × 10⁷ PFU/mL/rat (3.6%), respectively. The distribution of øPEV20 was not homogeneous; there was preferential accumulation in the liver and spleen. Deterministic simulations with a PD model confirmed the importance of the host immune system in facilitating phage-mediated bacterial elimination.

CONCLUSIONS

We developed a robust PK model to describe the disposition of phages in healthy rats. This model may have significant potential in facilitating future preclinical and clinical PK/PD investigations.

Effect of an upstream grid on the fluidization of pharmaceutical carrier powders

The influence of grid generated mixing on the fluidization of pharmaceutical carrier powders is studied in a channel-flow experiment using direct high-speed imaging and particle image velocimetry (PIV). Four different lactose powders with mass median diameters that range between 61 µm and 121 µm are used. The degree of powder mixing in the flow as a function of grid position relative to the powder bed and grid area blockage ratios (ranging from ~25% to ~40%) is studied for a range of flow-rates. The study presents comprehensive mappings of how pharmaceutical powders are fluidised under the influence of mixing, by examining powder bed morphology, powder emptying rate, and the local flow-field surrounding the pocket. The use of a grid results in higher evacuation percentages (void fraction) and a faster evacuation rate but is associated with randomized evacuation behaviour as observed from the powder bed morphology. Use of a grid can enable evacuation of powder at lower overall flow-rates, which may have important implications on respiratory drug delivery. PIV results show the trend of mean velocities with the mass median powder diameter and demonstrates how a grid with lower blockage ratio can increase the degree of mixing of the evacuating powder and make the evacuation process more rapid. This study contributes towards a better understanding of fluidization processes as relevant to dry powder inhaler devices and sheds light on how simple design alterations, such as adding an upstream grid, can be incorporated to optimise device effectiveness.

Influence of bariatric surgery on weight reduction and control of chronic disease among obese patients in Malaysia

INTRODUCTION

This study was designed to determine the influence of bariatric surgery on changes in the body mass index (BMI), and the control of diabetes, hypertension and dyslipidaemia among obese patients in Malaysia.

MATERIALS AND METHODS

This was a retrospective cohort study undertaken at a public tertiary care centre in the state of Perak, Malaysia. Information of obese patients who underwent bariatric surgery was obtained from their medical records. The changes in the BMI, HbA1C, systolic and diastolic blood pressure (SBP and DBP), and lipid levels between three months before and after the surgery were assessed.

RESULTS

The patients (n=106) were mostly Malay (66.0%), had at least one comorbidity (61.3%), and had a mean age of 40.38±11.75 years. Following surgery, the BMI of the patients was found to reduce by 9.78±5.82kg/m2. For the patients who had diabetes (n=24) and hypertension (n=47), their mean HbA1C, SBP and DBP were also shown to reduce significantly by 2.02±2.13%, 17.19±16.97mmHg, and 11.45±12.63mmHg, respectively. Meanwhile, the mean total cholesterol, triglyceride and low-density lipoprotein levels of those who had dyslipidaemia (n=21) were, respectively, lowered by 0.91±1.18mmol/L, 0.69±1.11mmol/L and 0.47±0.52mmol/L.

CONCLUSION

The findings suggest that in addition to weight reduction, bariatric surgery is helpful in improving the diabetes, hypertension and dyslipidaemia control among obese patients. However, a large-scale trial with a control group is required to verify our findings.

Interleukin-28 Polymorphism: Ethnic variations and the response to chronic hepatitis C treatment in Malaysia

No abstract provided.

In vitro evaluation of novel inhalable dry powders consisting of thioridazine and rifapentine for rapid tuberculosis treatment

Thioridazine is an orally administered antipsychotic drug with potential for treatment of drug-resistant tuberculosis (TB). However, drug-induced adverse cardiac effects have been reported when thioridazine was used at an efficacious oral dose of 200mg/day to treat TB. Pulmonary delivery of thioridazine could be a rational approach to reduce dose-related side effects while enabling high drug concentrations at the primary site of infection. The present study compares in vitro aerosol performance, storage stability, and in vitro antimicrobial activity and cytotoxicity of two inhalable powders composed of thioridazine and a first-line anti-TB drug, rifapentine. Formulation 1 is a combination of amorphous thioridazine and crystalline rifapentine, while Formulation 2 consisted of both drugs as amorphous forms. Both thioridazine-rifapentine formulations were found suitable for inhalation with a total fine particle fraction (<5μm) of 68-76%. The two powders had similar MIC90 to rifapentine alone, being 0.000625μg/mL and 0.005μg/ml against Mycobacterium tuberculosis H37Ra and M. tuberculosis H37Rv, respectively. In contrast, thioridazine alone had a MIC90 of 12.5μg/mL and 500μg/mL, against M. tuberculosis H37Ra and M. tuberculosis H37Rv, respectively, demonstrating no synergistic anti-TB activity. However, thioridazine and rifapentine in a ratio of 1:3 enhanced the killing of M. tuberculosis H37Ra within the human monocyte-derived macrophages (THP-1) compared to the single drug treatments. Both powders showed an acceptable half maximal inhibitory concentration (IC50) of 31.25μg/mL on both THP-1 and human lung epithelial (A549) cells. However, Formulation 1 showed greater chemical stability than Formulation 2 after three months of storage under low humidity (vacuum) at 20±3°C. In conclusion, we have demonstrated a novel inhalable powder consisted of amorphous thioridazine and crystalline rifapentine (Formulation 1) with a good aerosol performance, potent anti-TB activity and storage stability, which deserves further in vivo investigations.

In Vitro Evaluation of Inhalable Verapamil-Rifapentine Particles for Tuberculosis Therapy

Recent studies have demonstrated that efflux pumps of Mycobacterium tuberculosis (M. tb) provide a crucial mechanism in the development of drug resistant to antimycobacterial drugs. Drugs that inhibit these efflux pumps, such as verapamil, have shown the potential in enhancing the treatment success. We therefore hypothesized that the combined inhaled administration of verapamil and a first-line rifamycin antibiotic will further improve the treatment efficacy. An inhalable dry powder consisting of amorphous verapamil and crystalline rifapentine with l-leucine as an excipient was produced by spray drying. The in vitro aerosol characteristic of the powder, its microbiological activity and stability were assessed. When the powder was dispersed by an Osmohaler, the total fine particle fraction (FPFtotal, wt % of particles in aerosol <5 μm) of verapamil and rifapentine was 77.4 ± 1.1% and 71.5 ± 2.0%, respectively. The combination drug formulation showed a minimum inhibitory concentration (MIC90) similar to that of rifapentine alone when tested against both M. tb H37Ra and M. tb H37Rv strains. Importantly, the combination resulted in increased killing of M. tb H37Ra within the infected macrophage cells compared to either verapamil or rifapentine alone. In assessing cellular toxicity, the combination exhibited an acceptable half maximal inhibitory concentration (IC50) values (62.5 μg/mL) on both human monocytic (THP-1) and lung alveolar basal epithelial (A549) cell lines. Finally, the powder was stable after 3 months storage in 0% relative humidity at 20 ± 3 °C.

Using pictograms to assist caregivers in liquid medication administration: a systematic review

WHAT IS KNOWN AND OBJECTIVE

It has been reported that more than 80% of out-of-hospital medication errors among the young children involve liquid formulations. The usefulness of pictorial aids to improve communication of medication instructions has not been extensively investigated for child health. The objective of this study was to determine the effectiveness of pictorial aids used to assist caregivers in the administration of liquid medications.

METHODS

MEDLINE, CINAHL, PsycINFO, ScienceDirect, Scopus and the Cochrane Library were searched for articles published up to February 2015. Studies that used pictorial aids with liquid medications and measured at least one of the following outcomes were included: dosing accuracy, comprehension of medication instructions, recall of information and adherence of caregivers. Two authors independently selected studies, extracted data and assessed methodological quality of studies using the Cochrane Collaboration's tool.

RESULTS AND DISCUSSION

Five experimental studies (four hospital based and one community based) with a total of 962 participants were included. A wide range of liquid formulations were studied, including both prescription and over-the-counter medications. The existing findings suggest that pictographic interventions reduced dosing errors, enhanced comprehension and recall of medication instructions and improved adherence of caregivers. Incorporating pictorial aids into verbal medication counselling or text-based instructions was more beneficial than using the single approach alone. Mixed results were identified for the relationship between health literacy of caregivers and effectiveness of pictorial aids.

WHAT IS NEW AND CONCLUSION

The evidence remains limited due to the small number of studies found and variations in methodological quality. This review suggests that pictorial aids might be potential interventions, but more high-quality studies are needed to support the routine use of any pictogram-based materials with liquid medications in the clinical settings.

Dense packings of spheres in cylinders: simulations

We study the optimal packing of hard spheres in an infinitely long cylinder, using simulated annealing, and compare our results with the analogous problem of packing disks on the unrolled surface of a cylinder. The densest structures are described and tabulated in detail up to D/d=2.873 (ratio of cylinder and sphere diameters). This extends previous computations into the range of structures which include internal spheres that are not in contact with the cylinder.

A critical view on lactose-based drug formulation and device studies for dry powder inhalation: which are relevant and what interactions to expect?

Many years of research have not led to a profound knowledge of the mechanisms involved in the formulation and dispersion of carrier based mixtures for inhalation. Although it is well understood that the mixing is a key process in DPI carrier based formulation, there remains a limited understanding of how blending processes affect in-process material properties and the resulting distribution of the drug in the final dosage form. A great number of variables are considered relevant to the interfacial forces in adhesive mixtures, but their effects have mostly been investigated individually, without taking account of the influence they may have on each other. Interactions may be expected and without proper choices made and definitions given for all the variables involved, conclusions from studies on adhesive mixtures are of less relevance. By varying any of the variables that are not subject of the study, an opposite effect may be obtained. Currently, there is a strong focus on exploring techniques for the characterisation of drug and carrier surface properties that are believed to have an influence on the interparticulate forces in adhesive mixtures. For a number of surface properties it may be questioned whether they are really the key parameters to investigate however. Their orders of magnitude are subordinate to the effects they are supposed to have on the drug-to-carrier forces. Therefore, they seem rather indicators of other variability and their influence may be dominated by other effects. Finally, the relevance of inhaler design is often ignored. By using powerful inhalers, the effect of many variables of current concern may become less relevant. Carrier properties that are considered disadvantageous at present may even become desirable when a more appropriate type of dispersion force is applied. This can be shown for the effect of carrier surface rugosity when inertial separation forces are applied instead of the more widely applied lift and drag forces. Therefore, inhaler design should be taken into consideration when evaluating studies on adhesive mixtures. It should also become an integral part of powder formulation for inhalation.

Phyllotactic description of hard sphere packing in cylindrical channels

We develop a simple analytical theory that relates dense sphere packings in a cylinder to corresponding disk packings on its surface. It applies for ratios R=D/d (where d and D are the diameters of the hard spheres and the bounding cylinder, respectively) up to R=1+1/sin(π/5). Within this range the densest packings are such that all spheres are in contact with the cylindrical boundary. The detailed results elucidate extensive numerical simulations by ourselves and others by identifying the nature of various competing phases.

Muscle coordination is key to the power output and mechanical efficiency of limb movements

The purpose of this study was to determine which features of muscle mechanics and muscle coordination affect the power output from a limb during locomotion. Eight subjects were tested while cycling at maximum exertion for 25 min on a stationary dynamometer. Cadence and load were varied to span a range of power outputs and myoelectric activity was measured from 10 muscles in the leg. Cycle-by-cycle variations in muscle coordination, cadence and power output were observed and the EMG intensity across all muscles was used as an estimate of the metabolic cost for each cycle. Data for the cycles at greatest power output were separated into three groups: maximum power, 80% power but lower EMG intensity and 80% power and higher EMG intensity. Torque-angular velocity relations were determined for the ankle and knee joints. During cycling at maximum power output the ankle joint was not extending at the velocity necessary for maximum power output; thus, maximum limb power occurs when some of the individual muscles cannot be generating maximum power output. Increases in EMG intensity occurred with no increase in power output from the limb: these corresponded to decreases in the efficiency and changes in coordination. Increases in power were achieved that were not matched by equivalent increases in EMG intensity, but did occur with changes in coordination. It is proposed that the power output from the limb is limited by the coordination pattern of the muscles rather than the maximum power output from any one muscle itself.

Characterisation and aerosolisation of mannitol particles produced via confined liquid impinging jets

Mannitol particles, produced by spray drying (SD), have been used commercially (Aridol) in bronchial provocation test. In this study, we propose an alternative method to produce inhalable mannitol powders. The elongated mannitol particles (number median length 4.0microm, and axial ratio of 3.5) were prepared using a confined liquid impinging jets (CLIJs) followed by jet milling (JM). Spray dried and jet milled raw mannitol particles were compared in an attempt to assess the performance of the particles produced by the new method. Aerosol performance of the three different powders (CLIJ, SD, and JM) was relatively poor (fine particle fraction or FPF(loaded) below 15%) when dispersed by the Rotahaler. Dispersion through the Aeroliser led to better aerosol performance of the CLIJ mannitol (FPF(loaded) 20.3%), which is worse than the JM (FPF(loaded) 30.3%) and SD mannitol particles (FPF(loaded) 45.7%) at 60 L/min, but comparable (FPF(loaded) 40.0%) with those of the JM (FPF(loaded) 40.7%) and SD (FPF(loaded) 45.5%) powders at 100L/min. Hence, the optimum use of these elongated mannitol particles can be achieved at increased air flow with a more efficient inhaler. In addition to crystallinity, morphology, and particle size distribution, the surface energies of these powders were measured to explain the differences in aerosol performance. A major advantage of using the CLIJ method is that it can be scaled up with a good yield as the precipitate can be largely collected and recovered on a filter, compared with spray drying which has a low collection efficiency for fine particles below 2microm.

Growth models of pure supercooled materials

For a pure material, the dynamics of the growth of one phase in a supercooled other phase for the case of a shallow temperature quench is traditionally understood via a kinetic thermal diffusion equation model or a quasistatic Laplace equation model, if order-parameter details can be neglected. In the quasistatic model, the interfacial boundary temperature T(R) is equal to the phase transition temperature T(m) . In the kinetic model, however, growth is driven by a nonzero interfacial undercooling T(m)-T(R) . By assuming that the growth process occurs at small but finite, identical spatial steps, the growth laws for the cases of shallow and deep temperature quenches were derived analytically from the kinetic model in the limit of zero thermal diffusivity. For the case of a shallow temperature quench, it is shown that the apparent difference between the assumed interfacial boundary conditions of the quasistatic and the kinetic model does not exist.

Growth dynamics of a liquid crystal at the three- to two-dimensional crossover in a hele-shaw cell

The radial growth of a cholesteric liquid crystal phase was studied experimentally in a thick Hele-Shaw cell. In the experiments, nucleation and growth of the cholesteric phase occurs after a temperature quench from the isotropic liquid. The growth process changes from three- to two-dimensional when the growing phase touches the substrates of the Hele-Shaw cell. It was found that the growth rate generally increases at the dimensional crossover. Also, this increase in growth rate is approximately constant, independent of the depth of the temperature quench. Possible causes for the observed experimental behavior are discussed.

Solubility prediction of drugs in water-cosolvent mixtures using Abraham solvation parameters

PURPOSE

To provide predictive cosolvency models, the Abraham solvation parameters of solutes and the solvent coefficients were combined with the Jouyban-Acree and the log-linear models. These models require two and one solubility data points to predict the solubility of drugs in water-cosolvent mixtures. Ab initio prediction methods also were employed and the results were discussed.

METHOD

The Jouyban-Acree model constants were correlated with variables derived from the Abraham solvation parameters of solutes and the solvent coefficients to present quantitative structure property relationship (QSPR) models. The calculated model constants using the QSPR models were used to predict the solubility in water-cosolvent mixtures. The mean percentage deviation (MPD), average absolute error (AAE) and root mean square error (RMSE) criteria were calculated to show the accuracy of the predictions.

RESULTS

The overall MPD (+/-SD) of the proposed method employing solubility data in mono-solvents, i.e. two data points for each set, was 18.5+/-12.0 which indicates an acceptable prediction error from the practical point of view. The best cosolvency model employing aqueous solubility data was produced overall MPD of 75.2+/-72.6. The overall MPD of the proposed ab initio method was 74.9+/-19.3%. The models produced the same accuracy pattern considering MPD, AAE and RMSE criteria.

CONCLUSION

The proposed model employing two solubility data points for each set produced acceptable prediction error (>>18%) and could be recommended for practical applications in pharmaceutical industry. MPD, AAE and RMSE criteria produced similar results considering various models. However, MPD criterion was preferred since its numerical values could be compared with experimental relative standard deviations for repeated experiments.

Modified Bilston nonlinear viscoelastic model for finite element head injury studies

This paper proposes a modified nonlinear viscoelastic Bilston model (Bilston et al., 2001, Biorheol., 38, pp. 335-345). for the modeling of brain tissue constitutive properties. The modified model can be readily implemented in a commercial explicit finite element (FE) code, PamCrash. Critical parameters of the model have been determined through a series of rheological tests on porcine brain tissue samples and the time-temperature superposition (TTS) principle has been used to extend the frequency to a high region. Simulations by using PamCrash are compared with the test results. Through the use of the TTS principle, the mechanical and rheological behavior at high frequencies up to 10(4) rads may be obtained. This is important because the properties of the brain tissue at high frequencies and impact rates are especially relevant to studies of traumatic head injury. The averaged dynamic modulus ranges from 130 Pa to 1500 Pa and loss modulus ranges from 35 Pa to 800 Pa in the frequency regime studied (0.01 rads to 3700 rads). The errors between theoretical predictions and averaged relaxation test results are within 20% for strains up to 20%. The FEM simulation results are in good agreement with experimental results. The proposed model will be especially useful for application to FE analysis of the head under impact loads. More realistic analysis of head injury can be carried out by incorporating the nonlinear viscoelastic constitutive law for brain tissue into a commercial FE code.

Mathematical representation of solubility of amino acids in binary aqueous-organic solvent mixtures at various temperatures using the Jouyban-Acree model

Applicability of a solution model for calculating solubility of amino acids in binary aqueous-organic solvent mixtures at various temperatures was shown. The accuracy of the proposed model was evaluated by computing mean percentage deviation (MPD) employing available solubility data of amino acids in binary solvents at various temperatures from the literature. The overall MPD (+/- SD) for correlation of solubility data was 16.5 +/- 8.8%. In addition, the equations calculating solubility of amino acids in binary solvent mixtures at a fixed temperature was revisited.

Solubility prediction of salicylic acid in water-ethanol-propylene glycol mixtures using the Jouyban-Acree model

To show the applicability of a solution model, i.e. the Jouyban-Acree model, for predicting the solubility of a solute in ternary solvent systems based on model constants computed using solubility data of the solute in binary solvent systems, the solubility of salicylic acid in water-ethanol, water-propylene glycol, ethanol-propylene glycol mixtures was determined. A minimum number of three data points from each binary system was used to calculate the binary interaction parameters of the model. Then the solubility in other binary solvent compositions and also in a number of ternary solvents was predicted, and the mean percentage deviation (MPD) was calculated as an accuracy criterion. The overall MPD (+/-SD) was 7.3 (+/-7.3)% and those of a similar predictive model was 15.7 (+/-11.5)%. The mean difference between the proposed and a previous model was statistically significant (paired t-test, p < 0.004).

Fractal growth of a conventional calamitic liquid crystal

We report observation of liquid crystal phase ordering via fractal growth aggregates for a calamitic, non-bent-core mesogen. Fractal growth of a conventional smectic- C (Sm-C) phase from the isotropic melt after a temperature quench was experimentally investigated with respect to time, cell gap, quench depth, and quench rate. The determined fractal dimensions relating to the area as well as the perimeter of the growing aggregates suggest a phase formation process via a percolation mechanism. Computer simulations of the phase ordering process give further evidence for percolation growth, qualitatively reproducing the observed textures and quantitatively leading to the same fractal dimensions. We propose a general model of fractal smectic liquid crystal growth, which accounts for all of the different systems observed so far, bent-core or "banana" phases as well as the observation of fractal phase ordering of a conventional Sm-C phase. The model is based on the "breaking" of the commonly observed growth anisotropy by strong in-layer molecular interactions. These are provided by hydrogen bonding in the Sm-C case discussed here and by steric interactions in the case of the bent-core phases discussed in previous publications.

Solubility prediction in water-ethanol mixtures based on the excess free energy approach using a minimum number of experimental data

The solubility of nalidixic acid in water-ethanol mixtures has been determined at 25 degrees C. The generated solubility data sets have been used to assess the accuracy of different numerical analyses for the excess free energy model and a new numerical method for solubility prediction in water-ethanol mixtures based on four experimental determinations is proposed. The accuracy of a previously presented numerical method to fit all data points is compared with that of a proposed analysis using average percentage deviation (APD). The APD obtained are 14.6 (+/- 8.0) and 8.4 (+/- 4.1), respectively for previous and proposed methods. A minimum number of three and four data points employed to train the original forms of the excess free energy model and the solubility at other solvent compositions were predicted. The APDs obtained were 61.4 and 23.0%, respectively. The APD produced for the proposed numerical method was 16.1%.

An improved empirical model to calculate solute solubility in supercritical carbon dioxide

To provide more accurate solubility predictions in supercritical carbon dioxide (SC-CO2) using an empirical model employing density as an independent variable, the density of SC-CO2 at different temperatures and pressures has been calculated and compared with experimental densities. The average percentage deviation (APD) has been determined as an accuracy criterion and the obtained APD for the equations studied were between 1.3 (+/-1.4)-11.6 (+/-8.9)%. To show the effects of density values on solubility prediction, the solubility of 18 drug compounds in SC-CO2 has been calculated using an empirical equation with respect to temperature, pressure and density. The APD values for correlative analysis was 8.5 (+/-5.8)% for the most accurate density values calculated by BACK equation of state. A minimum number of experimental data (i.e. 6 points) has been used to train the model then the solubility at other temperatures and pressures has been predicted and the APD value for the most accurate densities obtained was 14.2 (+/-9.4)%. This prediction error could be considered as acceptable when it is compared with RSD values for repeated measurements (approximately 10%) and the proposed predictive method could be employed in industry to calculate the solubility of a drug using a limited number of experimental data.

Calculation of electrophoretic mobility in ternary solvent electrolyte systems

Electrophoretic mobility of salmeterol and phenylpropanolamine in capillary electrophoresis has been determined using acetate buffer containing different concentrations of water, methanol and acetonitrile. Maximum electrophoretic mobilities for salmeterol and phenylpropanolamine have been observed at water-methanol-acetonitrile (5:50:45, v/v) and (3:60:37, v/v), respectively, while minimum mobilities of both compounds occurred at methanol-acetonitrile (30:70, v/v). The generated experimental data have been used to evaluate a mathematical model to compute the electrophoretic mobility of the analytes. The proposed model reproduced the mobility data with mean percentage deviations within 1-4%.

Mathematical representation of electrophoretic mobility of basic drugs in ternary solvent buffers in capillary zone electrophoresis

The electrophoretic mobilities of two beta-blocker drugs, i.e., labetalol and atenolol, have been determined in a mixed solvent background electrolyte system containing sodium acetate+acetic acid as buffering agent and different volume fractions of water, methanol and ethanol using capillary electrophoresis. The produced data and three other sets collected from a recent work are employed to study the accuracy and prediction capability of a mathematical model to calculate the electrophoretic mobility with respect to the volume fractions of the solvents in the mixture. The results show that the proposed model is able to correlate/predict the mobility within an acceptable error range and it is possible to use the model in industry to achieve the optimum solvent composition for the buffer where using a ternary solvent system is required. The average percentage deviations (APDs) obtained for correlated and predicted data points are 0.71-2.48 and 1.72-4.39%, respectively. The accuracy of the proposed model is compared with that of a mixture response surface method and the results show that the proposed model is superior from both correlation and prediction points of view. The possibility of calculation of the mobility of chemically related drugs in water-methanol-ethanol mixtures using the proposed model is also shown and the produced prediction APD is approximately 8%.

Effects of terbutaline in combination with mannitol on mucociliary clearance

Beta2-agonists and osmotic agents stimulate mucociliary clearance (MCC) via different mechanisms which could potentially interact. The effects of inhaling terbutaline in combination with mannitol on MCC were investigated in nine healthy (aged 19+/-1 yrs) and 11 mild (aged 21+/-4 yrs) asthmatic subjects. Using 99mTc-sulphur colloid radioaerosol and a gamma camera, MCC was studied on four separate days with each of the following interventions: 1) terbutaline or its placebo inhaled 10 min before mannitol (in random, double blind); 2) terbutaline inhaled 5 min after mannitol; and 3) terbutaline inhaled 10 min before the control for mannitol. Lung images were collected over a period of 120 min postintervention and over 150 min in total. The mannitol-induced increase in clearance was transiently inhibited by terbutaline pretreatment and transiently enhanced when terbutaline was administered after mannitol both in asthmatic and healthy subjects. The order of administration of mannitol and terbutaline did not affect the total clearance of radioactive mucus over 140 min from the start of intervention in both groups. The pathways through which terbutaline and mannitol increase mucociliary clearance may transiently interact in an inhibitory or synergistic way, depending on the order of administration. However, this did not affect the overall increase in mucociliary clearance over 140 min.

Use of aerosols for bronchial provocation testing in the laboratory: where we have been and where we are going

Bronchial provocation testing with pharmacological agents that act directly on airway smooth muscle has important limitations. These include the inability to identify exercise-induced asthma (EIA), to differentiate the airway hyperresponsiveness (AHR) of airway remodelling from the AHR of active inflammation and to differentiate between doses of steroids. Recent studies show that tests that act indirectly to narrow airways are more sensitive than pharmacological agents for identifying airway inflammation and response to treatment. Adenosine monophosphate (AMP) is an indirect challenge that acts on mast cells to cause release of mediators. Hypertonic saline is another and, since its development in the 1980s, has become widely used in Australia. Hypertonic (4.5%) saline is used to identify those with active asthma, those with EIA and those who wish to enter certain occupations or sports (e.g., diving). The recent development, again in Australia, of a test that uses dry powder mannitol has promise for use in the laboratory, the office, or for testing in the field. AHR to mannitol identifies people with EIA and is an estimate of its severity. The mannitol response is modified by drugs used to prevent EIA, implying that similar mediators are involved. A mannitol test can be used to monitor response to steroids and is more sensitive than histamine for identifying persistent airway hyperresponsiveness in asthmatics well controlled on steroids. These findings suggest that indirect challenges give more useful clinical information about currently active asthma and the response to treatment than direct challenge and they will become more widely used.

Calculation of electrophoretic mobility in mixed solvent buffers in capillary zone electrophoresis using a mixture response surface method

The electrophoretic mobilities of three beta-blocker drugs, practolol, timolol and propranolol, have been measured in electrolyte systems with mixed binary and ternary water-methanol-ethanol solvents with acetic acid/sodium acetate as buffer using capillary electrophoresis. The highest mobilities for the analytes studied have been observed in pure aqueous, the lowest values in ethanolic buffers. The measured electrophoretic mobilities have been used to evaluate the accuracy of a mathematical model based on a mixture response surface method that expresses the mobility as a function of the solvent composition. Mean percentage error (MPE) has been computed considering experimental and calculated mobilities as an accuracy criterion. The obtained MPE for practolol, timolol and propranolol in the binary mixtures are between 0.9 and 2.6%, in the ternary water-methanol-ethanol solvent system the MPE was about 2.7%. The MPE values resulting from the proposed equation lie within the experimental relative standard deviation values and can be considered as an acceptable error.

A model to represent solvent effects on the chemical stability of solutes in mixed solvent systems

The applicability of the combined nearly ideal binary solvent/Redlich-Kister (CNIBS/R-K) equation for quantification of solvent effects on the stability of a solute is shown employing the experimental data of three solutes in different aqueous binary solvents. The proposed model provides a simple computational method to correlate/predict the instability rate constant of a drug in mixed solvent systems. The accuracy of the model is compared with that of a model proposed by Connors and co-workers employing various methods including mean percentage deviation (MPD) as comparison criteria. The obtained overall MPD values for the proposed model to correlate and predict the instability rate constants are 2.05 +/- 1.44 and 4.41 +/- 3.21%, respectively, where the corresponding values for Connors' model are 4.34 +/- 3.28 and 10.74 +/- 9.86%. The results suggest that by using only five experimental instability rate constants at different concentrations of the cosolvent in a binary mixture, it is possible to predict unmeasured values falling between data points within an acceptable error range.

In vitro aerosol performance and dose uniformity between the Foradile Aerolizer and the Oxis Turbuhaler

Dry powder inhalers for eformoterol fumarate dihydrate, a long-acting beta-2 agonist for bronchodilation, are currently available as the Foradile Aerolizer and the Oxis Turbuhaler. The two products are different in the formulation, the aerosol production mechanism, and the device resistance to air flow. These disparities are likely to lead to different aerosol characteristics. Our objective was to compare the in vitro performance of these two inhalers in producing eformoterol aerosols. Emitted dose uniformity was measured using a sampling apparatus described in the British Pharmacopaeia. Ten individual doses (dose number 2, 3, 15, 16, 30, 31, 45, 46, 59, and 60) of the entire content (60 doses) were collected from the Aerolizer and the Turbuhaler (six inhalers each). Particle size distribution of the aerosols generated by the two inhalers were measured by a multiple stage liquid impinger at four different air flows (30-120 L/min). Eformoterol collected from the sampling devices was measured by HPLC. Fine particles are those of < or = 1.7-5.0 microm in size in the aerosols obtained by interpolation of the data at the specified air flow. The Aerolizer showed a slight dependence of the emitted dose on the air flow, with the average emitted dose increased from 80% (at 30 L/min) to 90% (at higher flows) of the 12-microg label claim as compared with 60% for the Turbuhaler. When the emitted dose was normalized by the average emitted dose value, the Aerolizer showed less variation in the normalized emitted dose uniformity than the Turbuhaler. At high air flows, 90 and 120 L/min, both inhalers produced similar amounts (4 microg) of fine particles in the aerosol per dose discharged. As the flow as decreased to 30 and 60 L/min, both inhalers produced significantly less fine particles (p < 0.05), with the Oxis Turbuhaler producing lesser amounts than the Foradile Aerolizer. However, due to the different device resistance, comparing the inhaler performance at the same inspiratory effort may be more appropriate. At a comfortable effort of 40 cm H2O, the Foradile Aerolizer would produce a significantly higher fine particle mass in the aerosols. We conclude that the two inhalers were dissimilar in the emitted dose uniformity. The fine particle mass of eformoterol produced by the two inhalers was equivalent at high but not at low air flows. The disparities may be due to the difference in the formulation and the aerosol generation mechanism of the inhalers.

Use of solid corrugated particles to enhance powder aerosol performance

PURPOSE

To study the dispersion performance of non-porous corrugated particles, with a focus on the effect of particle surface morphology on aerosolization of bovine serum albumin (BSA) powders.

METHODS

The solid-state characteristics of the spray-dried BSA powders, one consisting of smooth spherical particles and another corrugated particles, were characterized by laser diffraction, X-ray powder diffraction, scanning electron microscopy, confocal microscopy, thermogravimetric analysis, surface area analyzer, and buoyancy method. The powders were dispersed using the Rotahaler and the Dinkihaler coupled to a four-stage liquid impinger operating at 30 to 120 L/min. Fine particle fraction (FPF) was expressed as the wt. % of BSA particles of size < or =5 microm collected from the liquid impinger.

RESULTS

Apart from the morphology and morphology-related properties (specific surface area, envelope density), the corrugated particles and spherical particles of BSA had very similar solid-state characteristics (particle size distribution, water content, true density, amorphous nature). Using the Dinkihaler, the FPFs of the corrugated particles were 10-20 wt. % higher than those of the smooth particles. Similar FPF differences were found for the powders dispersed by the Rotahaler, but the relative changes were larger. In addition, the differences were inversely proportional to the air flows (17.3% at 30 L/min, 25.2% at 60 L/min, 13.8% at 90, 8.5% at 120 L/min). Depending on the inhaler, capsule and device retention and impaction loss at the impinger throat were lower for the corrugated particles.

CONCLUSIONS

Enhanced aerosol performance of powders can be obtained by surface modification of the particles. The surface asperities of the corrugated particles could lower the true area of contact between the particles, and thus reduce the powder cohesiveness. A distinct advantage of using corrugated particles is that the inhaler choice and air flow become less critical for these particles.

Markers of airway inflammation and airway hyperresponsiveness in patients with well-controlled asthma

In steroid-naive asthmatics, airway hyperresponsiveness correlates with noninvasive markers of airway inflammation. Whether this is also true in steroid-treated asthmatics, is unknown. In 31 stable asthmatics (mean age 45.4 yrs, range 22-69; 17 females) taking a median dose of 1,000 microg inhaled corticosteroids (ICS) per day (range 100-3,600 microg x day(-1)), airway responsiveness to the "direct" agent histamine and to the "indirect" agent mannitol, lung function (forced expiratory volume in one second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF)), exhaled nitric oxide (eNO), and number of inflammatory cells in induced sputum as a percentage of total cell count were measured. Of the 31 subjects, 16 were hyperresponsive to mannitol and 11 to histamine. The dose-response ratio (DRR: % fall in FEV1/cumulative dose) to both challenge tests was correlated (r=0.59, p=0.0004). However, DRR for histamine and DRR for mannitol were not related to basic lung function, eNO, per cent sputum eosinophils and ICS dose. In addition, NO was not related to basic lung function and per cent sputum eosinophils. In clinically well-controlled asthmatics taking inhaled corticosteroids, there is no relationship between markers of airway inflammation (such as exhaled nitric oxide and sputum eosinophils) and airway responsiveness to either direct (histamine) or indirect (mannitol) challenge. Airway hyperresponsiveness in clinically well-controlled asthmatics appears to be independent of eosinophilic airway inflammation.

Aerosol deposition and clearance measurement: a novel technique using dynamic SPET

Planar gamma camera scintigraphy is a well-established technique for characterising the deposition and clearance of radiolabelled aerosols. While single-photon emission tomography (SPET) can offer superior assessment of radioaerosol deposition and better differentiation between peripheral and central deposition, the long acquisition times of single-headed SPET have largely prevented its use for measuring clearance or deposition of fast-clearing radioaerosols. This study investigated the feasibility of fast dynamic SPET imaging (1 min/frame) using a three-headed gamma camera to assess the regional and total deposition and clearance of different radioaerosols over a period of 26 min. Six subjects inhaled nebulised technetium-99m diethylene triamine penta-acetic acid radiolabelled aerosols with small and large droplet sizes [mass median aerodynamic diameter (MMAD) 3.2 +/- 0.2 and 6.5 +/- 0.2 microm, span 1.8 and 1.7, respectively] and in normal (0.9%) or hypertonic (7%) saline with controlled breathing on four separate occasions. The penetration indices (PIs) calculated from the SPET data for normal saline were 0.50 +/- 0.04 and 0.36 +/- 0.02 for the small and large droplet sizes, respectively. Consistent with the hygroscopic growth of the hypertonic aerosols, the PIs for hypertonic saline were lower, at 0.43 +/- 0.02 and 0.34 +/- 0.02 for the small and large droplet sizes, respectively. PIs calculated from the planar data showed similar trends, but failed to detect the significant difference seen with SPET between small normal and small hypertonic saline radioaerosols. In conclusion, the feasibility of using fast dynamic SPET for imaging radioaerosol deposition and associated radiolabel clearance in the lung has been successfully demonstrated. The fast SPET was able to reveal important differences in aerosol deposition that were not detected by planar imaging.

Solubility prediction for furosemide in water-cosolvent mixtures using the minimum number of experiments

The mole fraction solubility of a poorly water soluble loop diuretic, furosemide, was determined in aqueous binary mixtures of ethanol, propylene glycol, and glycerol from 0% to 100% cosolvent concentrations at 25 degrees C. Solubility predictions based on the minimum number of experimental data points were performed using the commonly used accurate cosolvency models: the three-suffix excess free energy (3xEFE), the mixture response surface (MRS), the combined nearly ideal binary solvent/Redlich-Kister (CNIBS/R-K), and the general single model (GSM). This prediction method was tested using three sets of solubility data for furosemide generated in this study and 11 data sets collected from the literature. The average percentage deviations (APDs) were 8.4 +/- 3.8, 13.6 +/- 7.3, 7.4 +/- 2.8, and 7.6 +/- 2.9, respectively, for 3xEFE, MRS, CNIBS/R-K, and GSM models. Using 3xEFE, CNIBS/R-K, and GSM models, which are theoretically related, a mean predicted solubility (MPS) approach was also proposed. The APD for this method was 7.3 +/- 2.3. The mean differences between MRS and the others were statistically significant (p < .001). The results showed that one can employ solubility prediction based on a minimum of five experimental data points, and the expected APD is less than 10%.

Fexofenadine decreases sensitivity to and montelukast improves recovery from inhaled mannitol

We studied, separately, the effects of the histamine antagonist, fexofenadine hydrochloride, and the leukotriene antagonist, montelukast sodium, and their placebos on airway sensitivity to and recovery from inhaled mannitol in subjects with asthma. Two 180-mg doses of fexofenadine were taken over 14 h, and three 10-mg doses of montelukast over 36 h, with the last dose 5 h before challenge. Fexofenadine reduced sensitivity to mannitol and the PD(15) was (mean [95% confidence interval] 138 [95, 201]) mg versus placebo (51 [25, 106] mg) (p < 0.001). The final percent reduction in FEV(1) with fexofenadine was 20.8 +/- 5.4% and not different from placebo (20.1 +/- 5.3%) (p = 0.7); however, recovery was slower with fexofenadine compared with placebo (p < 0.001). By contrast, montelukast had no effect on sensitivity to mannitol and the PD(15) was 71 [36, 144] mg versus placebo (87 [51, 148] mg (p = 0.35). The total dose of mannitol delivered and the final percent reduction in FEV(1) with montelukast were 171 +/- 142 mg and 21 +/- 4% and for placebo were 182 +/- 144 mg and 20 +/- 5% (p = 0.35, p = 0.59, respectively). However, recovery of FEV(1) to baseline was faster with montelukast, with the area under the percent reduction FEV(1)-versus-time curve reduced (220 +/- 121% change.min) compared with placebo (513 +/- 182% change.min) (p < 0.001). We conclude that whereas histamine is important for the initial airway response, leukotrienes are important in sustaining the airway response to inhaled mannitol.

Inhibition of serine proteases by functionalized sulfonamides coupled to the 1,2,5-thiadiazolidin-3-one 1,1 dioxide scaffold

A challenge associated with drug design is the development of selective inhibitors of proteases (serine or cysteine) that exhibit the same primary substrate specificity, that is, show a preference for the same P(1) residue. While these proteases have similar active sites, nevertheless there are subtle differences in their S and S' subsites which can be exploited. We describe herein for the first time the use of functionalized sulfonamides as a design and diversity element which, when coupled to the 1,2,5-thiadiazolidin-3-one 1,1 dioxide scaffold yields potent, time-dependent inhibitors of the serine proteases human leukocyte elastase (HLE), proteinase 3 (PR 3) and cathepsin G(Cat G). Our preliminary findings suggest that (a) appending to the 1,2,5-thiadiazolidin-3-one 1,1 dioxide scaffold recognition and diversity elements that interact with both the S and S' subsites of a target protease may result in optimal enzyme selectivity and potency and, (b) functionalized sulfonamides constitute a powerful design and diversity element with low intrinsic chemical reactivity and potentially wide applicability.

Predictive markers of asthma exacerbation during stepwise dose reduction of inhaled corticosteroids

To determine predictors for failed reduction of inhaled corticosteroids (ICS), in 50 subjects with well-controlled asthma (age 43.7 [18-69]; 22 males) taking a median dose of 1,000 microg ICS/d (100-3,600 microg/d), ICS were halved every 8 wk. Airway hyperresponsiveness (AHR) to a bronchial provocation test (BPT) with histamine was measured at baseline. AHR to BPT with mannitol, spirometry, exhaled nitric oxide (eNO), and, in 31 subjects, sputum inflammatory cells were measured at baseline and at monthly intervals. Thirty-nine subjects suffered an asthma exacerbation. Seven subjects were successfully weaned off ICS. Using a Kaplan- Meier survival analysis, the significant predictors of a failure of ICS reduction were being hyperresponsive to both histamine and mannitol at baseline (p = 0.039), and being hyperresponsive to mannitol during the dose-reduction phase of the study (p = 0.02). Subjects older than 40 yr of age tended to be at greater risk of ICS reduction failure (p = 0.059). Response to mannitol and percentage sputum eosinophils were significantly greater before a failed ICS reduction than before the last successful ICS reduction, whereas there were no significant differences in symptoms, spirometry, or eNO. These findings suggest that documentation of patient's AHR or sputum eosinophils may be useful in guiding the reduction of ICS doses.

The 24-h effect of mannitol on the clearance of mucus in patients with bronchiectasis

STUDY OBJECTIVE

To investigate the acute effect of mannitol on the clearance of mucus, and (1) the 24-h mucus retention, and (2) the mucus clearance rate and lung function 24 h after inhalation of a single dose of mannitol.

DESIGN

Clearance of mucus was measured on 3 consecutive days using (99m)Tc-sulfur colloid radioaerosol and a gamma camera.

INTERVENTIONS

Mannitol, 330 +/- 68 mg (mean+/- SD), was inhaled using a dry powder inhaler only on day 2.

PATIENTS

Eight patients with bronchiectasis (age range, 29 to 70 years).

MEASUREMENTS AND RESULTS

On each day, lung images were collected over 2 h and at 24 h. Key findings of the study are as follows: (1) the 24-h retention of mucus was reduced the day after mannitol had been inhaled, compared to the day without mannitol (day 1) in the whole right lung (57.6 +/- 6.2% vs 68.1 +/- 5.9%), central (47.5 +/- 6.7% vs 56.9 +/- 6.5%), intermediate (61.7 +/- 5.6% vs 73.8 +/- 5.5%), and peripheral regions (70.9 +/- 4.3% vs 86.6 +/- 4.6%)(p < 0.02); and (2) mannitol helped patients clear mucus within 2 h that might otherwise take up to 24 h, from the whole right lung and defined regions. However, clearance over 60 min measured 24 h after mannitol inhalation was not significantly different to baseline clearance without mannitol (8.7 +/- 1.9% on day 1 vs 9.7 +/- 3.7% 24 h after mannitol; p > 0.8). The patients maintained the same lung function the day before and after mannitol had been inhaled: FEV(1) (percent predicted), 79 +/- 5 on day 1 vs 80 +/- 5 on day 3; and forced expiratory flow, midexpiratory phase (percent predicted), 50 +/- 6 on day 1 vs 51 +/- 6 on day 3; p > 0.6).

CONCLUSIONS

Mannitol inhalation acutely increases clearance of mucus, and this effect extends beyond the acute study period, resulting in decreased mucus retention at 24 h.

Inhaled mannitol shifts exhaled nitric oxide in opposite directions in asthmatics and healthy subjects

We investigated if healthy subjects could release NO upon hyperosmolar challenge as a defence mechanism, and whether asthmatics with atopy showed an altered response. A plot of NO output versus flow rate was used to calculate the alveolar level and the NO-flux from the airways. The asthmatics had a higher NO output and this was due to an increased NO-flux from the airways, 86+/-30 nl min(-1) compared with control 21+/-2 nl min(-1) (P<0.05). The alveolar NO levels showed no difference. In response to a dry powder of mannitol the exhaled NO concentration decreased in asthmatics by 37+/-7%, but increased in the control by 9+/-4% (P<0.001). The FEV(1.0) decreased 13+/-2% and airway conductance 42+/-7% in asthmatics and in the controls 2+/-1% and 0+/-7%, respectively (P<0.001). We conclude that asthmatics have an altered response to mannitol challenge in regards to exhaled NO. This may result from down regulation of constitutive NO production as a result of high levels of NO flux from the airways.

Use of montelukast in the treatment of early childhood wheezing from clinical experience with three cases

Leukotrienes were found to be raised in respiratory syncytial virus bronchiolitis. Montelukast is a cysteinyl leukotrienes antagonist. We report our experience with the use of montelukast in three young children from 5-months to 20-months old. The first case was a 5-month-old boy with previous good health. He had prolonged respiratory distress secondary to adenovirus type 3 infection. The second case was a 20-month-old boy with bronchopulmonary dysplasia. He had respiratory syncytial virus and an adenovirus type 3 infection leading to prolonged wheeze. The third case was a 20-month-old girl with chronic lung disorder after an episode of severe E. coli pneumonia at 1 month old. She developed acute virus-negative severe wheeze after a few days of running nose and low-grade fever. All three cases responded poorly to inhaled steroids and bronchodilators. Addition of montelukast was associated with marked clinical improvement within 1 week. The three cases were very heterogeneous and differed from usual simple virus-induced acute bronchiolitis. The use of multiple drugs including montelukast did not enable any definite conclusions; however, the addition of montelukast was closely related to clinical improvement. Further studies in the use of montelukast in severe virus-induced bronchiolitis are warranted.

Generation of micro-particles of proteins for aerosol delivery using high pressure modified carbon dioxide

PURPOSE

To investigate the feasibility of using the Aerosol Solvent Extraction System (ASES) to generate microparticles of proteins suitable for aerosol delivery from aqueous-based solutions.

METHODS

The ASES technique using high-pressure carbon dioxide modified with ethanol was utilised for the generation of microparticles of proteins (lysozyme, albumin, insulin and recombinant human deoxyribonuclease (rhDNase)) from aqueous solutions. Particle size, morphology, size distributions and powder aerosol performance were examined. The biochemical integrity of the processed proteins was assessed by testing the level of molecular aggregation using size exclusion chromatography and by bioassay technique for lysozyme.

RESULTS

Proteins were precipitated as spherical particles ranging in size from 100 to 500 nm. The primary nano-sized particles agglomerated to form micron-sized particles during the precipitation process. The median size of the particles was a function of the operating conditions. In-vitro aerosol performance tests showed that the percent fine particle mass (< 5 microm) was approximately 65%, 40% and 20% for lysozyme, albumin and insulin, respectively. Negligible loss in the monomer content or biological activity was observed for lysozyme. Insulin exhibited slight aggregation and 93% of the monomer was retained after processing. Albumin was affected by processing and only 50-75% of the monomer was retained compared with 86% in the original material. However, rhDNase was substantially denatured during processing as shown by the significantly reduced monomer content.

CONCLUSIONS

Micron-sized particles of lysozyme, albumin and insulin with satisfactory inhalation performance were successfully generated from aqueous solutions using the modified ASES technique. The biochemical integrity of the processed proteins was a function of the operating conditions and the nature of the individual protein.

Nasal hyperosmolar challenge with a dry powder of mannitol in patients with allergic rhinitis. Evidence for epithelial cell involvement

BACKGROUND

The responses to airway hyperosmolar challenges probably involve various inflammatory mediators. However, it is not fully understood which cell type/types are the source of these mediators. Potential cell types include mast cell, epithelial cell and the sensory c-fibre nerve cell.

OBJECTIVE

To clarify which cell types are involved with the mediator response to hyperosmolarity in the human airway.

METHODS

Ten healthy subjects, 11 patients with nonactive allergic rhinitis, and nine with active allergic rhinitis were challenged intranasally with mannitol powder, and with sham provocation, on separate days. Symptoms were assessed by visual analogue scales and nasal patency by measuring the nasal peak inspiratory flow (nPIF). Nasal lavage fluid levels of alpha(2)-macroglobulin (an index of plasma extravasation), substance P (an index of sensory nerve cell activation), tryptase (an index of mast cell activation) and 15-hydroxyeicosatetraenoic acid (15-HETE, an index of epithelial cell activation) were analysed.

RESULTS

Immediate, although transient burning was the most prominent symptom in all groups whereas only the patients with active rhinitis experienced a fall in nPIF. Mannitol significantly increased the nasal lavage fluid 15-HETE levels in the allergic patients (P < 0.01 vs the sham challenge), but not in the healthy subjects. The increase in 15-HETE correlated with nasal symptoms for itching (r(s) = 0.65, P = 0.019) and burning (r(s) = 0.72, P = 0.009). Detectable levels of tryptase was found only in five allergic subjects. Lavage levels of substance P and alpha(2)-macroglobulin did not not change.

CONCLUSION

Epithelial cell seems to be involved with the mediator response to airway hyperosmolar challenge. The roles of sensory c-fibre nerve cell and mast cell remained less clear.

Effect of particle size, air flow and inhaler device on the aerosolisation of disodium cromoglycate powders

Recently, the dispersion of mannitol powders has demonstrated the importance of particle size, air flow and inhaler device (Chew and Chan, 1999). The aim of the present study is to extend our investigation to a different compound, disodium cromoglycate (DSCG) powders. Solid state characteristics of the powders were assessed by particle sizing, scanning electron microscopy, X-ray powder diffraction, moisture content, particle density determination and freeze fracture. The aerosol behaviour of the powders was studied by dispersion using Rotahaler(R) and Dinkihaler(R), connected to a four-stage liquid impinger operating at 30-120 l/min. Three amorphous powders with a mass median diameter (MMD) of 2.3, 3.7, 5.2 microm and a similar polydispersity were prepared. The particles were nearly spherical with a particle density of 1.6 g/cm(3) and moisture content of 6.6 wt.%. Using Rotahaler(R), the maximum fine particle fraction (FPF(max)) for all three powders was only 15 wt.%, attained at the highest flow of 120 l/min. Using Dinkihaler(R), the FPF(max) was two to four times higher, being 36 and 29 wt.% for the 2.3 and 3.7 microm powder, respectively, at 60 l/min; and 18 wt.% for the 5.2 microm powder at 120 l/min. Hence, the study shows that the FPF in the DSCG powder aerosols was determined by the interaction of the particle size, air flow and inhaler design. The attribution of the amorphous nature and the different physico-chemical properties of the powder may explain the incomplete and low dispersibility of DSCG.

Potent inhibition of serine proteases by heterocyclic sulfide derivatives of 1,2,5-thiadiazolidin-3-one 1,1 dioxide

The existence of subtle differences in the Sn' subsites of closely-related (chymo)trypsin-like serine proteases, and the fact that the 1,2,5-thiadiazolidin-3-one 1,1 dioxide scaffold docks to the active site of (chymo)trypsin-like enzymes in a substrate-like fashion, suggested that the introduction of recognition elements that can potentially interact with the Sn' subsites of these proteases might provide an effective means for optimizing enzyme potency and selectivity. Accordingly, a series of heterocyclic sulfide derivatives based on the 1,2,5-thiadiazolidin-3-one 1,1 dioxide scaffold (I) was synthesized and the inhibitory activity and selectivity of these compounds toward human leukocyte elastase (HLE), proteinase 3 (PR 3) and cathepsin G (Cat G) were then determined. Compounds with P1 = isobutyl were found to be potent, time-dependent inhibitors of HLE and, to a lesser extent PR 3, while those with P1 = benzyl inactivated Cat G rapidly and irreversibly. This study has demonstrated that 1,2,5-thiadiazolidin-3-one 1,1 dioxide-based heterocyclic sulfides are effective inhibitors of (chymo)trypsin-like serine proteases.

Nedocromil sodium inhibits responsiveness to inhaled mannitol in asthmatic subjects

Nedocromil sodium inhibits the response to exercise-induced asthma (EIA). Mannitol given as a powder by inhalation is an osmotic stimulus that identifies EIA. We studied the acute effect of nedocromil on airway responsiveness to mannitol in 24 asthmatic subjects. After a control day, nedocromil (8 mg) or its placebo was administered randomized, double blind, 10 min before a challenge with progressively increasing doses of mannitol. Nedocromil inhibited the response to mannitol and there was a significant increase in the dose of mannitol required to cause a 15% reduction in FEV(1) (PD(15)) after nedocromil 409 (316,503) mg compared with placebo 156 (106,229) mg (p < 0.001). In the presence of nedocromil 12 subjects no longer recorded a 15% decrease in FEV(1) in response to mannitol. The remaining 12 required a significantly greater dose of mannitol to achieve a 15% decrease in FEV(1) after nedocromil. Following nedocromil, a plateau in responsiveness to mannitol was observed in 14 subjects. Nedocromil significantly inhibits the responsiveness to inhaled mannitol in asthmatic subjects.

The effect of spacers on the delivery of metered dose aerosols of nedocromil sodium and disodium cromoglycate

The effect of the spacers (Fisonair, Breath-A-Tech, Volumatic and Nebuhaler) on the in vitro aerosol characteristics of two propellant-driven metered dose inhalers (MDIs), Tilade (nedocromil sodium) and Intal (disodium cromoglycate), was studied. The measurement was carried out on a Marple-Miller impactor operating at 30 l/min. Five actuations were collected for the drug assay. The results showed that Tilade (label claim 2 mg active per actuation) and Intal (label claim 5 mg active per actuation) generated aerosols with a fine particle mass (FPM, i.e. mass of particles 5 microm in the aerosol) of 0.34 mg (S.D. 0.01, n = 4) and 0.02 mg (S.D. 0.01, n = 4) per actuation, respectively. For both inhalers, large volume spacers increased (Fisonair > Nebuhaler > Volumatic) while small volume spacer (Breath-A-Tech) decreased the FPM. The FPM (per actuation) for Tilade with Fisonair, Nebuhaler, Volumatic and Breath-A-Tech was 0.52 (0.03), 0.45 (0.03), 0.41 (0.04) and 0.09 (0.04) mg, respectively, while for Intal the corresponding values were 0.41 (0.02), 0.32 (0.04), 0.28 (0.03) and 0.08 (0.01) mg. Thus, the fine particle mass can be either increased or decreased, depending on the spacer selected. In addition, all spacers significantly reduced the coarse particle (> or = 10 microm) mass, with Fisonair, Breath-A-Tech, Nebuhaler and Volumatic producing only 7.6, 0.4, 5.2 and 2.6, respectively of that from Tilade alone and 15.6, 0.7, 5.4 and 4.1%, respectively of that from Intal alone. The general trends for Tilade and Intal were similar but not quantitatively identical. The proper choice of spacers is therefore important for the optimal delivery of Tilade and Intal.

Inhaled mannitol identifies methacholine-responsive children with active asthma

Inhaled mannitol has been developed for bronchial challenge testing in adults. This study determined if mannitol could identify children with active asthma and responsive to methacholine, and whether mannitol challenge was faster to complete than methacholine challenge. Twenty-five children (aged 6-13 years) responsive to methacholine and 10 nonasthmatic children unresponsive to methacholine were studied. The methacholine challenge (Cockcroft protocol) was followed by a mannitol challenge on separate days. Twenty-one asthmatic children were positive to mannitol. Three taking inhaled corticosteroids with borderline methacholine responsiveness did not respond to mannitol, and one could not complete the mannitol challenge due to cough. The geometric mean (GM) and 95% confidence interval (CI) for PD(15) for mannitol was 39 mg (19, 78), and PC(20) for methacholine was 0.6 mg/mL (0.35-1.02) (r(p) = 0.75, p < 0.001, n = 21). Responses to mannitol were repeatable: GM PD(15) for the first challenge was 29 mg (CI: 17,50), and for the second challenge, 33 mg (CI: 20, 55) (P = 0.44, n = 9). Mannitol was faster to administer than methacholine (median (range)) 14 min (5-32) vs. 29 min (19-49), respectively (P < 0.001). Time to recover to baseline FEV(1) spontaneously and after bronchodilator administration was similar for both challenges. There were no significant falls in arterial oxygen saturations. During mannitol challenge, the mean (SD) fall in FEV(1) in nonasthmatic children was 3.1% (2.9). We conclude that mannitol identifies children with airway hyperresponsiveness and is faster to perform than the methacholine challenge.