In Vitro Permeability, Irritability, and Release Evaluation of Commonly Used Topical Diclofenac Gel Preparations (1%, 5%, and 10%)

Recently, there has been an increase in the use of compounded topical pain preparations, raising concerns that clinicians and patients may not be aware of the potential safety risks. Topical diclofenac is one of the most widely used pain medications, often used for joint ailments such as osteoarthritis and other musculoskeletal pain. Systemic exposure to diclofenac has a dose-related risk for gastrointestinal, cardiovascular, and renal adverse events, particularly in elderly patients. Topical diclofenac preparations are frequently compounded in pharmacies at the concentrations of 1% to 10% (or higher) with or without other active ingredients such as camphor. Considering the significantly higher strengths of the compounded preparations as compared to the commercially available products (1% to 3%) and the frequency of application (sometimes up to six times a day), concerns arise as to the levels of absorption with these formulations and their potential toxicity. The objective of this initial study was formulated in an attempt to shed light on safety concerns of topical diclofenac preparations. A study was designed to evaluate the in vitro release, irritability, and permeability of three different concentrations of compounded diclofenac gels (1%, 5%, and 10%) in PLO GEL MEDIFLO and VersaPro Gel bases. Using MatTek's EpiDerm system, skin irritability and the in vitro permeation of compounded diclofenac gels were evaluated. Additionally, the in vitro release profile, drug content, content uniformity, and physical properties of the compounded gels (pH, homogeneity) were assessed. In all cases, the drug content, content uniformity, physical properties, and preparation stability during the recommended beyond-use dating (90 days) were acceptable. The release profiles of all tested preparations followed the Higuchi model. The in vitro skin irritation evaluation of the tested formulations indicated no irritant preparation. The permeability assessment of the formulated gels revealed that there is a correlation between drug release and percutaneous absorption. VersaPro Gelbased preparations, which showed a lower percentage of drug release over the experiment time, showed a significantly lower average flux at steady-state and the average percentage of absorbed dose after 24 hours. The percentage absorption (%abs) from different formulations ranged from 11.18% to 19.6% depending on the gel base. The permeability coefficient, kp, (cm/hr) ranged from 0.019 to 0.037, and the average flux (µg/cm2/hr) ranged from 8.7 to 103 depending on the gel base and the diclofenac concentration. Based on our findings and previously reported data, the possibility exists that higher diclofenac concentrations in compounded topical preparations may lead to significantly higher blood concentrations as compared to commercially available products, which in turn may also lead to serious side effects. Accordingly, there is a need for clinical studies to evaluate the safety of compounded diclofenac preparations with higher diclofenac contents than United States Food and Drug Administrationapproved formulations.

Two clusters of Toscana virus meningo-encephalitis in Livorno Province and Elba Island, July-September 2018

BACKGROUND

Toscana virus (TOSV) is an arbovirus transmitted to humans by Phlebotomus spp sandflies. It causes aseptic meningitis and meningoencephalitis with marked seasonality. Here we describe the clinical, microbiological and epidemiological features of two clusters of cases occurred in Tuscany in 2018.

METHODS

A confirmed case was defined as the detection of anti-TOSV IgM and IgG in serum sample, in presence of typical clinical manifestations. We consulted hospital records of hospitalized patients to collect clinical information and obtained epidemiological information from the local health authority investigation report. We telephonically interviewed patients using a standard questionnaire for a 6 months follow-up.

RESULTS

A total of 12 cases of TOSV meningo-encephalitis with onset between 4th of July and 12th of September accessed health care services in the province of Livorno. Eight cases were males with median age 41,5 and four were not resident in the area. Serological investigations confirmed a recent TOSV infection. Eight cases reported visiting Elba Island and four had a possible occupational-related exposure.

CONCLUSIONS

This surge of infection emphasizes the need of information campaigns coupled with adequate surveillance and control interventions against TOSV that, among other arboviruses, is a growing issue of concern in Italy.

Possible Histologic Markers for Early and Late Stages of Breast Cancer

The degree of productive fibrosis, amount of lymphoid infiltrate and nuclear grade have been studied in 492 consecutive cases of duct-infiltrating breast cancer. It has been found that highly significant relationships exist between these morphologic parameters of breast cancer: lymphoid infiltrate is directly related to nuclear anaplasia and antagonized by productive fibrosis; conversely, productive fibrosis is inversely related to nuclear anaplasia and antagonized by lymphoid infiltrate. Significant inverse relationships between productive fibrosis and lymphoid infiltrate persist in tumors that have the same nuclear grade. It is suggested that lymphoid infiltrate and productive fibrosis are suitable candidates as morphologic markers to estimate the age of breast cancer, while the nuclear grade is a suitable tool to identify subgroups with different behavior in the NOS (not otherwise specified) category of breast cancer.

Calcitriol Reverses Induced Expression of Efflux Proteins and Potentiates Cytotoxic Activity of Gemcitabine in Capan-2 Pancreatic Cancer Cells

Purpose. Efflux and influx proteins play a major role in chemo-resistance by affecting the net cellular uptake of anti-cancer drugs. Hence, alteration of the efflux and influx protein expression may result in variations of chemotherapeutics uptake and consequently cell death rate. The present study investigated the effects of pre-treatment of capan-2 pancreatic cancer cells with calcitriol, butylated hydroxytoluene (BHT), butylated hydroxyanisole (BHA) or silibinin on the induction of three major efflux proteins and the main gemcitabine influx protein. The influence of the pre-treatments on the net cellular uptake of gemcitabine, total ATPase activity, and cell death rate were also evaluated. Methods. Capan-2 pancreatic cancer cells were pre-treated for 24 h with calcitriol, BHT, BHA, or silibinin, followed by gemcitabine treatment. The concentration of gemcitabine was quantified using ultra-performance liquid chromatography (UPLC). Real-time polymerase chain reaction (RT-PCR) was utilized in order to investigate the expression of the mRNAs. The expression of the proteins was assessed using western blotting. Measurement of the ATPase activity was conducted utilizing a colorimetric method and viability of the cells was determined using a luminescent cell viability assay. Results. Protein expression studies showed that BHT, silibinin, and BHA increased expression of the efflux proteins and decreased the overall uptake of gemcitabine, whereas calcitriol significantly inhibited expression of the efflux proteins and increased gemcitabine uptake. Expression of specific mRNAs correlated reasonably well with the levels of corresponding proteins. Additionally, the expression of efflux proteins and ATPase activity were well correlated, signifying that the induced efflux proteins are functionally active. Moreover, pre-treatment with calcitriol resulted in a significant increase in cell death with gemcitabine treatment, whereas, BHA significantly reduced the cell death rate. On the other hand, pre-treatment with BHT and silibinin had no significant effect on the cell death rate. Conclusions. Pre-treatment of the pancreatic cancer cells with calcitriol significantly increased gemcitabine cellular uptake and consequently decreased cell viability after treatment with gemcitabine, whereas BHA significantly reduced gemcitabine uptake and decreased cell death rate, which were at least partially attributed to the alteration of expression of efflux and influx proteins. This article is open to POST-PUBLICATION REVIEW. Registered readers (see “For Readers”) may comment by clicking on ABSTRACT on the issue’s contents page.

High-frequency measurement of depressive severity in a patient treated for severe treatment-resistant depression with deep-brain stimulation

Although there have been previous studies of deep-brain stimulation (DBS), we present, to our knowledge, the first example of high-frequency depressive severity measurement-based DBS treatment in particular and psychiatric treatment in general. Daily post-surgical e-mail prompts for a period of 6 months resulted in 93 administrations of a computerized adaptive test (CAT) of depression severity (CAT-Depression Inventory or CAT-DI) via the internet. There was an average of 3.37 weekly measurements with an average separation of 2.12 days. No additional incentive was provided to the patient for completing the adaptive tests. The patient is a 55-year-old female with six psychiatric hospitalizations for depression, two suicide attempts, marginal response to eight electroconvulsive therapy (ECT) treatments and 35 psychotropic medications. We report results after high-frequency stimulation of the superolateral branch of the medial forebrain bundle. The CAT-DI was used for daily assessments before, during and after (remotely in response to an e-mail prompt) the DBS procedure. Two follow-up Hamilton Depression Scales (HAM-Ds) were also collected. Response to treatment varied markedly, with a decrease from severe (>75) to mild (60), which is three times the size of the uncertainty level. Although the HAM-D scores decreased, they missed the more complete temporal pattern identified by CAT-DI daily monitoring. We demonstrated feasibility of daily depressive severity measurement at high levels of precision and compliance. Clinician ratings confirm the general pattern of treatment benefit, but mask the marked variability in mood and more marked periods of benefit and decline.

PD-1 and PD-L1 expression in molecularly selected non-small-cell lung cancer patients

BACKGROUND

Agents targeting programmed death-1 receptor (PD-1) and its ligand (PD-L1) are showing promising results in non-small-cell lung cancer (NSCLC). It is unknown whether PD-1/PD-L1 are differently expressed in oncogene-addicted NSCLC.

METHODS

We analysed a cohort of 125 NSCLC patients, including 56 EGFR mutated, 29 KRAS mutated, 10 ALK translocated and 30 EGFR/KRAS/ALK wild type. PD-L1 and PD-1 expression were assessed by immunohistochemistry. All cases with moderate or strong staining (2+/3+) in >5% of tumour cells were considered as positive.

RESULTS

PD-1 positive (+) was significantly associated with current smoking status (P=0.02) and with the presence of KRAS mutations (P=0.006), whereas PD-L1+ was significantly associated to adenocarcinoma histology (P=0.005) and with presence of EGFR mutations (P=0.001). In patients treated with EGFR tyrosine kinase inhibitors (N=95), sensitivity to gefitinib or erlotinib was higher in PD-L1+ vs PD-L1 negative in terms of the response rate (RR: P=0.01) time to progression (TTP: P<0.0001) and survival (OS: P=0.09), with no difference in PD1+ vs PD-1 negative. In the subset of 54 EGFR mutated patients, TTP was significantly longer in PD-L1+ than in PD-L1 negative (P=0.01).

CONCLUSIONS

PD-1 and PD-L1 are differentially expressed in oncogene-addicted NSCLC supporting further investigation of specific checkpoint inhibitors in combination with targeted therapies.

Melioidosis in a Traveller from Thailand: Case Report

A 42-year old Italian male with type 2 diabetes and HCV-related chronic hepatitis spent 6 months in Thailand. After his return in June 2002 he was admitted to the Infectious Diseases Unit of the Hospital of Livorno (Italy) because of fever, chest pain and skin abscesses in the legs. Chest X-rays and CT scan revealed multiple bilateral cavitary lesions in the lungs. Ultrasonography and CT scan showed numerous subcentimetric spleen abscesses. Burkholderia pseudomallei was isolated from the cutaneous lesions and sputum and thus melioidosis was diagnosed. A 6-week course of i.v. ceftazidime plus oral doxycycline was given during the acute phase of the illness. The in vitro susceptibility testing showed that long-term (20 weeks) antimicrobial therapy with doxycycline and moxifloxacin was required. Complete resolution of pulmonary and spleen lesions was obtained within 6 weeks of therapy and of cutaneous abscesses in 10 weeks. No significant side effects were noted during the follow-up period using this scheme of antimicrobial therapy.

Cluster of invasive Neisseria meningitidis infections on a cruise ship, Italy, October 2012

We describe a cluster of four cases of invasive meningococcal disease that occurred on a cruise ship sailing along the Italian coast in October 2012. All four cases were hospitalised with severe illness and one of them died. This report illustrates the importance of rapid implementation of emergency control measures such as administration of prophylaxis to all crew members and passengers to prevent the spread of the disease in such a close environment.

Cluster of invasive Neisseria meningitidis infections on a cruise ship, Italy, October 2012

We describe a cluster of four cases of invasive meningococcal disease that occurred on a cruise ship sailing along the Italian coast in October 2012. All four cases were hospitalised with severe illness and one of them died. This report illustrates the importance of rapid implementation of emergency control measures such as administration of prophylaxis to all crew members and passengers to prevent the spread of the disease in such a close environment.

Quantification of neurometabolites in subacute sclerosing panencephalitis by 1H-MRS

The authors studied 20 patients with subacute sclerosing panencephalitis (SSPE) to investigate the correlations between MRI, magnetic resonance spectroscopy (MRS), and clinical status. MRI findings did not correlate with clinical status. By contrast, all patients had reductions in N-acetyl aspartate (NAA) and increase in myoinositol (mI) (p < 0.01), and NAA and mI concentrations correlated with clinical severity (p < 0.05). During follow-up, NAA continued to decline. (1)H-MRS may be a useful measure of disease severity and progression in SSPE.

[Bacterial meningitis in adults: a retrospective multicentric study in Tuscany (Italy)]

The Infectious Diseases Unit of Lucca Hospital conducted a multicentric retrospective study to evaluate the epidemiological and clinical features of adult patients affected by bacterial meningitis attending all the Infectious Diseases Units of Tuscany (Italy) from July 1999 to June 2004. A specific questionnaire was sent to all the units to collect information about each case of bacterial meningitis occurring in patients older than sixteen. Patients with meningitis by Mycobacterium tuberculosis were excluded from the analysis. Nine out of 12 Infectious Diseases Units of Tuscany took part in the study and 197 cases were identified. Most cases of meningitis occurred during 2002 with a slight reduction in cases in subsequent years. Streptococcus pneumoniae and Neisseria meningitidis were the most frequently isolated pathogens with an increase in diagnosis from 1999 to 2004; in 23.8% of patients no pathogens were isolated, with a reduction in meningitis from unknown aetiology from 1999 to 2004. Most patients were treated with a combination of two antibiotics, and corticosteroid drugs were added to the therapy; in the group of patients treated with corticosteroid drugs invalidating complications occurred in 23% of cases and 5% of patients died. In all, 27 out of 197 subjects (13.7%) developed invalidating complications and 20 out of 197 patients (10.2%) died.

[Attempted suicide during interferon therapy: a case report and literature review]

Occasionally, in the medical literature, attempted or successful suicides during interferon therapy are reported. We report a case of a 32-year-old man who developed a psychotic syndrome with attempted suicide at the third month of treatment. The cessation of interferon and an appropriate psychiatric therapy determined a complete remission of symptoms. A medical literature review, through several computerized searches, showed a lack of research into the subject. The main conclusion of our article emphasizes the importance of recognizing the early neuropsychiatric symptoms, that are reversible at the cessation of treatment.

Role of renal PGE2 in the adaptation from foetal to extrauterine life in term and preterm infants

Urinary PGE(2) concentrations were assayed using a new EIA method, in 16 preterm and 18 term neonates at birth and 3 days later, since there is evidence that PGE(2) in urine are likely to reflect their renal generation and then could be correlated with kidney maturation or renal problems. PGE(2) concentrations were not different at birth (1.50+/-1.12 vs 1.56+/-1.94 ng/day), while resulted significantly higher in preterms, compared to terms, three days after birth (2.22+/-1.23 vs 1.39+/-0.79 ng/day). This increase in daily PGE(2) excretion observed only in preterm neonates could be due to an increased renal biosynthesis as a mechanism of compensatory response to prevent further decrements in renal plasma flow, since prostanoids play an important role in protecting the immature kidney from high levels of angiotensin II. Otherwise, the passive reabsorption of PGE(2) along the distal nephron could be altered because of kidney immaturity. The measurement of PGE(2) in urine of neonates, particularly prematures, could be useful to provide a better understanding of the homeostatic function of the kidney in the phase of adaptation to extra-uterine life.

Aerosol particle and organic vapor concentrations at industrial work sites in Malaysia

The objective of this study was to establish baseline data about air pollutants potentially related to nasopharyngeal carcinoma (NPC) in the Federal Territory and Selangor, Malaysia. During 1991-1993, ambient air quality was monitored at 42 work sites representing ten industrial sectors: adhesive manufacturing, foundries, latex processing, metalworking, plywood/veneer milling, ricemilling, rubber tire manufacturing, sawmilling, shoemaking, and textile related industries. At each work site, aerosol particle size distributions and concentrations of formaldehyde, benzene, toluene, isopropyl alcohol, and furfural were measured. Mean aerosol particle concentrations ranged from 61 micrograms/m3 in foundries to 5,578 micrograms/m3 in ricemills, with five industries (adhesives, metalworking, ricemilling, sawmilling, and shoemaking) exceeding the US EPA 24-hr ambient air standard for PM-10. Formaldehyde concentrations exceeded the threshold limit value (TLV) in adhesives factories. Other vapours and elements measured were well below TLVs.

Nasopharyngeal carcinoma in Malaysian Chinese: occupational exposures to particles, formaldehyde and heat

BACKGROUND

During 1990-1992, 282 Chinese residents of Selangor and the Federal Territory, Malaysia with histologically confirmed nasopharyngeal carcinoma (NPC) were interviewed about occupational history, diet, alcohol consumption, and tobacco use, as were an equal number of Malaysian Chinese population controls, pair-matched to cases by age and sex.

METHODS

Exposures to 20 kinds of workplace substances, solar and industrial heat, and cigarette smoke, were analysed by univariate and multivariate methods.

RESULTS

Nasopharyngeal carcinoma was associated with occupational exposures to construction, metal and wood dusts; motor fuel and oil; paints and varnishes; certain other chemicals; industrial heat; solar heat from outdoor occupations; certain smokes; cigarette smoking; and childhood exposure to parental smoking. After adjustment for risk from diet and cigarette smoke, only wood dust (OR = 2.36; 95% CI : 1.33- 4.19), and industrial heat (OR = 2.21; 95% CI : 1.12-4.33) remained clearly associated. Wood dust remained statistically significant after further adjustment for social class. No significant crude or adjusted association was found between NPC and formaldehyde (adjusted OR = 0.71; 95% CI : 0.34-1.43).

CONCLUSIONS

This study supports previous findings that some occupational inhalants are risk factors for NPC. The statistical effect of wood dust remained substantial after adjustment for diet, cigarette smoke, and social class. Intense industrial heat emerged as a previously unreported risk factor, statistically significant even after adjustment for diet and cigarette smoke. No association was found between NPC and formaldehyde.

Nasopharyngeal carcinoma in Malaysian Chinese: salted fish and other dietary exposures

We interviewed 282 histologically confirmed cases of nasopharyngeal carcinoma (NPC) in Chinese residents of Selangor and the Federal Territory, Malaysia, and an equal number of Chinese age-, sex-, and length-of-residence-matched controls sampled from the general population. Consumption of 55 dietary items during childhood, and 5 years pre-diagnosis of NPC, was analyzed by univariate and multivariate methods. Four salted preserved foods (fish, leafy vegetables, egg and root), fresh pork/beef organ meats and beer and liquor consumption exhibited strong positive associations, and 4 vegetable/fruit combinations strong negative associations with NPC. Factor analysis and multivariable modeling using estimated factor scores strongly supported separate effects on NPC of vegetables/fruits, salted preserved foods, pork/beef organ meats and beer/liquor consumption. Multivariable modeling associated NPC most clearly with high consumption of salted fish, salted eggs, pork/beef liver and beer and low consumption of Chinese flowering cabbage, oranges/tangerines and shrimp. A strong residual association of social class with NPC remained after adjustment for diet, which is consistent with a substantial role for non-dietary environmental factors.

[Epidemiology of beta-hemolytic streptococcus group B colonization in perinatology. Methodology considerations and personal data]

GBS have attracted increasing attention in recent years as a major cause of serious neonatal sepsis. The maternal genital tract is the principal source of organism for babies with the most serious early onset form of disease. Reported rates of GBS carriage in the genital and anorectal tract of pregnant women vary widely: much of the variations is undoubtedly associated with differences in laboratory technique, sampling site and number of samples taken. The key bacteriological factor is the use of enrichment culture technique. We have studied GBS colonization in 274 pregnant women during labor and in their newborns (275). Carriage was documented in 25.91% women by vaginal (low portion) and anorectal swabs, and in 6.14% newborns by auricolar, pharyngeal and rectal swabs taken at birth and before leaving nursery. The higher rectal colonization rate in pregnant women suggests that the gastrointestinal tract is the primary site of GBS carriage. Colonized newborns have no obstetrics risk factors, except for maternal GBS carriage. Our data confirms that limiting antimicrobial intrapartum prophylaxis to premature infants leaves term infants (who account for 60% of the fetal cases of early onset disease) unprotected, unless membrane rupture is prolonged. Prevention of early onset infections among low-risk term infants will require additional investigations.

[Group B beta-hemolytic Streptococcus: study on colonization of mother-neonate couples observed in January-May 1988 at the obstetrics and gynecology unit and the neonatal section at the Pistoia Hospital]

In a previous study, carried out on women at delivery recovered at the obstetric ward of the Pistoia Hospital, we noted a high incidence of group B Streptococci cultured from vaginal site. Because group B streptococcal infection is very serious in neonates we decided to examine the frequence of vertical and horizontal transmission among the mother-neonate couples. We have also compared their rate of colonisation by doing rectal and vaginal swabs on women and rectal, vaginal and external auditory canal swabs on babies. In fact we known that infants moderately to heavily colonised with group B Streptococci at birth, appear to have a significant higher risk of developing serious disease than do infants only lightly colonised. In our work we haven't observed any acute group B streptococcal infection, but we have identified 18 couples mother-neonate colonised by the same group B Streptococci serotype, which is proof of an easy vertical transmission of group B Streptococci whilst horizontal transmission is very rare (only one case).

Profile of contraceptive clients in Katsina, northern Nigeria

In 375 women who accepted contraception at a clinic in northern Nigeria there were significant differences between IUD and pill acceptors. The pill acceptors were younger women of lower parity who tended to be less educated and mostly not engaged in any profession. The IUD clients were older women of high parity with better education and many had occupations outside the home. The most striking difference was in the religious affiliations of the two groups. The majority of Muslim women (72·9%) opted for the pill whereas the majority of Christian women (55·9%) chose the IUD.

Undersulfated urinary glycosaminoglycans in preterm newborns

The glycosaminoglycans (GAG) isolated from pooled urine of preterm newborns were fractionated by stepwise elution from a Dowex 1-X2 column. Analytical reactions, cellulose acetate electrophoresis and enzymatic digestions with chondroitinases and testicular hyaluronidase were performed on each fraction. Chondroitin-4-sulfate and chondroitin-6-sulfate constitute about 60% of urinary GAG; heparan sulfate amounts to about 20%, while chondroitin represents 12% of total GAG; dermatan sulfate, hyaluronic acid and keratan sulfate are present in small traces. Approximately 30% of the total is constituted by nonsulfated GAG.