Comparing nitric acid treatment and microwave digestion for efficiency of metal extraction from bioprocess samples

Metal ions may act as enzyme cofactors and influence the kinetics of biochemical reactions that may also influence the biological production of therapeutic proteins and quality attributes such as glycosylation. Because sample preparation is a significant step in the reliable analysis of metals, we compared two sample preparation procedures for metal analysis of bioreactor culture media samples by ICP-MS: (i) samples were diluted in 2 % nitric acid (treatment with nitric acid, TNA); and (ii) samples were mixed with equal volume of 5 % nitric acid and closed vessel digestion was performed in a microwave (closed vessel digestion, CVD). In the comparison of extraction efficiencies between TNA and CVD procedures, CVD showed better extraction for Ca and Cu among bulk metals (∼30 %) and for Ni among the trace metals (∼65 %) for the bioreactor broth supernatant samples. For the cell pellet samples, the CVD procedure was found to be better for extraction of Fe (∼65 % more) among bulk metals, Zn (∼20 % more) among minor metals and Co (∼60 % more) and Ni (∼45 % more) among trace metals. Differences between the two procedures were less than 10 % and TNA was better for all other metals quantified from both supernatant samples and cell pellet samples. The current study helps bring more clarity to the methodology on comprehensive metal analysis to monitor and maintain trace metal content for biologics production.

Effect of feeding Bengal gram residual forage-based pelleted total mixed ration on growth performance, nutrient availability, carcass traits and composition in finisher Barbari kids

The study aimed to assess the impact of feeding Bengal gram residual forage-based pelleted Total Mixed Ration (TMR) with varying concentrate (C) to roughage (R) ratios on feed intake, nutrient utilization, growth, and carcass characteristics in Barbari kids. Sixteen weaned male Barbari kids (av. age, 233 ± 11 days; weight, 13.86 ± 0.76 kg) were divided into two groups (T1 and T2), each receiving different pelleted diets (TMR) with distinct concentrate to roughage ratios (T1 with 60:40; T2 with 40:60). The kids were fed for 133 days, and a digestion trial was conducted at the end of the study. After completion, all kids were slaughtered. Although, kids under T1 consumed higher (P < 0.001) amount of dry matter, and crude protein compared to T2, which was due to a higher concentrate to roughage ratio in T1. But, the average daily body weight gain (ADG) of finisher kids was 88.53, and 79.83 g/d/kid in T1 and T2, respectively; however, the difference was non-significant. Digestibility of organic matter, crude protein, and total carbohydrate was also greater in T1 compared to T2. Total digestible nutrients intake was higher (P < 0.001) in T1; similarly intake of digestible energy, and metabolizable energy were significantly increased (P < 0.01) in T1 compared to T2. Concentrations of volatile fatty acids and NH3-nitrogen were also enhanced (P < 0.05) in T1 compared to T2. We observed similar carcass weight, and dressing percentage in both groups, and carcass composition remained unaffected. The pelleted diet containing greater ratio of concentrate: roughage (60:40) had no additional benefits in terms of ADG, and carcass traits in finisher kids. Therefore, it may be concluded that the Bengal gram residual forage-based pelleted TMR diet containing C40: R60 (TDN 57.13%, DCP 7.64%, ME 9.11MJ/kg feed) is suitable for optimizing growth performance with desirable carcass traits, and meat composition in finisher Barbari kids reared under the intensive system.

Bumetanide as a Model NDSRI Substrate: N-nitrosobumetanide Impurity Formation and its Inhibition in Bumetanide Tablets

Nitrosamine compounds are classified as potential human carcinogens, the origin of these impurities can be broadly classified in two categories, nitrosamine impurity found in drug products that are not associated with the Active Pharmaceutical Ingredient (API), such as N-nitrosodimethylamine (NDMA) or nitrosamine impurities associated with the API, such as nitrosamine drug substance-related impurities (NDSRIs). The mechanistic pathway for the formation of these two classes of impurities can be different and the approach to mitigate the risk should be tailored to address the specific concern. In the last couple of years number of NDSRIs have been reported for different drug products. Though, not the only contributing factor for the formation of NDSIRs, it is widely accepted that the presence of residual a nitrites/nitrates in the components used in the manufacturing of the drug products can be the primary contributor to the formation of NDSRIs. Approaches to mitigate the formation of NDSRIs in drug products include the use of antioxidants or pH modifiers in the formulation. The primary objective of this work was to evaluate the role of different inhibitors (antioxidants) and pH modifiers in tablet formulations prepared in-house using bumetanide (BMT) as a model drug to mitigate the formation of N-nitrosobumetanide (NBMT). A multi-factor study design was created, and several bumetanide formulations were prepared by wet granulation with and without sodium nitrite spike (100 ppm) and different antioxidants (ascorbic acid, ferulic acid or caffeic acid) at three concentrations (0.1%, 0.5% or 1% of the total tablet weight). Formulations with acidic and basic pH were also prepared using 0.1 N hydrochloric acid and 0.1 N sodium bicarbonate, respectively. The formulations were subjected to different storage (temperature and humidity) conditions over 6 months and stability data was collected. The rank order of N-nitrosobumetanide inhibition was highest with alkaline pH formulations, followed by formulations with ascorbic acid, caffeic acid or ferulic acid present. In summary, we hypothesize that maintaining a basic pH or the addition of an antioxidant in the drug product can mitigate the conversion of nitrite to nitrosating agent and thus reduce the formation of bumetanide nitrosamines.

Stress perceived by drivers in public healthcare facilities in Negeri Sembilan during the first year of the COVID-19 pandemic

INTRODUCTION

Healthcare drivers, including ambulance drivers, were less concerned about health and safety during the COVID-19 pandemic, with not only the risk of COVID-19 infection but also a higher risk of prolonged states of alertness, stress, burnout, fatigue and road traffic accident. This study aimed to determine the prevalence of stress and its associated factors among healthcare drivers, especially during the COVID-19 pandemic.

MATERIALS AND METHODS

This study employs a crosssectional study design and utilises self-reported data obtained from locally validated personal stress inventory questionnaires. The data collection period spanned from August 1 to 31, 2020. The study sample consisted of 163 healthcare drivers affiliated with the Negeri Sembilan State Health Department. The Chi-square test and Fisher's exact test were the first used to determine the association between variables prior to conducting multiple logistic regression to predict the relationship between dependent and independent variables.

RESULTS

In COVID-19's first year, 7.4% (n = 12) of healthcare drivers reported perceived stress with ambulance drivers reporting more stress (10.6%; n = 5) than non-ambulance drivers (6.0%; n = 7). Simple statistical analysis identified perceived stress significantly associated with household income, smoking status and performing on-call. Further analysis by multiple logistic regression found that perceived stress was significantly related to smoking (aOR 19.9, 95% CI: 1.86-213.90), and performing on-call (aOR 8.69, 95% CI 1.21-62.28). Nevertheless, no association was found between perceived stress and age, ethnicity, marital status, education, household income, co-morbidities, driving assignment, employment duration, needing a part-time job or motor vehicle accident history.

CONCLUSION

The study found that the perceived stress amongst Malaysian healthcare drivers during the COVID-19 pandemic was relatively low. This could be due to fewer lifethreatening tasks, emergencies, assigned tasks and increase income due to overtime during the COVD-19 pandemic. The OSH team's efforts to provide consistent safety and health training, including stress management, may have contributed to the healthcare driver's ability to effectively manage the stressful circumstances encountered during the pandemic. In order to enhance salary competitiveness, employers should provide financial management education alongside subsidised housing and childcare provisions. Healthcare drivers who smoke should be taught different stress reduction techniques so that they can handle their stress in a healthy way.

Exploring the Traditional Chinese Medicine (TCM) database chemical space to target I7L protease from monkeypox virus using molecular screening and simulation approaches

In the current study, we used molecular screening and simulation approaches to target I7L protease from monkeypox virus (mpox) from the Traditional Chinese Medicines (TCM) database. Using molecular screening, only four hits TCM27763, TCM33057, TCM34450 and TCM31564 demonstrated better pharmacological potential than TTP6171 (control). Binding of these molecules targeted Trp168, Asn171, Arg196, Cys237, Ser240, Trp242, Glu325, Ser326, and Cys328 residues and may affect the function of I7L protease in in vitro assay. Moreover, molecular simulation revealed stable dynamics, tighter structural packing and less flexible behaviour for all the complexes. We further reported that the average hydrogen bonds in TCM27763, TCM33057, TCM34450 and TCM31564I7L complexes remained higher than the control drug. Finally, the BF energy results revealed -62.60 ± 0.65 for the controlI7L complex, for the TCM27763I7L complex -71.92 ± 0.70 kcal/mol, for the TCM33057I7L complex the BF energy was -70.94 ± 0.70 kcal/mol, for the TCM34450I7L the BF energy was -69.94 ± 0.85 kcal/mol while for the TCM31564I7L complex the BF energy was calculated to be -69.16 ± 0.80 kcal/mol. Although, we used stateoftheart computational methods, these are theoretical insights that need further experimental validation.

The Development of a Continuous Synthesis for Carbamazepine using Validated In-line Raman Spectroscopy and Kinetic Modelling for Disturbance Simulation

Mitigation of failure modes in continuous synthesis (CS) of drug substance (DS) has the potential to widen the adoption of continuous manufacturing (CM) technologies by the pharmaceutical industry. This work...

Rapid Quantitation of Four Nitrosamine Impurities in Angiotensin Receptor Blocker Drug Substances

Starting in July 2018, the FDA alerted patients and health care professionals to the recall of ARBs such as valsartan by several pharmaceutical companies because of their potential contamination with carcinogenic nitrosamine impurities, including: (1) N-nitrosodimethylamine (NDMA), (2) N-nitrosodiethylamine (NDEA), (3) N-nitrosoethylisopropylamine (NEIPA), (4) N-nitrosodiisopropylamine (NDIPA), (5) N-nitrosodibutylamine (NDBA) and (6) N-nitroso-N-methyl-4-aminobutyric acid (NMBA). The FDA initiated a laboratory investigation to develop analytical procedures to test multiple lots of marketed ARB drugs to determine the possible presence of carcinogenic impurities and, if present, quantitate the levels of these impurities. Here the FDA laboratory developed and validated an automated micro-solid phase extraction MS/MS method, where all the analytes are not separated prior to elution to the MS, to simultaneously quantify NEIPA, NDIPA, NDBA and NMBA in ARB drug substances with an instrument sample analysis time of 12 seconds. The method was validated according to the ICH Q2(R1) guideline, and was determined to be specific, accurate, precise and linear over the corresponding nitrosamine analytical ranges. The method has been successfully implemented to quantitate the four nitrosamine impurities in 129 generic losartan, valsartan, olmesartan, irbesartan and telmisartan drug substance samples from 32 lots; and 32 losartan and valsartan drug product samples from 6 lots.

Kinetics Modelling of an Environmentally Friendly Carbamazepine Synthesis via Urea and Iminostilbene in Batch and Continuous Processes

Accurate kinetic models for reaction systems allow for improved process understanding and greater quality control, which is particularly beneficial as the pharmaceutical industry shifts from batch to continuous manufacturing (CM)....

Effect of iron addition on mAb productivity and oxidative stress in Chinese hamster ovary culture

Trace metals play a critical role in the development of culture media used for the production of therapeutic proteins. Iron has been shown to enhance the productivity of monoclonal antibodies during Chinese hamster ovary (CHO) cell culture. However, the redox activity and pro-oxidant behavior of iron may also contribute toward the production of reactive oxygen species (ROS). In this work, we aim to clarify the influence of trace iron by examining the relationship between iron supplementation to culture media, mAb productivity and glycosylation, and oxidative stress interplay within the cell. Specifically, we assessed the impacts of iron supplementation on (a) mAb production and glycosylation; (b) mitochondria-generated free hydroxyl radicals (ROS); (c) the cells ability to store energy during oxidative phosphorylation; and (d) mitochondrial iron concentration. Upon the increase of iron at inoculation, CHO cells maintained a capacity to rebound from iron-induced viability lapses during exponential growth phase and improved mAb productivity and increased mAb galactosylation. Fluorescent labeling of the mitochondrial hydroxyl radical showed enhanced environments of oxidative stress upon iron supplementation. Additional labeling of active mitochondria indicated that, despite the enhanced production of ROS in the mitochondria, mitochondrial membrane potential was minimally impacted. By replicating iron treatments during seed train passaging, the CHO cells were observed to adapt to the shock of iron supplementation prior to inoculation. Results from these experiments demonstrate that CHO cells have the capacity to adapt to enhanced environments of oxidative stress and improve mAb productivity and mAb galactosylation with minimal perturbations to cell culture.

Evaluation of focused beam reflectance measurement (FBRM) for monitoring and predicting the crystal size of carbamazepine in crystallization processes

Pharmaceutical crystallization affects the properties of APIs as it determines the purity and crystal size distribution, among other attributes. This work presents two CLD–CSD models, theoretical and empirical, for a model compound.

Readily usable strategies to control mastitis for production augmentation in dairy cattle: A review

Mastitis in dairy cattle is the most common management disorder that causes higher economic losses by lowering production and quality of milk leads to substantial economical loss. The aim of this article was to review worldwide important advances in strategies to control mastitis for production augmentation in dairy cattle. Many scientists worked to identify effective strategies to control mastitis caused by Streptococcus agalactiae, Staphylococcus aureus, and others. It is necessary to identify mechanisms of infection, define clinical and subclinical states of disease, determine exposure time, and identify pathogen-specific characteristics. Evolvement of management strategies that incorporated hygienic procedures (animal, floor, and milkman), post milking standing period of animal and strategic use of antibiotic or herbal therapy at dry-off, nutritional supplementation, fly control, body condition score optimization, etc., resulted in widespread control of mastitis. The udder, teat of animal, scientific management of milking, automatic milking procedure, genetic selection are considered as important factors to control mastitis. As farm management changed, scientists were directed to redefine control of mastitis caused by opportunistic pathogens of environmental sources and have sought to explore management strategies which will maintain animal well-being in a judicial way. Although significant advances in mastitis management have been made changing herd structure, changing climatic scenario and more rigorous milk processing standards ensure that mastitis will remain important issue for future research.

Role of CMV-serostatus and CX3CR1 on lymphocyte kinetics and left ventricular remodelling in patients with acute myocardial infarction

Background

Patients with latent cytomegalovirus (CMV) infection have higher rates of adverse cardiovascular outcomes, but the reasons for this remain elusive. CMV-induced changes to T-lymphocyte populations, with a proliferation of CMV-specific, CX3CR1+ effector memory cells, may contribute. Effector T-cells are associated with cardiovascular mortality in CMV positive patients, and ischaemia-reperfusion injury after ST-elevation myocardial infarction (STEMI) and primary percutaneous coronary intervention (pPCI).

Purpose

To investigate the effect of CMV status on lymphocyte kinetics and cardiac MRI (cMRI) parameters in 52 STEMI patients receiving pPCI, and examine the prognostic relevance of pre-reperfusion lymphocyte count in a large cohort.

Methods

We retrospectively analysed the association between pre-reperfusion lymphocyte count, troponin, and long-term survival in 4874 consecutive STEMI patients. Using flow cytometry, we analysed lymphocyte kinetics in 52 STEMI patients, of known CMV status, during and after pPCI. We assessed the impact of CMV status on infarct size, left-ventricular (LV) function and microvascular obstruction with cMRI in the first week after reperfusion in 101 patients. Repeat cMRI at 12 weeks, to assess LV remodelling, was obtained in 48 patients.

Results

Pre-reperfusion lymphopenia is an independent predictor of mortality over 7.5 years (hazard ratio for lowest vs highest quartile: 2.0; 95% CI 1.7–2.4; p&lt;0.001), and is associated with higher admission troponins (p&lt;0.001 for lowest vs second-lowest quartile), suggesting lymphocyte count falls prior to reperfusion in response to myocardial injury. CMV positive patients had more cytotoxic T-cells, strongly expressing the fractalkine receptor, CX3CR1. In CMV positive patients these cells fell dramatically by 90 minutes post-reperfusion, and dropped more sharply in patients with extensive microvascular obstruction on cMRI (p≤0.05 in all effector subsets). CX3CR1 expression was lower at 90 minutes post-reperfusion than at 24 hours (return to physiological expression) in all effector T-cell subsets. All subsets lost a similar proportion of their 24-hour value, but consistently lost a larger proportion in CMV positive patients (−27% in CMV+, −18% in CMV−; p=0.007). CX3CR1 expression falls in the presence of fractalkine, and we hypothesise that membrane-bound fractalkine is induced more strongly in CMV positive patients, as soluble fractalkine levels were similar. At 12 weeks, LV remodeling was worse in CMV positive patients (change in end-diastolic volume: +10.7ml vs −6.1ml; p=0.02).

Conclusions

Lymphopenia occurs prior to reperfusion in STEMI, and predicts long-term mortality. Effector T-cells drop substantially after reperfusion only in CMV positive patients, likely mediated by CX3CR1-fractalkine interaction, and this is associated with adverse cMRI findings. Remodeling is worse in CMV positive patients at 12 weeks post-STEMI.

Lymphocytes, troponin and survival

Funding Acknowledgement

Type of funding source: Public Institution(s)

Interferon-gamma inducible protein IP-10 and left ventricular remodelling post-acute myocardial infarction: a longitudinal cardiovascular magnetic resonance imaging substudy of CAPRI clinical trial

Background

Adverse left ventricular (LV) remodelling is associated with development of heart failure and poor outcomes in patients with acute myocardial infarction (AMI). Understanding the immunomodulatory mechanisms of LV remodelling is an essential step for the development of novel therapies. Interferon-γ-inducible protein-10 (IP-10)/CXCL10 is a chemokine involved in the recruitment of activated T cells into sites of tissue inflammation. Although IP-10 was reported to reduce adverse LV remodeling in a preclinical myocardial infarction model, its role in LV remodeling in humans with AMI remains unknown.

Purpose

To determine the clinical predictive value of serum IP-10 in LV remodeling in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

This is a substudy of the double-blind, randomised controlled trial “Evaluating the effectiveness of intravenous ciclosporin on reducing reperfusion injury in patients undergoing primary percutaneous coronary intervention” (CAPRI; ClinicalTrials.gov registry number NCT02390674), which enrolled 52 acute STEMI patients. LV remodeling was assessed by cardiovascular magnetic resonance (CMR) imaging and was defined as the 12-week vs. the 3-day post-myocardial infarction change of the left ventricular ejection fraction (ΔLVEF), LV end-diastolic volume (ΔEDV) or LV end-systolic volume (ΔESV). Serum IP-10 was measured before and 5min, 15min, 30min, 90min and 24h after reperfusion by ELISA. Linear regression analysis was used to determine the independent association of IP-10 with the endpoints of the study.

Results

Serum IP-10 concentration peaked at 30min after reperfusion followed by a 2-fold decrease at the 24h post reperfusion compared to pre-reperfusion levels (P&lt;0.001 for all). Comparison of the 12-week CMR to the baseline CMR imaging revealed that baseline pre-reperfusion as well as 5min, 15min, 30min and 90min, but not 24h, post-reperfusion IP-10 serum levels associated with increased LVEF and decreased ESV at 12-weeks (range correlation coefficient r=[0.35–0.41], P&lt;0.05 with ΔLVEF and r=[−0.33 to −0.44], P&lt;0.05 with ΔESV) indicating that the increase of IP-10 at the acute phase of myocardial infarction confers a cardioprotective role. Multivariable linear regression analysis for ΔLVEF showed that in a model including baseline pre-reperfusion or 5min or 15min or 30min or 90min post-reperfusion IP-10 and age, gender, traditional risk factors (arterial hypertension, body-mass index, hyperlipoproteinemia, diabetes mellitus, smoking, family history of CAD), infarct location, admission high-sensitivity troponin T, door-to-balloon time and ciclosporin treatment, only IP-10 was the independent determinant of ΔLVEF.

Conclusions

Increased serum IP-10 levels early after reperfusion are associated with reverse LV remodeling in patients with STEMI undergoing primary PCI. The clinical application of IP-10 as a novel biomarker of LV remodeling post-AMI should be further explored and validated.

Funding Acknowledgement

Type of funding source: None

In vitro physicochemical characterization and dissolution of brinzolamide ophthalmic suspensions with similar composition

The quality of an ophthalmic suspension is crucial for its in vivo performance, and often impact product's effectiveness. An in-depth understanding of critical quality attributes (CQAs) of ophthalmic suspensions such as particle size distribution (PSD) and rheology, as well as the impact of these CQAs on product performance are important for successful product development, quality control, and regulatory approval. This study employed brinzolamide ophthalmic suspension, 1%, as a model ophthalmic product, and six batches were manufactured using an innovative planetary centrifugal milling (PCM) process. Three batches were manufactured to have distinctly different PSD. These three batches had qualitatively (Q1) and quantitatively (Q2) the same composition as the model drug product (i.e., Azopt), while the differences in PSD were introduced by changing only the manufacturing process parameters. On the other hand, changes in rheology were introduced by altering the input level of the viscosity enhancing polymer in the formulation. A systematic approach was employed to understand the relation between manufacturing process parameters, CQAs, and in vitro product performance. Among the evaluated CQAs, PSD, rheology, surface tension, and drug dissolution were found more sensitive to the changes in the manufacturing processes. Most notably, we developed a rapid dissolution method (completed within minutes) employing in-situ fiber optic UV dissolution system. This novel dissolution method mimics the environmental conditions of the eye such as dissolution under "non-sink" condition and under high shear (from blinking). The method was highly discriminatory to differences in the PSD in the suspension. This study also revealed an important relation between the PSD of the suspension and its rheology which originated as a result of an interaction at the molecular level between the solid drug particles and the viscosity enhancing polymers. These findings underscore the need to evaluate CQAs of the ophthalmic suspensions in concert rather than separately when comparing ophthalmic drug products and product performance.

Factors affecting the particle size distribution and rheology of brinzolamide ophthalmic suspensions

Drug particle size distribution (PSD) and dispersion viscosity are two critical quality attributes that govern the performance of topical ophthalmic suspensions, such as suspension physical stability, ocular retention, and drug release characteristics.. An in-depth knowledge of the effects of formulation and manufacturing process on these critical quality attributes may facilitate the product and process development, quality control, as well as support regulatory policy and approval. The current study has investigated the effect of formulation and process parameters on the quality attributes of brinzolamide ophthalmic suspensions. In the first step, three milling techniques (probe sonication, microfluidization, and media milling with a planetary centrifugal mixer) were evaluated for manufacturing of brinzolamide suspension. Out of the three techniques, the planetary centrifugal media milling yielded the narrowest PSD and thus was considered the most viable lab-scale technique for this purpose. In the next step, various process parameters of media milling were evaluated using a central-composite experimental design. The independent variables included bead size, agitating intensity, and process time while the PSD of drug particles (D₅₀) was the response variable. The effect of shear rate and shear time of the homogenization process and the concentration of carbomer on the rheological properties of the suspension were studied using a Box-Behnken design. Additionally, effects of sodium chloride and mannitol concentration on the rheological properties of the suspension was also investigated. Sodium chloride was found to exert a pronounced effect on rheology of the suspension. Despite variations in the carbomer concentration, a suspension of comparable rheology could be prepared by controlling the process parameters namely the shear rate and process time.

Impacts on product quality attributes of monoclonal antibodies produced in CHO cell bioreactor cultures during intentional mycoplasma contamination events

A mycoplasma contamination event in a biomanufacturing facility can result in costly cleanups and potential drug shortages. Mycoplasma may survive in mammalian cell cultures with only subtle changes to the culture and penetrate the standard 0.2‐µm filters used in the clarification of harvested cell culture fluid. Previously, we reported a study regarding the ability of Mycoplasma arginini to persist in a single‐use, perfusion rocking bioreactor system containing a Chinese hamster ovary (CHO) DG44 cell line expressing a model monoclonal immunoglobulin G 1 (IgG1) antibody. Our previous work showed that M. arginini affects CHO cell growth profile, viability, nutrient consumption, oxygen use, and waste production at varying timepoints after M. arginini introduction to the culture. Careful evaluation of certain identified process parameters over time may be used to indicate mycoplasma contamination in CHO cell cultures in a bioreactor before detection from a traditional method. In this report, we studied the changes in the IgG1 product quality produced by CHO cells considered to be induced by the M. arginini contamination events. We observed changes in critical quality attributes correlated with the duration of contamination, including increased acidic charge variants and high mannose species, which were further modeled using principal component analysis to explore the relationships among M. arginini contamination, CHO cell growth and metabolites, and IgG1 product quality attributes. Finally, partial least square models using NIR spectral data were used to establish predictions of high levels (≥10⁴ colony‐forming unit [CFU/ml]) of M. arginini contamination, but prediction of levels below 10⁴ CFU/ml were not reliable. Contamination of CHO cells with M. arginini resulted in significant reduction of antibody product quality, highlighting the importance of rapid microbiological testing and mycoplasma testing during particularly long upstream bioprocesses to ensure product safety and quality.

P1587Comparison of effects of lowering blood pressure in individuals with blood pressure <140/90 mmHg and hypertension guideline recommendations: a systematic review and meta-analysis of randomised trials

Background

Implementation of evidence-based medicine requires minimising delays between data generation and guideline creation. We examined the temporal relationship between accumulating evidence from randomized controlled trials (RCTs) of blood pressure (BP) lowering drug therapy among individuals with SBP<140 mmHg, DBP<90 mmHg, or both, and hypertension guideline recommendations over time.

Methods

A systematic review was conducted by searching MEDLINE for RCTs between January 1966 and February 2018. Included trials randomized patients to BP lowering drug(s) vs placebo/no treatment or to more vs less BP lowering with at least 1000 patient-years of follow-up per treatment group, and provided data relevant to BP lowering in patients with SBP<140 mmHg, DBP<90 mmHg, or both (hereafter <140/90 mmHg). Included trials were classified according to major patient groups and whether all patients had baseline BP <140/90 mmHg, or most control group patients had BP <140/90 mmHg during follow-up, which was selected because this is the BP against which interventions were compared. Two reviewers independently extracted relevant data from included RCTs and hypertension guidelines. Cumulative meta-analyses of cardiovascular events were conducted and were compared to hypertension guideline recommendations. The primary outcome was major cardiovascular events.

Results

A total of 73 trials (n=300,805) were included, including 16 trials/subgroups with all participants baseline BP <140/90mmHg. Benefits of BP lowering in individuals with usual BP <140/90 mmHg began to emerge in the 1970s (Figure). Most evidence was from trials that included some or all patients with hypertension at baseline, but most patients had BP <140/90 mmHg during follow-up due to regression to the mean and background treatment. Starting from 1992, 22 trials reported results by baseline hypertension status with no difference in cardiovascular event relative risk reduction among those with and without hypertension (relative risk 0.87 [95% CI 0.84–0.90] vs 0.86 [0.83–0.90], respectively. Until 2017, no major guidelines recommended treatment initiation or intensification for patients with baseline BP <140/90 mmHg, apart from the periods during which some guidelines recommended treatment at lower thresholds for patients with diabetes and chronic kidney disease (Joint National Committee 1997 to 2014; European Society of Hypertension 2007 to 2009).

Cumulative meta-analyses of trials

Conclusions

Evidence of benefits of BP lowering among individuals with usual BP <140/90 mmHg have been demonstrated for decades. However, there has been a substantial delay between data generation and guideline recommendations. This delay was may be due to the inappropriate emphasis on baseline rather than usual BP levels, and relatively narrow evidence synthesis, which does not fully account for evidence generated across various major patient groups.

Quantitative evaluation of the thallium binding of soluble and insoluble Prussian blue hexacyanoferrate analogs: A scientific comparison based on their critical quality attributes

There has been a long-standing discussion in the scientific literature on the thallium (Tl) binding capacity of ferric hexacyanoferrate (insoluble) and potassium hexacyanoferrate (soluble) forms of Prussian blue (PB). The literature sometime suggests that the soluble form of PB should be used to treat thallium poisoning, instead of the FDA approved insoluble form of PB. The literature debate is further complicated by the lack of fundamental characterization data such as critical quality attributes (CQAs) that clearly define the analog forms. The purpose of this study is to compare, the binding capacity of soluble and insoluble PB analogs with the same CQAs (particle size/distribution and water content). Water content and particle size/particle distribution were determined by TGA, and solid-state laser diffraction particle sizing. Thallium binding studies were conducted at physiological pH to determine the maximal binding capacity (MBC) at equilibrium. Multiple linear regression and principal component analysis was also used for multivariate data analysis. Results indicate that insoluble and soluble analogs, with similar quality attributes, have nearly identical, MBC binding capacities of (441.5 mg/g) for insoluble vs soluble (458.4 mg/g). However, when both analog forms with different CQAs such as water, particle size were compared, results indicated significantly higher or lower thallium binding levels. In conclusion, it is essential that the FDA approved iron form with well-defined CQAs is used to treat thallium poisoning and radioactive thallium metal contamination for consistent therapeutic outcomes.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Evaluation of Abuse-Deterrent Characteristics of Tablets Prepared via Hot-Melt Extrusion

In this study, the effect of formulation variables and process parameters on the abuse-deterrent (AD) characteristics of a matrix tablet manufactured using hot-melt extrusion (HME) was investigated. The formulation variables included polyethylene oxide (PEO) grades and its input level, while the HME process parameters varied were barrel temperature profile and die diameter. Depending on the diameter of the extrudate (2.5 mm or 5.0 mm), two different downstream processes were used to prepare the tablets: cryo-milling followed by compression for the 2.5 mm extrudate, and cutting followed by compression for the 5.0 mm extrudate. A D-optimal statistical design was used to evaluate the impact of formulation and process parameters on various responses, including tablet physical strength, particle size after manipulation, syringeability and injectability, solution viscosity, extractability in solvents, and dissolution rates. It was found that the post-HME extrusion processing method played a critical role in affecting the AD characteristics of abuse-deterrent formulations, likely through changing the tablet compactability and porosity. When the extrudates were cryo-milled-compressed, the tablets could be readily manipulated by milling, which led to high degree of extractability. Under high alcohol concentration, burst drug release was observed for the tablets compressed from cryo-milled extrudates. Additionally, heat exposure during HME process caused significant drop in PEO solution viscosity, likely due to thermal degradation.

Occupational medicine specialist referral triggers: Mixed-methods analysis of teleconsult cases

Background

Qualitative analyses can yield critical lessons for learning organizations in healthcare. Few studies have applied these techniques in the field of occupational and environmental medicine (OEM).

Aims

To describe the characteristics of complex cases referred for OEM subspecialty evaluation and variation by referring provider's training.

Methods

Using a mixed methods approach, we conducted a content analysis of clinical cases submitted to a national OEM teleconsult service. Consecutive cases entered between April 2014 and July 2015 were screened, coded and analysed.

Results

108 cases were available for analysis. Local Veterans Health Administration (VHA) non-specialist providers entered a primary medical diagnosis in 96% of cases at the time of intake. OEM speciality physicians coded significant medical conditions based on free text comments. Coder inter-rater reliability was 84%. The most frequent medical diagnosis types associated with tertiary OEM referral by non-specialists were endocrine (19%), cardiovascular (18%) and mental health (16%). Concern for usage of controlled and/or sedating medications was cited in 1% of cases. Compared to referring non-specialists, OEM physicians were more likely to attribute case complexity to musculoskeletal (OR: 2.3, 1.68-3.14) or neurological (OR: 1.69, 1.28-2.24) conditions. Medication usage (OR: 2.2, 1.49-2.26) was more likely to be a source of clinical concern among referring providers.

Conclusions

The findings highlight the range of triggers for OEM physician subspecialty referral in clinical practice with employee patients. The results of this study can be used to inform development of provider education, standardized clinical practice pathways, and quality review activities for occupational medicine practitioners.

An ICP-MS platform for metal content assessment of cell culture media and evaluation of spikes in metal concentration on the quality of an IgG3:κ monoclonal antibody during production

Metal ions can be enzyme cofactors and can directly influence the kinetics of biochemical reactions that also influence the biological production and quality attributes of therapeutic proteins, such as glycan formation and distribution. However, the concentrations of metals in commercially available chemically defined media can range from 1 to 25,000 ppb. Because such concentration changes can impact cell growth, manufacturing yield and product quality the alteration/fluctuation in media composition should be well controlled to maintain product quality. Here, we describe a platform of analytical methods to determine the composition of several metals in different sample matrices using an advanced automated Inductively Coupled Plasma-Mass Spectrometry (ICP-MS). These methods, validated to ICH Q2R1 regulatory validation parameters, were successfully applied to- (a) screen cell culture media; (b) determine changes in the metal concentration during cell growth in spinner flasks, and, (c) determine effect on the glycosylation pattern and homogeneity of an IgG3:κ produced from a murine-hybridoma cell line in bench-top parallel bioreactors due to a spike in copper and iron concentration. Our results show that maintenance of metal content in the cell culture media is critical for product consistency of the IgG3:κ produced.

Comparative Evaluation of U.S. Brand and Generic Intravenous Sodium Ferric Gluconate Complex in Sucrose Injection: Biodistribution after Intravenous Dosing in Rats

Relative biodistribution of FDA-approved innovator and generic sodium ferric gluconate (SFG) drug products was investigated to identify differences in tissue distribution of iron after intravenous dosing to rats. Three equal cohorts of 42 male Sprague-Dawley rats were created with each cohort receiving one of three treatments: (1) the innovator SFG product dosed intravenously at a concentration of 40 mg/kg; (2) the generic SFG product dosed intravenously at a concentration of 40 mg/kg; (3) saline dosed intravenously at equivalent volume to SFG products. Sampling time points were 15 min, 1 h, 8 h, 1 week, two weeks, four weeks, and six weeks post-treatment. Six rats from each group were sacrificed at each time point. Serum, femoral bone marrow, lungs, brain, heart, kidneys, liver, and spleen were harvested and evaluated for total iron concentration by ICP-MS. The ICP-MS analytical method was validated with linearity, range, accuracy, and precision. Results were determined for mean iron concentrations (µg/g) and mean total iron (whole tissue) content (µg/tissue) for each tissue of all groups at each time point. A percent of total distribution to each tissue was calculated for both products. At any given time point, the overall percent iron concentration distribution did not vary between the two SFG drugs by more than 7% in any tissue. Overall, this study demonstrated similar tissue biodistribution for the two SFG products in the examined tissues.

Association of Condylar Bone Quality with TMJ Osteoarthritis

The etiology and treatment of temporomandibular joint (TMJ) osteoarthritis (TMJOA) remain complex and unclear. Based on clinical observations, we hypothesized that low condylar bone quality is significantly correlated with TMJOA and explored this association in a cross-sectional study with human patients. A total of 254 postmenopausal female participants were included in this study. Radiographic findings from cone beam computed tomography (CBCT) and clinical symptoms were used to classify each TMJ data sample as healthy control ( n = 124) or TMJOA ( n = 130). Condylar bone mineral density (BMD) (computed tomography Hounsfield unit [CT HU]) and bone volume fraction (BV/TV) were measured and modeled as predictors of healthy control versus TMJOA status in multilevel logistic regression analyses. Both CT HU (adjusted odds ratio [AOR] = 0.9989, interquartile odds ratio [IOR] = 0.4206) and BV/TV (AOR= 0.8096, IOR = 0.1769) were negatively associated with TMJOA ( P = 0.049, 0.011, respectively). To assess the diagnostic performance of CT HU and BV/TV for identification of TMJOA, receiver operating characteristic (ROC) curves were plotted. The estimated areas under the curve (AUC) were 0.6622 for BV/TV alone, 0.6074 for CT HU alone, and 0.7136 for CT HU and BV/TV together. The model incorporating CT HU and BV/TV together had a significantly higher AUC than the models using BV/TV alone ( P = 0.038) or HU alone ( P = 0.021). In conclusion, we found that low condylar bone quality was significantly correlated with TMJOA development and that condylar CT HU and BV/TV can be used together as a potential diagnostic tool for TMJOA. Careful clinical evaluation of the condyle coupled with appropriate radiographic interpretation would thus be critical for the early detection of TMJOA.

Validity of visceral adiposity estimates from DXA against MRI in Kuwaiti men and women

OBJECTIVES

The prevalence of obesity and diabetes in the Middle East is among the highest in the world. Valid measures of abdominal adiposity are essential to understanding the metabolic consequences of obesity. Dual-energy X-ray absorptiometry (DXA) is increasingly being utilised to assess body composition in population studies, and has recently been used to estimate visceral adipose tissue (VAT). The aim of this study was to determine the accuracy of DXA-derived VAT in a Middle Eastern population using magnetic resonance imaging (MRI) as the criterion measure.

METHOD

VAT was estimated from abdominal DXA measures in 237 adult men (n=130) and women (n=107), aged 18-65 years, participating in the Kuwait Wellbeing Study. These estimates were compared with MRI measures of the corresponding anatomical region. The agreement between methods was assessed using Bland-Altman as well as correlation analysis.

RESULTS

Median MRI VAT was 1148.5 cm3 (95% confidence interval: 594.2-1734.6) in men and 711.3 cm3 (95% confidence interval: 395.5-1042.8) in women. DXA estimates of VAT showed high correlations with corresponding MRI measures (r=0.94 (P<0.0001) in men; r=0.93 (P<0.0001) in women). DXA overestimated VAT with a mean bias (95% limits of agreement) of 79.7 cm3 (-767 to 963) in men and 46.8 cm3 (-482 to 866) in women. The imprecision of DXA increased with increasing VAT level in both men and women.

CONCLUSION

DXA estimates of VAT are valid for use in Middle Eastern populations, although accuracy decreases with increasing level of visceral adiposity.

Increase in migraine diagnoses and guideline-concordant treatment in veterans, 2004-2012

Background and aim Health administrators, policy makers, and educators have attempted to increase guideline adherence of migraine medications while reducing inappropriate use of opioid- and barbiturate-containing medications. We evaluated the burden of migraine and proportion of guideline-concordant care in a large, national health care system over time. Methods We conducted a time-series study using data from the Veterans Health Administration (VHA) electronic health record. Veterans with migraines were identified by ICD-9 code (346.X). Prescriptions and comorbid conditions were evaluated before and after migraine diagnosis. Chi-square tests and logistic regression were performed. Results A total of 57,064 veterans were diagnosed with migraine headache (5.3%), with women significantly more likely diagnosed (11.6% vs. 4.4%, p < 0.0001). The number of veterans diagnosed with migraine has significantly increased over the years. By 2012, triptans were prescribed to 43% of people with migraine, with no difference by gender. However, triptan prescriptions increased from 2004 to 2012 in men, but not women, veterans. Preventive medicines showed a significant increase with the year of migraine diagnosis, after controlling for age, sex, race, and for comorbidities treated with medications used for migraine prevention. Conclusions The burden of migraines is increasing within the VHA, with a corresponding increase in the delivery of guideline-concordant acute and prophylactic migraine-specific medication.

Fabrication of nanofiber stationary phases from chopped polyacrylonitrile co-polymer microfibers for use in ultrathin layer chromatography of amino acids

Polyacrylonitrile co-polymer microfibers of diameter 12.5 μm was used for electrospinning to produce nanofibers and then used as a stationary phase in UTLC for on-plate identification and separation of amino acid from drug sample.

Comparison of Univariate and Multivariate Models of ¹³C SSNMR and XRPD Techniques for Quantification of Nimodipine Polymorphs

The focus of the present investigation was to explore the use of solid-state nuclear magnetic resonance ((13)C ssNMR) and X-ray powder diffraction (XRPD) for quantification of nimodipine polymorphs (form I and form II) crystallized in a cosolvent formulation. The cosolvent formulation composed of polyethylene glycol 400, glycerin, water, and 2.5% drug, and was stored at 5°C for the drug crystallization. The (13)C ssNMR and XRPD data of the sample matrices containing varying percentages of nimodipine form I and form II were collected. Univariate and multivariate models were developed using the data. Least square method was used for the univariate model generation. Partial least square and principle component regressions were used for the multivariate models development. The univariate models of the (13)C ssNMR were better than the XRPD as indicated by statistical parameters such as correlation coefficient, R (2), root mean square error, and standard error. On the other hand, the XRPD multivariate models were better than the (13)C ssNMR as indicated by precision and accuracy parameters. Similar values were predicted by the univariate and multivariate models for independent samples. In conclusion, the univariate and multivariate models of (13)C ssNMR and XRPD can be used to quantitate nimodipine polymorphs.

Evaluation of the In Vitro Efficacy of Sevelamer Hydrochloride and Sevelamer Carbonate

The objective of this project is to develop an in vitro approach that can be used to determine the phosphate binding capacity of sevelamer hydrochloride and carbonate for both drug products and active pharmaceutical ingredients (APIs). A simple and efficient inductively coupled plasma spectrometer method for analysis of phosphate at physiologically relevant pH conditions has been developed and validated. The method addresses each of the analytical validation characteristics such as linearity, accuracy, precision, stability, and selectivity, and meets the acceptance criteria defined in the United States Food and Drug Administration guidance (Food and Drug Administration, Center for Drug Evaluation and Research. 2001. Guidance for industry-Bioanalytical method validation, May). The in vitro phosphate binding efficacies were systematically evaluated and compared for two drug products and two APIs. The phosphate binding profiles appeared similar between the drug products. Under all conditions, the sevelamer-phosphate binding reached equilibrium at 6 h. The 90% confidence interval for the k2 ratio (sevelamer carbonate vs. sevelamer hydrochloride) was well within 80%-125% under all pH conditions. However, the k1 ratio varied, indicating that there exists difference in the binding affinity. Our findings will be useful in assisting with "in vivo" biowaiver for the approval of generic sevelamer drug products.

Long-term stability study of Prussian blue-A quality assessment of water content and cyanide release

CONTEXT

Prussian blue, ferric hexacyanoferrate is approved for (oral) treatment of internal contamination with radioisotopes of cesium or thallium. Cyanide makes up 35-40% of Prussian blue's molecular composition; thus, cyanide may be released during transit through the digestive tract under physiological pH conditions.

OBJECTIVES

The purpose of this study is to assess the long-term stability of Prussian blue drug products and active pharmaceutical ingredients and its impact on cyanide release. The study involves the determination and comparison of the loss in water content and cyanide released from Prussian blue under pH conditions that bracket human physiological exposure.

METHODS

Test samples of active pharmaceutical ingredient and drug product were stored for 10 years at ambient temperatures that mimic warehouse storage conditions. Water loss from Prussian blue was measured using thermogravimetric analysis. An in vitro physiological pH model that brackets gastric exposure and gastrointestinal transit was utilized for cyanide release. Prussian blue was incubated in situ at pH: 1.0, 5.0, and 7.0 @ 37°C for 1-24 h. Cyanide was measured using a validated colorimetric method by UV-Vis spectroscopy.

RESULTS

Although the water content (quality attribute) of Prussian blue active pharmaceutical ingredient and drug product decreased by about 10.5% and 13.8%, respectively, since 2003, the cyanide release remained comparable. At pH of 7.0 for 24 h cyanide released from active pharmaceutical ingredient-1 was 21.33 ± 1.76 μg/g in 2004, and 28.45 ± 3.15 μg/g in 2013; cyanide released from drug product-1 was 21.89 ± 0.56 μg/g in 2004, and 27.31 ± 5.78 μg/g in 2013. At gastric pH of 1.0 and upper gastrointestinal pH of 5.0, the data for active pharmaceutical ingredients and drug products were also comparable in 2013. The cyanide release is still pH-dependent and follows the same trend as observed in 2003 with minimum release at pH of 5.0 and maximal release at pH of 1.0. In summary, this is the long-term stability study of Prussian blue which correlates cyanide release to water loss. Cyanide released from Prussian blue was maximum at pH of 1.0 (47.47 μg/g) and minimum at pH of 5.0-7.0 (20.01 μg/g).

CONCLUSIONS

Based on maximal dose, maximal residence time in stomach and intestine, the maximal cyanide released from Prussian blue is about 1.31 mg, which is far below the minimal lethal dose of cyanide of 50 mg, and therefore does not present a safety concern following long-term storage.