Current challenges and future perspectives in oral absorption research: An opinion of the UNGAP network

Although oral drug delivery is the preferred administration route and has been used for centuries, modern drug discovery and development pipelines challenge conventional formulation approaches and highlight the insufficient mechanistic understanding of processes critical to oral drug absorption. This review presents the opinion of UNGAP scientists on four key themes across the oral absorption landscape: (1) specific patient populations, (2) regional differences in the gastrointestinal tract, (3) advanced formulations and (4) food-drug interactions. The differences of oral absorption in pediatric and geriatric populations, the specific issues in colonic absorption, the formulation approaches for poorly water-soluble (small molecules) and poorly permeable (peptides, RNA etc.) drugs, as well as the vast realm of food effects, are some of the topics discussed in detail. The identified controversies and gaps in the current understanding of gastrointestinal absorption-related processes are used to create a roadmap for the future of oral drug absorption research.

Triple Antioxidant Therapy, an Alternative for Patients with Chronic Liver Disease - A Prospective Multicenter Interventional Study

Background: Non-alcoholic fatty liver disease (NAFLD) has increased exponentially in recent years in Western European countries, where the number of hepatitis of viral etiology has been declining, and it is thought to be the most common cause of chronic liver disease in the near future (1). Currently, NAFLD is both the second most common cause of hepatocellular carcinoma (HCC) and the second most common indication for liver transplantation (2-4). This problem is very serious, as cases of NAFLDs are increasingly in children, a population with a long life ahead, and in whom the disease has all the time to progress to cirrhosis and HCC (5, 6). Objectives: The goal of this prospective study is to determine the effect of an original formula consisting in silymarin, organic selenium and alpha lipoic acid, in reducing liver damage in patients with chronic liver disease. Material and methods: The study started in March 2018, initially with a group of patients from Bucharest, integrated in the study at St. Mary's Hospital. In October 2018 it was expanded at the national level to 1 718 patients, monitored by 145 investigating physicians from 134 centers, with an average of 11.8 patients per investigating physician. Outcomes: Taking each stage of fatty liver disease (FLD) at T0 moment (the beginning of the study), we observed that 25% of patients with grade I FLD had no sign of disease at the end of the study, 74% of those with grade II FLD recovered or improved their health, and 83% of patients with grade III FLD recovered or improved their health. There were 149 patients with no FLD detected at the end of the study (recovered). Conclusion: Based on triple antioxidant therapy, the original formula improved the evolution and prognosis of patients with chronic liver disease.

Interrelations between elevated alpha-fetoprotein levels and tumor morphology of patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer related deaths worldwide, while at the same time having a constant growth in incidence. A commonly used biomarker in managing liver cancer cases, alpha-fetoprotein (AFP) is losing clinical ground in favor of imaging studies and emerging biomarkers. The study aims to reassess potential prognosis indicators and risk factors for an elevated level of this glycoprotein by analyzing its relationship with macroscopic morphology tumor-related features.

PATIENTS, MATERIALS AND METHODS

One hundred and thirty-one newly diagnosed HCC patients had their clinical, tumor and liver disease features investigated in contrast to elevated AFP levels with 200 IU∕mL being used as preferred cut-off.

RESULTS

Tumor size =5 cm [odds ratio (OR) 3.36, 95% confidence interval (CI): 1.29-8.74, p=0.013] is an independent tumor-related predictor of markedly elevated AFP values. Noteworthy connections with the type of tumor, multinodular appearance and portal vein thrombosis were also found through univariate analysis.

CONCLUSIONS

AFP could still be a reliable tool in diagnosis and prognosis of HCC patients especially in developing countries due to its relevant association with aspects of advanced tumor and liver disease, gender and a poor functional status.

Population Study on the Impact Food Chemical Composition on Patients with Non-Alcoholic Fatty Liver Diseases

Non-alcoholic fatty liver disease (NAFLD) has become of major interest worldwide, it is estimated that more than 20% of the general population suffer from liver steatosis. NAFLD is highly associated with metabolic risk factors like type 2 diabetes mellitus, obesity and dyslipidemia, the patients diagnosed with NAFLD should adopt a high fiber low calorie diet, with reduced saturated fat and carbohydrates content, leading to weight loss and improvement of metabolic profile. Our study is aiming to shape the profile of the patient interested in being informed related to food quality and chemical composition and to evaluate the aspects on the food products label which are important for the customer. Between June 2017 and December 2017, 83 patients diagnosed with NASH were included in the study, representing the study group, while 33 subjects, without metabolic syndrome or digestive diseases, selected from patient list belonging to two general practitioners, constituted the control group. Related to the interest of being informed about the chemical composition and nutritional value of the products bought, the study showed a low interest for the provided information on nutritional value. lack of confidence in the provided information and complexity of the information are understandable, the high number of subject reasoning through lack of immediate clinical benefit is surprising. Among the healthy population the willingness to pay attention to this aspect is extremely low.

Biochemical Markers with Low-grade Inflammation as Predictors of Thrombotic Events in Antiphospholipid Syndrome

The study aimed to test the inflammation hypothesis in antiphospholipid syndrome (APS) by assessing biochemical markers of inflammation and platelet activation. Forty one patients with APS were compared to 40 controls. High-sensitivity C-reactive protein (hs-CRP) (as inflammatory biomarker), P-selectin and soluble CD40L (sCD40L) (as platelet activation markers) were measured by ELISA at enrolment and after 12 months follow-up. Serum hs-CRP, P-selectin and sCD40L levels were significantly higher in patients with APS compared to controls. P-selectin was significantly higher in APS patients with recurrent or acute thrombosis compared to APS patients with no recurrent thrombotic events. Serum hs-CRP and anticardiolipin antibodies (aCL) and were independent predictors of thrombosis in APS. In conclusion, persistent increased hs-CRP titres demonstrated low-grade inflammation in APS. Serum biomarkers as aCL and hs-CRP were independent thrombotic cumulative risk predictors in patients with APS.

Correlation Between the Tyrozinkinazine Inhibitor Sunitinib - Dose, Schedule of Administration and Adverse Events

Sunitinib, a multi-targeted receptor tyrosine kinase inhibitor, has demonstrated survival benefit in patients with metastatic renal cell carcinoma (mRCC) and is generally well tolerated with most adverse events, manifesting as mild to moderate in severity. The most frequent related adverse events include hand-foot syndrome (HFS), hypertension, proteinuria, cardiac toxicities, myelosuppression, fatigue/asthenia, hypothyroidism, diarrhea and hepatotoxicity. The study aims to determine incidence of adverse events among patients with metastatic renal cell carcinoma (mRCC) treated Sunitinib within five years from 2010 to 2015 and comparing the results with data from literature. The study included a total of 56 patients treated with Sunitinib, with a dose of 50 mg (Schedule 4/2). Due to adverse events and individual safety and tolerability, at the indication of the personal clinician, 11 patients needed dose reduction, with a continuous dose of 37.5 mg, daily and 28 patients continued the dose of 50 mg taken daily, on a different schedule (2/1 schedule). The most important toxicities were anemia, leukopenia, thrombocytopenia, gastrointestinal effects (diarrhea), fatigue and hypertension. After dose reduction or modified schedule the incidence of the most frequent toxicities (HFS, leukopenia, thrombocytopenia and fatigue) decreased, but hypertension was still observed in 30% of patients. The results are similar with data from literature. Early identification of individuals at risk and monitoring patients during Sunitinib treatment is very important and it can facilitate early intervention with prophylactic measures or supportive treatment, thus increasing quality of life and adherence to treatment. Further studies need to establish which targeted population can benefit the most from adjusted regimens and to correlate them with prognostic factors for survival.

Use of Methadone as First Line Strong Opioid for Moderate-Severe Pain

The present study evaluates the use of methadone in patients with advanced cancer and moderately-severe pain under palliative care at home over a period of 5 years, from 1996 to 2000. We calculated the index for methadone dosage increase (as a percentage and value in milligrams). Of the 1,079 patients cared for, 247 (22.89%) received methadone treatment: 126 from the very beginning, average dose of 15 mg / day (5- 50), and in 121 patients treatment with methadone was initiated at a later moment during the period they were cared for (5- 40). The median period of time of methadone administration was 27 days (1-416), the median dose of methadone at the moment of treatment discontinuation being 20 mg (5-60). The main reason for methadone treatment discontinuation was impossibility of oral administration (49.8% in terminal stages, 7.3% presenting nausea, vomiting), and 62.3% showed no side effects. Dosage increase index was 0.33 mg, 2.33% respectively. Methadone has been used mainly as a potent first line opioid, and has been shown to be effective and safe.

New Aspects Concerning Sulphur Hexafluoride Use As Contrast Agent for Ultrasonographyc Diagnosis

Introduction of contrast agents as microbubbles and to improve ultrasound examination techniques has increased the rate of detection and characterization of liver lesions. Contrast-enhanced ultrasonography (CEUS) is a relatively new method of exploring the liver and diagnosing focal liver lesions (FLL). The aim of this study is to determine the efficiency of microbubbles used for CEUS in managing patients detected in conventional ultrasonography with FLL. We examined 84 patients with FLL, detected on conventional ultrasonography (US), during October 2012-September 2015. We performed contrast-enhanced ultrasonography, using sulphur hexafluoride as a contrast agent, and contrast-enhanced MRI to set the diagnosis. For 37 patients (44.1%) CEUS showed a malignity pattern of enhancement (according to the EFSUMB - European Federation of Societies for Ultrasound in Medicine and Biology- Guidelines 2012), while for 54 (64.3%) patients MRI set the diagnosis of malignity. CEUS detected fewer malignant lesions than MRI, in 20.1% of the cases MRI set de diagnosis. We need further studies in order to improve the quality of CEUS images and technique.

Extra-intestinal malignancies in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (III)

The incidence of lymphoproliferative disorders (LD) is increasing in developed countries. Patients with inflammatory bowel disease (IBD) exposed to thiopurines are at additional risk of three specific forms of LD: Epstein-Barr-Virus-related post-transplant like LD, hepato-splenic T-cell lymphoma and post-mononucleosis lymphoproliferation. The risk of the two latter forms of LD can be reduced when considering specific immunosuppressive strategies in young males. It is still unclear whether the risk of uterine cervix abnormalities is increased in IBD women, irrespective of the use of immunosuppressants. Given the excess risk demonstrated in various other contexts of immunosuppression, it is currently recommended that all women with IBD, particularly those receiving immunosuppressants, strictly adhere to a screening program of cervical surveillance and undergo vaccination against HPV, when appropriate. Patients with IBD receiving immunosuppressants are at increased risk of skin cancers. The risk of non-melanoma skin cancer is notably increased in patients receiving thiopurines. Recent data suggest that the risk of melanoma is mildly increased in patients exposed to anti-TNF therapy. All IBD patients should adhere to a program of sun protection and dermatological surveillance, whose details should take into account the other non-IBD-related risk factors.

Is there a risk for lymphoma or extracolonic cancer in patients with inflammatory bowel disease?

An important issue in the management of inflammatory bowel disease (IBD) is the risk for lymphatic or extracolonic malignancies reported in patients receiving prolonged immunosuppressive therapy and/or therapies with biological agents. Azathioprine (AZA), 6-mercaptopurine (6-MP), methotrexate. and anti-TNF (infliximab, adalimumab) are reference drugs for IBD forms unresponsive to conventional therapies. The administration of these drugs is a high responsibility because IBD itself is associated with an increased risk for cancer, namely colon cancer. The possibility of a drug-induced additional risk remains controversial, the relative risk for lymphoma being estimated at 1.2%. For extracolonic malignancies, there are variations in standardized incidence per reference population in terms of location (skin, liver and biliary tract, uterine cervix, prostate, etc.), and also IBD phenotype (ulcerative colitis or Crohn's disease). The uncertainty regarding the occurrence of neoplasia in IBD patients for many years on immunosuppressive therapy and/or biological agents is a strong argument both for treatment discontinuation and it's monitoring by inclusion in screening programs. In this paper we aimed to approach the conceptual model risk-benefit in the therapy with imunosuppressive and biological agents given the controversies in the literature generated by the drug-induced risk for malignant lymphatic and extracolonic tumor in patients with IBD.

Malignant tumors of digestive organs and liver metastases at the time of diagnosis

AIM

Malignant tumors localized in the digestive tract have a tendency to local growth and invasion with lymph node metastasis. Distant metastases through blood with prevalent liver location are detected late in disease progression, in an advanced stage, when therapeutic possibilities are often limited to palliative therapy.

MATERIAL AND METHODS

The study included a series of 139 patients with liver metastases admitted to the Center of Gastroenterology and Hepatology lasi between January 1 and October 10, 2011 for the identification of primitive tumor. The patients were investigated by endoscopy, imaging, laboratory tests including tumor markers.

RESULTS

At 99 of the patients (71%) we identified primitive digestive tumors, in 19 patients (13.6%) we found tumors with extradigestive location and in 21 patients (15%) the primitive tumor could not be identified. Primitive.tumor was located in various segments of the digestive tract, liver, and pancreas was follows: esophagus 4 - (4%), eso-cardial-tuberositary 2 - (2%), eso-cardial-tuberositary with pancreatic invasion 1 -(1%), stomach 15 - (15%), ileocolon 1 - (1%), colon 19 - (19%), rectum 12 - (12%), liver, multicentric hepatolcellular carcinoma 23 - (23%) billiary tract - cholangiocarcinoma 2 (2%), pancreas 2 - (20%). In a series of 586 patients with malignant tumors of the digestive organs referred to the Iasi Oncology Outpatient Unit between January 1 and September 30, 2011, 132 patients (23%) had liver metastases at the time of diagnosis; the most common locations were the stomach 41% cases (42/119 patients), followed by the pancreas, 35%, and colon 31% patients (28/79 patients and 37/119 patients, respectively). Males were most affected, regardless of primitive tumor.

CONCLUSIONS

Although diagnostic and therapeutic methods have made remarkable progress in recent years, these tumors, by their frequency and advanced stage at diagnosis, remain both an oncologic and public health problem mainly due to the limitations of curative treatment.

Isoflurane suppresses central cardiac parasympathetic activity in rats: a pilot study

BACKGROUND

Intraoperative circulatory stability is a function of both cardiac parasympathetic activity and cardiac and vascular sympathetic activity; however, cardiac parasympathetic activity is rarely considered. This experiment addresses the effect of isoflurane on central cardiac parasympathetic control, i.e., cardiac vagal motoneurons (CVM), which are located in the nucleus ambiguous of the brain stem and project to the sinus node.

METHODS

In urethane-anesthetized rats, the single unit activity of CVM, antidromically identified from the craniovagal cardiac branch, was observed following the introduction of isoflurane. Isoflurane was introduced slowly over 10 minutes to achieve 2% end tidal CO2 (ETCO2)

RESULTS

Following the introduction of isoflurane (2% ETCO2), all CVM were almost entirely silenced (N=6 cells in 6 different rats, 1.9 ±2.4 vs. 0.2 ±0.3 Hz, P<0.05).

CONCLUSION

The data obtained with antidromically identified cardiac vagal motoneurons confirm data obtained previously with whole vagal nerve recordings. The authors speculate on how the blunting of the cardiac parasympathetic activity by isoflurane that was observed in rats may impact intraoperative circulatory stability in humans.

[Correlational aspects of hematogenous osteomyelitis in children and adults]

Osteomyelitis is an inflammation of the bone caused by an infecting organism. The infection may be limited to a single portion of the bone or may involve a number of regions such as the marrow, cortex, periostium and even the surrounding soft tissue.

MATERIAL AND METHOD

This retrospective study included a number of 256 cases made by 152 children (56%) and 115 adults (44%).

RESULTS

Hematogenous osteomyelitis appears at any age, most frequently in growth period, 85% cases until 16 years. This study relieve a high frequency of subacute (40.1%) and acute (31.1%) hematogenous osteomyelitis compare with chronic form (28.8%). Regarding the distribution of cases by sex, there are no differences between man and woman in chronic osteomyelitis, but subacute form is most frequently at men. The analysis of the cases distribution by location and sex relieve that at womans metaphysis and diaphysis are most interested (70.09%) but only 53.7% at men. Regarding the treatment, the distribution of cases relieve that chronic osteomyelitis generally cannot be eradicated without surgical treatment (sequestrectomy and resection followed by reconstruction with material. Those others forms, acute and subacute hematogenous osteomyelitis, were resolved with medical and surgical treatment, equally.

CONCLUSION

Prompt diagnosis and early treatment are required to prevent further destruction and growth disturbance. Generally, a multidisciplinary approach is required, involving an orthopaedic surgeon, an infectious disease specialist and a plastic surgeon in complex cases with soft tissue loss.

Spatial steering of deep brain stimulation volumes using a novel lead design

OBJECTIVE

To investigate steering the volume of activated tissue (VTA) with deep brain stimulation (DBS) using a novel high spatial-resolution lead design.

METHODS

We examined the effect of asymmetric current-injection across the DBS-array on the VTA. These predictions were then evaluated acutely in a non-human primate implanted with the DBS-array, using motor side-effect thresholds as the metric for estimating VTA asymmetries.

RESULTS

Simulations show the DBS-array, with electrodes arranged together in a cylindrical configuration, can generate field distributions equivalent to commercial DBS leads, and these field distributions can be modulated using field-steering methods. Stimulation with implanted DBS-arrays showed directionally-selective muscle activation, presumably through spread of stimulation fields into portions of the corticospinal tract lying in the internal capsule.

CONCLUSIONS

Our computational and experimental studies demonstrate that the DBS-array is capable of spatially selective stimulation. Displacing VTAs away from the lead's axis can be achieved using a single simple and intuitive control parameter.

SIGNIFICANCE

Optimal DBS likely requires non-uniform VTAs that may differentially affect a nucleus or fiber pathway. The DBS-array allows positioning VTAs with sub-millimeter precision, which is especially relevant for those patients with DBS leads placed in sub-optimal locations. This may present clinicians with an additional degree of freedom to optimize the DBS therapy.

[p-ANCA prevalence in ulcerative colitis patients and first-degree relatives]

Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) are more common in patients with ulcerative colitis (UC) than in patients with Crohn's disease (CD), but its prevalence depends on the population being studied and the method employed for its detection.

AIM

To determinate the prevalence of p-ANCA in ulcerative colitis (UC) patients and their first degree in NE Romania area.

MATERIAL AND METHOD

In this study, we investigated the prevalence of p-ANCA as detected by ELISA, in the serum of 44 patients with UC and 22 first degree relatives. We also correlated the presence of this antibody with disease activity and extent, extraintestinal complications and therapy. 26 healthy individuals comprised the control group.

RESULTS

p-ANCA was detected in 11% of the patients with UC. Of the 5 p-ANCA positive UC patients, 1 case were found to have proctosigmoiditis, 1 cases had left-sided colitis and 3 cases had pancolitis. There was no correlation between the presence of this antibody and any of the studied clinical variables (extend disease, complication, family disease, surgery). No person of the first degree and control group presented positive test.

CONCLUSIONS

The prevalence of p-ANCA in NE Romania patients with UC (11%) is lower than that in the Western population. The negativity of p-ANCA in all first degree relatives of NE Romania UC patients should be further elucidated.

[Clinical extraintestinal manifestations in patients with ulcerative colitis]

Ulcerative colitis (UC) is a chronic disease clinically manifest either by bowel symptoms alone or extraintestinal symptoms.

MATERIAL AND METHOD

Our prospective study included 635 patients with ulcerative colitis (334 males and 301 females, mean age 37.54 +/- 13.84, range 20-70 years). The presence of the common extraintestinal symptoms (ES) was analyzed.

RESULTS

Of the 635 investigated patients, these symptoms were found in 83 (13%, 49 males and 34 females, mean age 41.6 +/- 13.95 range 21-70). Patients with ES suffered longer from UC on the average, that is 60.6 years. Most commonly ES involved the joints, 38 (45.8%) patients, hepatobiliary, 28 patients (33.7%), skin, 10 patients (12%) and eyes, 7 patients (8.4%). In 18% of the patients two or more ES were present. ES were clinically detectable after the intestinal symptoms in 81% patients. An increased tendency of ES to occur in patients with a more extensive disease was noticed.

CONCLUSION

The prevalence of ES in the UC patients from NE Romania is in agreement with data from other countries. The number of ES supports the need for complex follow-up in these patients.

Effect of systemic B-type natriuretic peptide on cardiac vagal motoneuron activity

Intravenous B-type natriuretic peptide (BNP) enhances the bradycardia of reflexes from the heart, including the von Bezold-Jarisch reflex, but its site of action is unknown. The peptide is unlikely to penetrate the blood-brain barrier but could act on afferent or efferent reflex pathways. To investigate the latter, two types of experiment were performed on urethane-anesthetized (1.4 g/kg iv) rats. First, the activity was recorded extracellularly from single cardiac vagal motoneurons (CVMs) in the nucleus ambiguus. CVMs were identified by antidromic activation from the cardiac vagal branch and by their barosensitivity. Phenyl biguanide (PBG), injected via the right atrium in bolus doses of 1-5 mug to evoke the von Bezold-Jarisch reflex, caused a dose-related increase in CVM activity and bradycardia. BNP infusion (25 pmol.kg(-1).min(-1) iv) significantly enhanced both the CVM response to PBG (n = 5 rats) and the reflex bradycardia, but the log-linear relation between those two responses over a range of PBG doses was unchanged by BNP. The reflex bradycardia was not enhanced in five matched time-control rats receiving only vehicle infusions. In five other rats the cervical vagi were cut and the peripheral right vagus was stimulated supramaximally at frequencies of 1-20 Hz. The bradycardic responses to these stimuli were unchanged before, during, and after BNP infusion. We conclude that systemic BNP in a moderate dose enhances the von Bezold-Jarisch reflex activation of CVM, in parallel with the enhanced reflex bradycardia. That enhancement is due entirely to an action before the vagal efferent arm of the reflex pathway.

[Role of video-capsule endoscopy in Crohn's disease]

The technical and scientific improvements of the miniature electronic equipment made possible the occurrence of video-capsule endoscopy (VCE), which is a device having an enormous noninvasive investigation potential of the small intestine. One of the most attractive indications of VCE is the suspicion of Crohn's disease that has not been confirmed using standard imaging techniques.

AIM

To assess the value of VCE in the diagnostic work-up of patients in whom there is clinical suspicion of small bowel Crohn's disease that cannot be confirmed using conventional techniques (upper and lower endoscopy, small bowel follow-through).

PATIENTS AND METHODS

A total of 21 patients (10 men, 11 women, mean age 36 +/- 7 years) with clinical and biochemical suspicion of Crohn's disease were included in the study. All the patients were evaluate before by the small bowel follow through, upper gastrointestinal endoscopy and colonoscopy.

RESULTS

In 15 patients (68%), lesions supporting the Crohn's disease diagnosis were detected by VCE. Complete visualization of the small bowel was achieved in all patients except for one where the capsule stopped upstream of a stenosis located at the terminal ileum level. The most frequent lesions included mucous erosions, aphthae, lineal or serpiginous mucous lesions, ulcers and fissures.

CONCLUSIONS

VCE is an effective modality for diagnosis patients with suspected Crohn's disease undetected by conventional diagnostic techniques.

[Clinical and epidemiological aspects in patients with colorectal cancer]

The aim of this study was to evaluate the clinical factors of the patients with CCR histologically confirmed.

PATIENTS AND METHODS

In the study group there were included 117 patients (females: 49-41%, males: 68-59%, range: 39-88 years) with CCR confirmed (rectosigmoidoscopy/colonoscopy + biopsy, X-ray) hospitalized in the Second Medical Clinic Gastroenterology during January 2000-May 2001.

RESULTS

For 56 (47.86%) patients the principal sign was rectal bleeding, intestinal disorders (diarrhoea--constipation) in 24 (20.51%) patients, anemia in 19 (16.23%) patients and abdominal pain in 18 (15.38%) patients. The time interval between the onset and the diagnosis of CCR was 1 month up to 2.5 years. For 83 patients (71%) was possible surgical treatment and for 34 patients (29%) palliative method.

CONCLUSIONS

At diagnosis the clinical data suggested a malignant disease for most of the patients. The delay of diagnosis was associated with advanced staging of the disease, with limiting therapeutic possibilities. Using the screening for CCR may give the possibility for a curative treatment.

[The confirmation of a correlation between atmospheric air pollution with sedimentation dusts and pediatric morbidity]

The obtained results support the data in the literature on the correlation of air pollution with morbidity in general and with the infantile one, particularly by respiratory diseases in urban areas of Iaşi district. The maintenance of the pollutants under the minimum admitted concentration by corresponding measures at the level of pollution source together with increasing the general resistance of the population are necessary.