Why do patients with DR-TB do not complete their treatment? Findings of a qualitative study from Pakistan

BACKGROUND

One of the major reasons for unsuccessful treatment outcomes among patients with drug-resistant tuberculosis (DR-TB) is the high rate of loss to follow-up (LTFU). However, in Pakistan, no qualitative study has been conducted to explore the perceptions of LTFU patients with regard to DR-TB treatment, the problems they face and the reasons for LTFU in detail.

METHODS

This was a qualitative study that involved semistructured, indepth, face-to-face interviews of 39 LTFU patients with DR-TB. All interviews were carried out in Pakistan's national language 'Urdu' using an interview guide in two phases: the first phase was from December 2020 to February 2021 among patients with extensively drug-resistant tuberculosis and the second phase from July 2021 to September 2021 among patients with multidrug-resistant tuberculosis.

RESULTS

The inductive thematic analysis of audio-recorded interviews generated the following four key themes, which were the major reasons reported by the participants of the current study to have led to LTFU: (1) patient-related factors, such as lack of awareness about the total duration of DR-TB treatment, fatigue from previous multiple failed episodes, lack of belief in treatment efficacy and perception of DR-TB as a non-curable disease; (2) medication-related factors, such as use of injectables, high pill burden, longer duration and adverse events; (3) socioeconomic factors, such as gender discrimination, poor socioeconomic conditions, non-supportive family members, social isolation and unemployment; and (4) service provider-related factors, such as distant treatment centres, non-availability of a qualified person, lack of adequate counselling and poor attitude of healthcare professionals.

CONCLUSION

In the current study, patients' perceptions about DR-TB treatment, socioeconomic condition, medication and service provider-related factors emerged as barriers to the successful completion of DR-TB treatment. Increasing patients' awareness about the duration of DR-TB treatment, interacting sessions with successfully treated patients, availability of rapid drug susceptibility testing facilities at treatment centres, decentralising treatment and using the recently recommended all-oral regimen may further decrease the rate of LTFU.

Synthesis of novel combinatorial drug delivery system (nCDDS) for co-delivery of 5-Fluorouracil and Leucovorin calcium for colon targeting and controlled drug release

Objective: Purpose of the current study was to improve the oral effectiveness of 5-Fluorouracil (5-FU) by developing novel controlled, combinatorial drug delivery system (nCDDS) for co-delivery of 5-FU and Leucovorin (LC) for colon targeting.Significance: on the basis of results obtained, novel controlled, combinatorial drug delivery system (nCDDS) could be an effective strategy for the colon targeting of 5-FU and LC.Methods: Free radical polymerization method was tuned and used to fabricate this nCDDS. The nCDDS is synthesized in two steps, firstly synthesis of 5-fluoruracil/leucovorin calcium loaded nanogels and secondly, pre-synthesized 5-FU & LC loaded nanogels were dispersed in pectin based polymerized matrix hard gel. The nanogels and nCDD gels were characterized for network structure, thermal stability and surface morphology. Swelling and in-vitro release studies were carried out at different pH 1.2 and 7.4 both for naive nanogels and combined matrix gels. In-vivo study of combinatorial gel was performed on rabbits by using HPLC method to estimate plasma drug concentration and pharmacokinetics parameters.Results: Structure and thermal analysis confirmed the formation of stable polymeric network. SEM of nanogels and combinatorial gels showed that the spongy and rough edges particles and uniformly distributed in the combinatorial gel. The prepared nCDDS showed excellent water loving capacity and pH responsiveness. Combinatorial gel showed excellent characteristic for colonic delivery of drugs, which were confirmed by various in-vitro and in-vivo characterization. Acute oral toxicity study of combinatorial gel confirmed the biocompatible and non-toxic characteristics of developed formulation.Conclusion: Conclusively it can be found that nCDDS showed excellent properties regarding drug targeting in a controllable manner as compared to naive PEGylated nanogels.

Highly Responsive Chitosan-Co-Poly (MAA) Nanomatrices through Cross-Linking Polymerization for Solubility Improvement

In this study, we report the highly responsive chitosan-based chemically cross-linked nanomatrices, a nano-version of hydrogels developed through modified polymerization reaction for solubility improvement of poorly soluble drug simvastatin. The developed nanomatrices were characterized for solubilization efficiency, swelling studies, sol-gel analysis, in vitro drug release studies, DSC, FTIR, XRD, SEM, particle size analysis, and stability studies. An in vivo acute toxicity study was conducted on female Winstor rats, the result of which endorsed the safety and biocompatibility of the system. A porous and fluffy structure was observed under SEM analysis, which supports the great swelling tendency of the system that further governs the in vitro drug release. Zeta sizer analyzed the particle size in the range of 227.8 ± 17.8 nm. Nano sizing and grafting of hydrophilic excipients to the nanomatrices system explains this shift of trend towards the enhancement of solubilization efficiency, and, furthermore, the XRD results confirmed the amorphous nature of the system. FTIR and DSC analysis confirmed the successful grafting and stability to the system. The developed nanomatrices enhanced the release characteristics and solubility of simvastatin significantly and could be an effective technique for solubility and bioavailability enhancement of other BCS class-II drugs. Due to enhanced solubility, efficient method of preparation, excellent physico-chemical features, and rapid and high dissolution and bio-compatibility, the developed nanomatrices may be a promising approach for oral delivery of hydrophobic drugs.

Synthesis And Evaluation of Polyethylene Glycol-4000-Co-Poly (AMPS) Based Hydrogel Membranes for Controlled Release of Mupirocin for Efficient Wound Healing

BACKGROUND

Chronic wound healing is a major challenge for health care system around the globe. Current study was conducted to develop and characterize chemically cross-linked polyethylene glycol-co-poly (AMPS) hydrogel membranes to enhanced the wound healing efficiency of antibiotic mupirocin (MP).

METHODS

Free radical polymerization technique was used for the development of hydrogel membranes. In aqueous medium, polymer PEG-4000 cross-linked with the monomer 2-acrylamido-2-methylpropane sulfonic acid (AMPS) in the presence of initiators ammonium peroxide sulfate (APS) and sodium hydrogen sulfite (SHS). N, N-Methylenebisacrylamide (MBA) was used as cross-linker in the preparation of hydrogel membranes. Developed membranes were spherical, transparent, and elastic. FTIR, TGA/DSC, and SEM were used to characterize the polymeric system. Swelling behavior, drug loading, and its release pattern at pH of 5.5 and 7.4, irritation study, ex vivo drug permeation, and deposition study was also evaluated.

RESULTS

Formed membranes were spherical, transparent and elastic. The formation of a stable polymeric network was confirmed by structural and thermal analysis. Permeation of the drug its deposition in the skin showed good permeation and retention. No irritancy to the skin was observed.

CONCLUSION

On the basis of results obtained, the present study concluded that it may be an ideal network for the delivery of mupirocin in skin infections.

Synthesis of PEG-4000-co-poly (AMPS) nanogels by cross-linking polymerization as highly responsive networks for enhancement in meloxicam solubility

Poor solubility is an ongoing issue and the graph of poorly soluble drugs has increased markedly which critically affect their dissolution, bioavailability, and clinical effects. This common issue needs to be addressed, for this purpose a series of polyethylene glycol (PEG-4000) based nanogels were developed by free radical polymerization technique to enhance the solubility, dissolution, and bioavailability of poorly soluble drug meloxicam (MLX), as improved solubility is the significant application of nanosystems. Developed nanogels formulations were characterized by FTIR, XRD, SEM, zeta sizer, percent equilibrium swelling, drug loaded content (DLC), drug entrapment efficiency (DEE), solubility studies, and in vitro dissolution studies. Furthermore, cytotoxicity studies were conducted in order to determine the bio-compatibility of the nanogels drug delivery system to biological environment. Nanogels particle size was found to be 156.19 ± 09.33 d.nm. Solubility study confirmed that the solubility of poorly soluble drug MLX was significantly enhanced up to 36 folds as compared to reference product (Mobic^®). The toxicity study conducted on rabbits and MTT assay endorsed the safety of the developed nanogels formulations to the biological system.

Porous and highly responsive cross-linked β-cyclodextrin based nanomatrices for improvement in drug dissolution and absorption

AIMS

Aim of the study was to enhance the solubility of Chlorthalidone by developing beta-cyclodextrin cross-linked hydrophilic nanomatrices.

MAIN METHODS

Nine different formulations were fabricated by free radical polymerization technique. All formulations were characterized through different studies. FTIR spectroscopy of unloaded and loaded nanomatrices was processed to determine compatibility of constituents and that of the drug with the system. Surface morphology of the nanomatrices was studied by SEM. The size of the optimized formulation was determined by zeta sizer. Swelling, in-vitro release and solubility studies were carried out in different media and results of in-vitro release profiles of nanomatrices and commercially available tablet of Chlorthalidone were compared. For determination of biocompatibility, toxicity studies were proclaimed in rabbits.

KEY FINDINGS

Main peaks of corresponding functional groups of individual constituents and that of drug were depicted in FTIR spectra of unloaded and loaded nanomatrices. Porous and fluffy structure was visualized through SEM images. Particle size of the optimized formulation was in the range of 175 ± 5.27 nm. Percent loading of optimized formulation showed the best result. Comparing the in-vitro drug release profiles of nanomatrices and commercially available tablet, the results of the synthesized nanomatrices were quite satisfactory. Solubility profiles were also high as compared to the drug alone. Moreover, toxicity studies confirmed that nanomatrices were biocompatible and no sign of any toxic effect was found.

SIGNIFICANCE

We concluded that our developed nanomatrices had successfully enhanced the solubility of Chlorthalidone and can also be used for other poorly aqueous soluble drugs.

Synthesis and evaluation of topical hydrogel membranes; a novel approach to treat skin disorders

The aim of the study was to synthesize and evaluate chitosan-based topical cross-linked hydrogel membranes of mupirocin for new pharmaceutical controlled release application. These cross-linked structured membranes were synthesized by modification of free radical polymerization. Low molecular weight (LMW) chitosan is cross-linked with 2-acrylamido-2-methylpropane sulfonic acid (AMPS) with a crosslinker N,N-methylenebisacrylamide (MBA). Hydrogel membranes were characterized by FTIR, DSC, TGA, SEM, Swelling behavior, sol-gel analysis, in vitro percent drug release at different pH, permeation across skin, ex vivo drug deposition study, irritation study and in vivo antibacterial activity of mupirocin loaded hydrogels. Developed membranes were spherical, adhesive and have good elastic strength. FTIR confirmed the cross-linking and formation of new structure having appropriate characteristics needed for controlled release delivery system. Drug release through rabbit's skin was evaluated by Franz diffusion cell and up to 6329.61 µg/1.5 cm² was permeated and drug deposition in skin revealed significant retention up to 1224 µg/1.5 cm². Formulated membranes were nonirritant to the skin as validated by Draize patch test. In surgical wound model, LMW chitosan-based hydrogel membranes showed prolong efficacy against bacterial infection caused by S. aureus. Enhanced retention of drug in skin demonstrated the good potential of topical delivery for skin bacterial infection.

Preparation and Evaluation of Skin Wound Healing Chitosan-Based Hydrogel Membranes

The purpose of the study was to synthesize and characterize a new form of topical membranes as chitosan-based hydrogel membranes for bacterial skin infections. The polymeric membranes were synthesized by modification in free radical solution polymerization technique. High molecular weight (HMW) chitosan polymer was cross-linked with monomer 2-acrylamido-2-methylpropane sulfonic acid (AMPS) through cross-linker N,N-methylenebisacrylamide (MBA). Mupirocin, an antibiotic, was used as model drug. The polymeric membranes were prepared in spherical form that found stable and elastic. Characterization of hydrogel membranes was performed by FTIR, SEM, DSC, TGA, swelling behavior, drug release, irritation study, and ex vivo drug permeation and deposition study. Structural and thermal studies confirmed the formation of new polymeric network with enhanced stability of hydrogel membranes. Permeation flux of drug from optimized formulation through rabbit's skin assessed by using Franz cell was up to 104.09 μg cm^-2 h^-1. Furthermore, hydrogel membrane has significant retention of drug in skin up to 2185 μg 1.5 cm^-2. Draize patch test confirmed the synthesized hydrogels as non-irritant to skin. The preparation of a topical membrane with improved antibacterial activity within controlled release manner is desirable for the advancement and treatment of skin diseases.

Squamous cell carcinoma of the external auditory canal in a patient with non-resolving ear discharge

Discharging ear is a common symptom in the primary care and private general clinics. Most of the cases are treated with the antibiotic ear drops for otitis externa or otitis media. However, despite an adequate standard therapy, a malignant tumour can also be present with non-specific symptom such as ear discharge, especially in the case of persistent ear discharge. In this paper we have reported a case of an adult woman presented with non-resolving ear discharge who was treated repeatedly with antibiotic ear drop, which was later diagnosed as squamous cell carcinoma.

Evaluation of nutritional status in advanced metastatic cancer

Consecutive cancer referrals to a palliative medicine program were evaluated to assess nutritional status using a standard protocol. The study included 352 patients (180 men, 172 women; median age 61 years, range 22-94 years). The most common diagnosis was lung cancer. All had metastatic disease, 139 with gastrointestinal involvement. The most common gastrointestinal symptoms were weight loss ( n=307), anorexia ( n=285), and early satiety ( n=243). Of those with any weight loss, 71% had lost >or0% of their pre-illness weight. The most common factor identified which might have contributed to weight loss was hypophagia ( n=275/307). Men had lost weight more often and to a greater extent than women. Triceps skinfold (TSF) was measured in 337: 51% had values that suggested severe fat deficiency. Upper mid-arm muscle area (AMA) was measured in 349: 30% had evidence of significant muscle mass reduction. The body mass index (BMI) was normal or increased in most patients. Calculated resting energy expenditure (REE) ( n=324) was high in 41%. C-reactive protein was elevated in 74% of those measured ( n=50). We conclude that: (1).most of this group of cancer patients referred to palliative medicine had severe weight loss; (2).there was a gender difference in the severity and type of weight loss; (3).males lost more weight overall and more muscle than females; (4).males with any degree of weight loss had a higher REE than females; (5).a significant correlation existed between the time from diagnosis to death and the severity of weight loss in the prior month; (6).BMI was normal in most patients, suggesting precancer diagnosis obesity; and (7).both TSF and AMA correlated well with body composition of both fat and protein as determined by bioelectrical impedance.

Intracranial extraskeletal myxoid chondrosarcoma: case report and review of the literature

BACKGROUND

We describe a patient with an intracranial extra skeletal myxoid chondrosarcoma (EMC), an unusual neoplasm of the deep soft tissues of the extremities. Very rarely are they localised as an intracranial lesion, and we believe it is very important to accurately distinguish EMC from other intracranial tumours such as classical or "skeletal" chondrosarcomas, mesenchymal chondrosarcoma, enchondroma, and myxoid tumours (chordoma, and chondromyxoid fibroma) in order to determine their prognostic implications. Furthermore, this case presents with the second local recurrence, higher-grade cellular areas, such an event has never been reported in intracranial cases.

METHOD

A 17 year-old female presented with tonic and clonic seizures, episodic left hemiplegia and intense right-sided headaches. Computed tomography and magnetic resonance of the skull showed a right fronto-parietal cortical lesion. Complete surgical excision of the lesion through a right parieto-temporal craniotomy was performed. The tumoral lesion recurred locally twice (16 and 19 months after the initial surgery respectively).

FINDINGS

First and second surgical specimens where diagnosed as extra skeletal myxoid chondrosarcoma. Microscopically, the third specimen (second local recurrence) showed abrupt transition from areas of conventional myxoid chondrosarcoma to high-grade cellular areas with fusiform features.

INTERPRETATION

Extra skeletal myxoid chondrosarcoma is very rarely described as an intracranial lesion. Reference on this topic is very confusing as there is no clear-cut distinction between skeletal chondrosarcomas with prominent myxoid matrix and extra skeletal myxoid chondrosarcoma which is a definite entity first defined by Enzinger and Shiraki in 1972 in deep soft tissues of the extremities. We review the cases reported in the literature with the diagnosis of myxoid chondrosarcoma either of extra skeletal origin or with skeletal attachment, and analyse their clinic and pathological features.

Common complications of advanced cancer

Complications due to cancer and its treatment are common and increase in incidence and severity as the disease progresses. Central nervous system complications affect 15% to 20% of patients, and up to 75% have bone metastases at some point during the disease process. Endocrine abnormalities include hypercalcemia, adrenal insufficiency, and inappropriate antidiuretic syndrome. Hematologic disorders, malignant effusions, and gastrointestinal (GI) problems may cause significant morbidity.

Clinical evaluation in advanced cancer

This chapter will outline a general approach to symptom assessment, using the interdisciplinary approach to pain as a model. Due to the implications of cognitive impairment for treatment compliance, consent, and caregiver burden, assessment of cognitive function will be reviewed in detail. Problem areas in assessment are identified, along with aids to improve assessment and emphasize the key contribution of the nurse. We will also focus on measurement issues from both clinical and research perspectives.

Common symptoms in advanced cancer

The relief of physical and psychological symptoms is an essential part of palliative care. Advanced cancer is an acute process; because the clinical picture changes rapidly, symptoms must be reassessed regularly, and a careful history is essential. Defining the relationship of the symptoms to the disease can defuse fear and encourage a sense of control in patients and their families. We review the pathophysiology, causes, prevalence, consequence, and management of common symptoms in advanced cancer.

[Spontaneous epidural spinal hematoma: report of 2 cases and review of the literature]

Spontaneous spinal epidural hematoma is an uncommon cause of cord compression. This lesion has been correlated with some precipitant factors, but frequently is idiopathic. It's a unusual process, more uncommon in children, and there are only 350 cases reported in the literature. Etiology is unknown and there are several theories about it. The clinical presentation is remarkably uniform, with local back and radicular pain followed by sensory and motor disfunction. Early diagnosis and treatment are very important for the functional recovery of the patient. In this article, the literature is reviewed, especially the etiological and therapeutic aspects, and two new cases are reported. These cases can help to define the etiology of this entity.