Ocular Pharmacokinetics

Although the fundamental concepts of pharmacokinetics remain the same, ocular pharmacokinetics has its own challenges due to the uniqueness of barrier properties posed by various ocular tissues and its growing complexity with different routes of ocular administration. A thorough understanding of the barrier nature will aid in tailoring a drug or its carrier's physicochemical properties to its advantage. In order to deliver the right payload of a drug at the target site, various approaches can be taken to leverage the pharmacokinetics that includes molecular design based on desirable physicochemical properties, formulation approaches, and alternative routes of administration. In this chapter, a brief overview of the barrier properties with respect to various routes of administration is presented along with the physicochemical properties that influence the pharmacokinetics of ocular drugs. Recent advances in ocular pharmacokinetics are discussed in addition to new perspectives in interpreting existing data.

Pharmacokinetic aspects of retinal drug delivery

Drug delivery to the posterior eye segment is an important challenge in ophthalmology, because many diseases affect the retina and choroid leading to impaired vision or blindness. Currently, intravitreal injections are the method of choice to administer drugs to the retina, but this approach is applicable only in selected cases (e.g. anti-VEGF antibodies and soluble receptors). There are two basic approaches that can be adopted to improve retinal drug delivery: prolonged and/or retina targeted delivery of intravitreal drugs and use of other routes of drug administration, such as periocular, suprachoroidal, sub-retinal, systemic, or topical. Properties of the administration route, drug and delivery system determine the efficacy and safety of these approaches. Pharmacokinetic and pharmacodynamic factors determine the required dosing rates and doses that are needed for drug action. In addition, tolerability factors limit the use of many materials in ocular drug delivery. This review article provides a critical discussion of retinal drug delivery, particularly from the pharmacokinetic point of view. This article does not include an extensive review of drug delivery technologies, because they have already been reviewed several times recently. Instead, we aim to provide a systematic and quantitative view on the pharmacokinetic factors in drug delivery to the posterior eye segment. This review is based on the literature and unpublished data from the authors' laboratory.

Modern Intermittent Haemodialysis (IHD) is an Effective Method of Removing Salicylate in Chronic Topical Salicylate Toxicity

INTRODUCTION

There are limited data on modern intermittent hemodialysis (IHD) efficacy on salicylate elimination from topical poisoning.

CASE REPORT

A 54-year-old male sought treatment for dyspnea but was then diagnosed with salicylate toxicity from topical application of Dencorub Extra Strength Heat Gel® for 1 week. Each tube contained 100 g with 26 % methylsalicylate (26 g). Laboratory workup was remarkable for an elevated anion gap of 30 and salicylate concentration of 78.7 mg/dL [5.7 mmol/L (N < 0.4 mmol/L)]. Treatment with urinary alkalinization was followed by hemodialysis for 5 h. Extraction ratios were 0.44 with clearance rates of 78.5 mL/min. Salicylate concentrations fell rapidly following initiation of hemodialysis with no rebound observed.

DISCUSSION

Modern high flux IHD is an effective method of removing salicylates in the treatment of chronic topical poisoning.

A randomized, blinded, multicenter trial of a gentamicin vancomycin gel (DFA-02) in patients undergoing abdominal surgery

BACKGROUND

SI is a significant medical problem. DFA-02 is an investigational bioresorbable modified release gel consisting of both gentamicin (16.8 mg/mL) and vancomycin (18.8 mg/mL). A Phase 2a study, where the drug was applied during surgical incision closure, suggested safety and tolerability but was not designed to assess its efficacy.

STUDY DESIGN

In a Phase 2b randomized, blinded trial patients undergoing abdominal, primarily colorectal, surgery were randomized (4:1:1) to one of three study arms: DFA-02, matching placebo gel, or standard of care (SOC) involving irrigation of the wound with normal saline. The DFA-02 and placebo gel groups received up to 20 mL of study drug inserted above the fascia during wound closure, and were treated in a double-blind manner; the SOC group was treated in a single-blind manner. The primary endpoint was SSI (adjudicated centrally by a blinded committee) through postoperative day 30.

RESULTS

Overall, 445 subjects (intention-to-treat) were randomized at 35 centers with 425 subjects completing the study and being evaluable. There were 67 SSIs (15.8%): 64.2% superficial, 7.5% deep, and 28.4% organ space. The incidence of SSI was not statistically significantly different between the DFA-02 and the placebo gel/SOC arms combined, 42/287 = 14.6% vs 25/138 = 18.1% (p = 0.36), respectively. Rehospitalization within 30 days was also similar between study groups (DFA-02 28.6%, placebo gel 21.4%, SOC 27.3%).

CONCLUSION

In this multicenter, blinded, randomized trial with central adjudication, the gentamicin/vancomycin gel was not associated with a significant reduction in SSI.

SUMMARY

Patients undergoing abdominal surgery were randomized to one of three study arms: DFA-02 gel consisting of both gentamicin and vancomycin, matching placebo gel, or standard of care (SOC). Of 425 patients completing the study at 35 sites the gentamicin/vancomycin gel was not associated with a significant reduction in SSI.

Topical versus intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic drug used widely to prevent bleeding in total knee arthroplasty (TKA). However, there is no consensus regarding the administration routes of TXA. This meta-analysis aimed to investigate the efficacy of topical (intra-articular) versus intravenous TXA in reducing blood loss and transfusion rate in patients who underwent TKA.

METHOD

We conducted a Pubmed, EMBASE, Cochrane Library, and Web of Science search for randomized controlled trials (RCTs) comparing topical versus intravenous TXA in TKA. Two authors conducted selection of studies, data extraction, and assessment of risk of bias independently. A pooled meta-analysis was performed using RevMan 5.3 software.

RESULT

Sixteen RCTs with a total of 1330 patients were included. Current meta-analysis indicated that there were no significant differences in total blood loss (MD = -41.64 ml; 95 % CI: -163.43 ml to 80.18 ml; P = 0.50), drain output (MD = 22.44, 95 % CI: -11.18 to 56.06, P = 0.19), transfusion rate (RR = 0.89, 95 % CI: 0.62 to 1.27, P = 0.52), the drop of Hb level at post-operative day 1 (MD = 0.26, 95 % CI -0.03 to 0.55, P = 0.03), day 2 (MD = -0.08, 95 % CI -0.76 to 0.59, P = 0.81), day 3 (MD = -0.20, 95 % CI -0.77 to 0.37, P = 0.49), and length of stay (MD = -0.10; 95 % CI: -0.17 to -0.02; P = 0.02) between the topical group and intravenous group. In addition, no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis (RR = 1.08, 95 % CI: 0.48 to 2.40, P = 0.86), pulmonary embolism (RR = 0.56, 95 % CI: 0.05 to 5.99, P = 0.63), wound complications (RR = 0.56, 95 % CI: 0.05 to 5.99, P = 0.63), and infection (RR = 0.74, 95 % CI: 0.30 to 1.85, P = 0.52) between the two groups.

CONCLUSION

Our meta-analysis of 16 RCTs revealed that both topical TXA and intravenous TXA are effective in reducing blood loss and transfusion rates in patients who underwent TKA.

Nanoparticles and nanofibers for topical drug delivery

This review provides the first comprehensive overview of the use of both nanoparticles and nanofibers for topical drug delivery. Researchers have explored the use of nanotechnology, specifically nanoparticles and nanofibers, as drug delivery systems for topical and transdermal applications. This approach employs increased drug concentration in the carrier, in order to increase drug flux into and through the skin. Both nanoparticles and nanofibers can be used to deliver hydrophobic and hydrophilic drugs and are capable of controlled release for a prolonged period of time. The examples presented provide significant evidence that this area of research has - and will continue to have - a profound impact on both clinical outcomes and the development of new products.

Treatment of plaque psoriasis with an ointment formulation of the Janus kinase inhibitor, tofacitinib: a Phase 2b randomized clinical trial

Background

Most psoriasis patients have mild to moderate disease, commonly treated topically. Current topical agents have limited efficacy and undesirable side effects associated with long-term use. Tofacitinib is a small molecule Janus kinase inhibitor investigated for the topical treatment of psoriasis.

Methods

This was a 12-week, randomized, double-blind, parallel-group, vehicle-controlled Phase 2b study of tofacitinib ointment (2 % and 1 %) applied once (QD) or twice (BID) daily in adults with mild to moderate plaque psoriasis. Primary endpoint: proportion of patients with Calculated Physician’s Global Assessment (PGA-C) clear or almost clear and ≥2 grade improvement from baseline at Weeks 8 and 12. Secondary endpoints: proportion of patients with PGA-C clear or almost clear; proportion achieving Psoriasis Area and Severity Index 75 (PASI75) response; percent change from baseline in PASI and body surface area; change from baseline in Itch Severity Item (ISI). Adverse events (AEs) were monitored and clinical laboratory parameters measured.

Results

Overall, 435 patients were randomized and 430 patients received treatment. The proportion of patients with PGA-C clear or almost clear and ≥2 grade improvement from baseline at Week 8 was 18.6 % for 2 % tofacitinib QD (80 % confidence interval [CI] for difference from vehicle: 3.8, 18.2 %) and 22.5 % for 2 % tofacitinib BID (80 % CI: 3.1, 18.5 %); this was significantly higher vs vehicle for both dosage regimens. No significant difference vs vehicle was seen at Week 12. Significantly more patients achieved PGA-C clear or almost clear with 2 % tofacitinib QD and BID and 1 % tofacitinib QD (not BID) at Week 8, and with 2 % tofacitinib BID at Week 12. Pruritus was significantly reduced vs vehicle with 2 % and 1 % tofacitinib BID (starting Day 2), and 2 % tofacitinib QD (starting Day 3). Overall, 44.2 % of patients experienced AEs, 8.1 % experienced application site AEs, and 2.3 % experienced serious AEs. The highest incidence of AEs (including application site AEs) was in the vehicle QD group.

Conclusions

In adults with mild to moderate plaque psoriasis, 2 % tofacitinib ointment QD and BID showed greater efficacy than vehicle at Week 8, but not Week 12, with an acceptable safety and local tolerability profile.

Trial registration

NCT01831466 registered March 28, 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s12895-016-0051-4) contains supplementary material, which is available to authorized users.

Topical Vasoconstrictors in Cosmetic Rhinoplasty: Comparative Evaluation of Cocaine Versus Epinephrine Solutions

BACKGROUND

The use of topical vasoconstrictors is a common practice in nasal surgery. These agents reduce bleeding and enable a good surgical field. Topical cocaine and epinephrine, which are frequently used in cosmetic rhinoplasty, are considered safe and effective, but secondary effects have been described. The aim of the present study was to evaluate and compare the benefits and risks of epinephrine and cocaine employed as topical vasoconstrictive agents in cosmetic rhinoplasty.

METHODS

This prospective non-randomised study included 65 consecutive female patients undergoing primary closed rhinoplasty. Patients were treated with topical aqueous solutions of 4 % cocaine (n = 33) or 1:1000 epinephrine (n = 32). Benefits and risks of drug use were compared between groups. Vasoconstriction was assessed by quantitative and qualitative evaluation of bleeding during surgery. Systemic effects were studied in terms of cardiovascular changes during the procedure. The Mann-Whitney test and mixed-effects models were used to compare continuous variables and to assess the effects of vasoconstrictor treatment, respectively.

RESULTS

Cocaine exerted a stronger and more predictable vasoconstrictive effect than epinephrine. This difference was linked to better field quality, but did not relate to shorter surgery times. Increased heart rate was detected with both agents and was significantly higher with cocaine (p < 0.05). Blood pressure did not significantly differ between groups.

CONCLUSIONS

Both cocaine and epinephrine, at the concentrations used in this study, are suitable as topical vasoconstrictive agents in aesthetic rhinoplasty.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Relative efficacy of topical non-steroidal anti-inflammatory drugs and topical capsaicin in osteoarthritis: protocol for an individual patient data meta-analysis

BACKGROUND

Pain is the most troubling issue to patients with osteoarthritis (OA), yet current pharmacological treatments offer only small-to-moderate pain reduction. Current guidelines therefore emphasise the need to identify predictors of treatment response. In line with these recommendations, an individual patient data (IPD) meta-analysis will be conducted. The study aims to investigate the relative treatment effects of topical non-steroidal anti-inflammatory drugs (NSAIDs) and topical capsaicin in OA and to identify patient-level predictors of treatment response.

METHODS

IPD will be collected from randomised controlled trials (RCTs) of topical NSAIDs and capsaicin in OA. Multilevel regression modelling will be conducted to determine predictors for the specific and the overall treatment effect.

DISCUSSION

Through the identification of treatment responders, this IPD meta-analysis may improve the current understanding of the pain mechanisms in OA and guide clinical decision-making. Identifying and prescribing the treatment most likely to be beneficial for an individual with OA will improve the efficiency of patient management.

SYSTEMATIC REVIEW REGISTRATION

CRD42016035254.

The efficacy, safety, and tolerability of ivermectin compared with current topical treatments for the inflammatory lesions of rosacea: a network meta-analysis

Background

Rosacea is a common chronic skin condition that manifests as recurrent inflammatory lesions. Long-term treatment is required to control symptoms and disease progression, with topical treatments being the first-line choice. Ivermectin 1 % cream is a new once-daily (QD) topical treatment for the inflammatory lesions of rosacea, and it is important to compare the efficacy, safety, and tolerability of ivermectin with other currently available topical treatments.

Methods

A systematic literature review was performed from January 2011 to June 2015, with articles published prior to 2011 retrieved from a Cochrane review on rosacea. Randomized controlled trials of the topical treatment of adult patients with moderate-to-severe papulopustular rosacea were identified from electronic databases and trial registers, and supplemented with data from clinical study reports. Mixed treatment comparisons (MTCs) were conducted to compare different treatments according to Bayesian methodology.

Results

57 studies were identified, with 19 providing data suitable for MTC. Ivermectin 1 % cream QD led to a significantly greater likelihood of success compared with azelaic acid 15 % gel twice-daily (BID) [relative risk (95 % credible interval): 1.25 (1.14–1.37)], and metronidazole 0.75 % cream BID [1.17 (1.08–1.29)] at 12 weeks. Ivermectin 1 % cream QD also demonstrated a significant reduction in inflammatory lesion count compared with azelaic acid 15 % gel BID [−8.04 (−12.69 to −3.43)] and metronidazole 0.75 % cream BID [−9.92 (−13.58 to −6.35)] at 12 weeks. Ivermectin 1 % cream QD led to a significantly lower risk of developing any AE or TRAE compared with azelaic acid 15 % gel BID [0.83 (0.71–0.97) and 0.47 (0.32–0.67), respectively].

Conclusions

Ivermectin 1 % cream QD appears to be a more effective topical treatment than other current options for the inflammatory lesions of rosacea, with at least an equivalent safety and tolerability profile, and could provide physicians and dermatologists with an alternative first-line treatment option.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-2819-8) contains supplementary material, which is available to authorized users.

Superior Efficacy with Ivermectin 1% Cream Compared to Metronidazole 0.75% Cream Contributes to a Better Quality of Life in Patients with Severe Papulopustular Rosacea: A Subanalysis of the Randomized, Investigator-Blinded ATTRACT Study

Introduction

Ivermectin 1% cream (IVM 1%) is indicated for the treatment of inflammatory lesions of rosacea. The objective of this subanalysis was to compare IVM 1% vs. metronidazole 0.75% cream (MTZ 0.75%) in the treatment of severe inflammatory lesions of rosacea.

Methods

A subanalysis of the investigator-assessed severe subjects from a Phase 3, investigator-blinded, randomized study comparing IVM 1% once daily (QD) with MTZ 0.75% twice daily (BID) over 16 weeks followed by a 36-week extension period was performed. Efficacy assessments were Dermatology Life Quality Index (DLQI) and EuroQol-5 Dimension (EQ-5D) questionnaires, investigator’s global assessment (IGA), subject assessment of rosacea improvement, and inflammatory lesion counts. Adverse events (AEs) were monitored throughout the study.

Results

A total of 161 subjects (16.7% of overall study population; 80 IVM 1% and 81 MTZ 0.75%) had an IGA score of 4 at baseline representing severe papulopustular rosacea. Significantly more IVM 1% subjects had a minimal clinically important difference (MCID, defined as a decrease from baseline of ≥4 points) in DLQI score than MTZ 0.75% subjects at week 16 (65.4% vs. 39.2%; P = 0.001) and week 52 (68.8% vs. 40.4%; P = 0.003). At week 16, the mean EQ-5D score for the IVM 1% subjects was higher (better quality of life) than for MTZ 0.75% subjects (0.941 vs. 0.896). Significantly more IVM 1% subjects were IGA “clear” or “almost clear” at week 16 compared to MTZ 0.75% (82.5% vs. 63.0%; P = 0.005). Incidence of AEs was comparable between groups.

Conclusion

Better efficacy with IVM 1% cream (QD) compared to MTZ 0.75% cream (BID) contributes to an improved quality of life with significantly more patients achieving an MCID in DLQI score at week 16 and higher mean EQ-5D score. IVM 1% cream is thus a better alternative than MTZ 0.75% cream for severe papulopustular rosacea patients.

Trial registration

EUDRACT number: 2011-004791-11.

Funding

Galderma R&D.

canis infestation in dogs

Background

The efficacy of fluralaner, formulated as a chewable tablet (Bravecto™) or topical solution (Bravecto™ Spot-on Solution), was evaluated against naturally acquired Sarcoptes scabiei var. canis infestation in dogs.

Methods

The study was performed in privately-owned dogs naturally infested with S. scabiei var. canis. All dogs living in the same household as the infested dog were enrolled into one of 3 groups (2 fluralaner treated and 1 negative control). All dogs within one household were administered the same treatment, with one dog per household included in further observations and assessments. In total, 29 dogs confirmed positive for sarcoptic mange were included. On Day 0, all dogs in group 1 (n = 9) were treated once orally with fluralaner at a minimum dose of 25 mg/kg body weight; all dogs in group 2 (n = 11) were treated once topically with fluralaner at a dose of 25 mg/kg body weight; and dogs in group 3 (n = 9) were treated once topically with saline solution. Sarcoptes scabiei var. canis mites on each dog were counted before treatment and at 4 weeks after treatment in deep skin scrapings (~4 cm²) from 5 different body areas. Clinical signs of infestation (i.e. erythematous papules; casts, scales and crusts; body areas with hair loss) and pruritus were recorded at the same time points.

Results

Single oral or topical treatment with fluralaner resulted in a 100 % reduction in mite counts post-treatment (group 1: P = 0.0009 and group 2: P = 0.0011). Resolution of clinical signs at four weeks post-treatment was variable, with improvement observed for erythematous papules, casts and crusts, and pruritus. All fluralaner treated dogs showed an improvement in overall hair re-growth compared with pre-treatment observations.

Conclusion

Fluralaner administered either orally or topically to naturally infested dogs eliminates Sarcoptes scabiei var. canis mites and improves clinical signs over a 4-week observation period.

Effect of Topical Anesthesia with Lidocaine-prilocaine (EMLA) Cream and Local Pressure on Pain during Infiltration Injection for Maxillary Canines: A Randomized Double-blind clinical trial

OBJECTIVES

This study compared the effect of local pressure and topical lidocaine-prilocaine (EMLA) cream on pain during infiltration injection for maxillary canine teeth.

MATERIALS AND METHODS

A total of 140 volunteer students participated in this split-mouth design randomized clinical trial. The subjects were randomly divided into four groups (n = 35). Before administration of anesthesia, in each group, one side was randomly selected as the experimental and the opposite side as the control. In group 1, finger pressure was applied on the alveolar mucosa on the experimental side and on the tooth crown on the control side. In group 2, 5% EMLA cream and placebo; in group 3, finger pressure and 5% EMLA cream; and in group 4, 5% EMLA cream and 20% benzocaine gel were applied. In all the groups, a buccal infiltration procedure was carried out. Pain during injection was recorded with visual analog scale (VAS). Wilcoxon and McNemar tests were used for statistical analysis of the results. Statistical significance was set at p < 0.05.

RESULTS

The results showed that EMLA reduced the injection pain significantly more than benzocaine (p = 0.02). Also, injection pain was significantly lower with the use of EMLA in comparison to placebo (p = 0.00). Application of local pressure reduced the injection pain, but the difference from the control side was not significant (p = 0.05). Furthermore, the difference between application of local pressure and EMLA was not statistically significant (p = 0.08).

CONCLUSION

Topical anesthesia of 5% EMLA was more effective than 20% benzocaine in reducing pain severity during infiltration injection. However, it was not significantly different in comparison to the application of local pressure.

Importance of Vehicles in Topical Treatment of Fungal Infections

Topical drug therapies are commonly used to manage dermatologic diseases and their manifestations in the skin, hair, nails, and mucous membranes. Compared with systemic treatment, topical drug delivery provides 2 notable benefits in the management of skin diseases. In addition to delivering the active drug, a well-designed vehicle can have supportive effects on the skin, whereas a poorly designed vehicle can have detrimental effects. In many cases, the same active drug is available in several dosage forms, offering the prescriber the ability to tailor treatment to the patient's unique presentation and needs.

Chemical ultraviolet absorbers topically applied in a skin barrier mimetic formulation remain in the outer stratum corneum of porcine skin

The objective of the present study was to evaluate the fate of three chemical sunscreens, isoamyl p-methoxycinnamate (IPMC), diethylamino hydroxybenzoyl hexyl benzoate (DHHB), and bis-ethylhexylphenol methoxyphenyl triazine (BEMT), topically applied to mammalian skin from a skin barrier mimetic oil-in-water formulation. High Performance Liquid Chromatography (HPLC) methods were developed for the analysis of each molecule and validated. Franz cell permeation studies were conducted following application of finite doses of the formulations to excised porcine skin. A vehicle formulation containing no sunscreens was evaluated as a control. Permeation studies were conducted for 12h after which full mass balance studies were carried out. Analysis of individual UV sunscreens was achieved with HPLC following application of the formulation to the skin with no interference from the vehicle components. No skin permeation of any of the chemical sunscreens was evident after 12h. While sunscreens were detected in up to 12 tape strips taken from the SC, 87% or more of the applied doses recovered in the first 5 tape strips. When corrected for the amount of protein removed per tape strip this corresponded to a penetration depth in porcine stratum corneum of ∼1.7μm. Mass balance studies indicated total recovery values were within accepted guidelines for cosmetic formulations. Overall, only superficial penetration into the SC was observed for each compound. These findings are consistent with the physicochemical properties of the selected UV absorbing molecules and their formulation into an ordered biomimetic barrier formulation thus support their intended use in topical consumer formulations designed to protect from UV exposure. To our knowledge this is the first report of depth profiling of chemical sunscreens in the SC that combines tape stripping and protein determination following in vitro Franz cell studies.

Hemostasis in Laryngeal Surgery

The larynx is a highly vascularized organ supplied by the superior and inferior laryngeal arteries. Both microphonosurgery and external laryngeal surgery require excellent hemostasis. Topical agents including adrenalin and fibrin-based products as well as surgical instrumentation, such as coagulation devices or in some cases embolization, are in the surgeon's armamentarium and facilitate efficient and successful surgery.

The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia

Purpose: To evaluate and compare the safety and efficacy of combined two-site phacoemulsification and trabeculectomy surgery with mitomycin C (MMC) in glaucoma-cataract patients with retrobulbar or topical anesthesia.

Patients and methods: A retrospective, nonrandomized review of consecutive phacotrabeculectomy patients with a minimum follow-up time of 6 months, no previous glaucoma surgeries, and a preoperative visual acuity (VA) greater than light perception. The main outcome measures were preoperative and postoperative VA, intraocular pressure (IOP), use of glaucoma medications, and complications. A complete surgical success required an IOP from 6 to 18 mm Hg, no visually devastating complications, no return to surgery, and no use of glaucoma medications. Qualified success allowed the use of up to two glaucoma medications. Anesthesia groups were compared by student t-tests and log rank comparison of Kaplan-Meier survival rates.

Results: Eighty-seven eyes (83 patients) met inclusion criteria, with a mean follow-up of 19 ± 12 months (6-57 months). The average eye gained 3.1 ± 4.9 lines of VA, lost 4.0 ± 7.1 mm Hg of IOP, and decreased 1.0 ± 1.3 glaucoma medications. Retrobulbar and topical anesthesia groups had statistically equivalent mean changes in VA (p = 0.910), IOP (p = 0.268), and use of glaucoma medications (p = 0.964). Postoperative complication rates were also statistically similar (p = 0.580). Complete success was greater in the retrobulbar group (p = 0.006), however, qualified success was equivalent in both groups (p = 0.769).

Conclusion: Two-site phacotrabeculectomy with MMC in West Indian patients is as safe and effective for glaucoma-cataract patients with topical anesthesia as it is under retrobulbar anesthesia, and without short-term losses in VA and the chance of serious complications from injection.

How to cite this article: Rodriguez R, Alburquerque R, Sauer T, Batlle JF. The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia. J Curr Glaucoma Pract 2016;10(1):7-12.

Antiseptic use in the neonatal intensive care unit - a dilemma in clinical practice: An evidence based review

Infants in the neonatal intensive care unit are highly susceptible to healthcare associated infections (HAI), with a substantial impact on mortality, morbidity and healthcare costs. Effective skin disinfection with topical antiseptic agents is an important intervention in the prevention or reduction of HAI. A wide array of antiseptic preparations in varying concentrations and combinations has been used in neonatal units worldwide. In this article we have reviewed the current evidence of a preferred antiseptic of choice over other agents for topical skin disinfection in neonates. Chlorhexidine (CHG) appears to be a promising antiseptic agent; however there exists a significant concern regarding the safety of all agents used including CHG especially in preterm and very low birth weight infants. There is substantial evidence to support the use of CHG for umbilical cord cleansing and some evidence to support the use of topical emollients in reducing the mortality in infants born in developing countries. Well-designed large multicentre randomized clinical trials are urgently needed to guide us on the most appropriate and safe antiseptic to use in neonates undergoing intensive care, especially preterm infants.

Hemostatic Materials and Devices

Numerous absorbable substances have been introduced to aid hemostasis in sinus and skull base surgery. Within the confines of the sinus and nasal cavities, ideal hemostatic agents must have several qualities. They must provide hemostasis, conform to an irregular wound bed, and enable healing of the traumatized mucosa without additional detriment to the epithelium. Traditional nasal packing has been substituted largely by absorbable materials designed to improve patient comfort and outcomes. Although many promising agents exist, none have become standard therapy.

G-quartet oligonucleotide mediated delivery of proteins into photoreceptors and retinal pigment epithelium via intravitreal injection

There is currently no available method to efficiently deliver proteins across the plasma membrane of photoreceptor or retinal pigment epithelium (RPE) cells in vivo. Thus, current clinical application of recombinant proteins in ophthalmology is limited to the use of proteins that perform their biological function extracellularly. The ability to traverse biological membranes would enable the mobilization of a significantly larger number of proteins with previously well characterized properties. Nucleolin is abundantly present on the surface of rapidly dividing cells including cancer cells. Surprisingly, nucleolin is also present on the surface of photoreceptor cell bodies. Here we investigated whether nucleolin can be utilized as a gateway for the delivery of proteins into retinal cells following intravitreal injection. AS1411 is a G-quartet aptamer capable of targeting nucleolin. Subsequent to intravitreal injection, fluorescently labeled AS1411 localized to various retinal cell types including the photoreceptors and RPE. AS1411 linked to streptavidin (a ∼50 kDa protein) via a biotin bridge enabled the uptake of Streptavidin into photoreceptors and RPE. AS1411-Streptavidin conjugate applied topically to the cornea allowed for uptake of the conjugate into the nucleus and cytoplasm of corneal endothelial cells. Clinical relevance of AS1411 as a delivery vehicle was strongly indicated by demonstration of the presence of cell surface nucleolin on the photoreceptors, inner neurons and ganglion cells of human retina. These data support exploration of AS1411 as a means of delivering therapeutic proteins to diseased retina.

Topical diltiazem for pain after closed hemorrhoidectomy

BACKGROUND

Anal sphincter spasm contributes to the appearance of postoperative pain following hemorrhoidectomy.

AIM

To determine the efficacy of topical diltiazem in the control of post-hemorrhoidectomy pain.

MATERIAL AND METHODS

A randomized, prospective, experimental, double-blind study was conducted on 2 groups of patients in the postoperative period of closed hemorrhoidectomy. Each group consisted of 17 patients. Group A received topical diltiazem in the anal region 3 times a day and group B received a placebo. Ketorolac was administered to both groups as rescue therapy.

RESULTS

In group A, the mean score on the visual analog scale was 2.97±1.18cm at 24h, 1.51±1.18cm at 48h, and 0.84±0.92cm at 72h. In group B, it was 6.82±1.9cm at 24h, 5.3±1.66cm at 48h, and 4.32±2.13cm at 72h (P<.001, 95% CI). The mean number of analgesic doses in group A was 2.41±0.87 at 24h, 1.11±0.85 at 48h, and 0.94±0.96 at 72h. In group B, it was 3.82±0.52 at 24h, 3.64±0.70 at 48h, and 2.88±1.26 at 72h (P<.001, 95% CI).

CONCLUSIONS

In this study, topical administration of diltiazem resulted in a statistically significant reduction of postoperative pain in patients that underwent closed hemorrhoidectomy.

Novel Treatment of Radicular Pain With a Multi-Mechanistic Combination Topical Agent: A Case Series and Literature Review

Introduction

Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence. While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7).

Case Presentation

Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient’s baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases.

Conclusions

This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.

Effect of local anesthesia on facial nerve blood flow and muscle action potential

BACKGROUND & OBJECTIVE

The effect of direct application of local lidocaine with epinephrine on the facial nerve (FN) has not been reported. The aim of this study is to assess the effects of 2% lidocaine with 1:100,000 epinephrine at clinically relevant concentrations in a rat FN model with respect to facial nerve blood flow (FNBF) and subsequent electrophysiological changes.

MATERIALS AND METHODS

To assess the influence of drugs on FNBF and electrically evoked muscle action potential (EMAP), small pieces of gelfoam were soaked in PBS 100μl (n=5, control group), 50μl (n=5, treatment group A) and 100μl (n=5, group B) of 2% lidocaine with 1:100,000 epinephrine, and 50μl (n=5, group C) and 100μl (n=5, group D) of 2% lidocaine. After 5min of stable recordings, we applied a 2% lidocaine with or without 1:100,000 epinephrine impregnated gelfoam over the main trunk of the facial nerve of rats for 30min. After removing the applied gelfoam, FNBF and threshold of EMAP were measured separately in each group.

RESULTS

Compared to the control group, the treatment groups showed a significant reduction in FNBF in a dose-dependent manner. The maximal reductions in FNBF were observed in all treatment groups for a period after 10min of the application. Synergistic reduction in FNBF was greater in groups A and B than in the lidocaine applied groups (C and D). The maximal increase in the EMAP threshold was observed immediately after the respective drug application in all groups. The greatest increase in the EMAP threshold was observed in group B. The increased EMAP threshold returned to the baseline value within 120min in groups A and C.

CONCLUSION

From these results, it can be considered that the topical application of lidocaine with epinephrine caused reduction in FNBF and elevation of EMAP threshold. These acute reductions in FNBF and elevations in the EMAP threshold were restored in a time-dependent manner.

Effect of topical administration of tramadol on corneal wound healing in rats

In this study, we aimed to investigate the effects of topical tramadol administration on corneal wound healing, and examine ophthalmic structures and intraocular pressure 7 days after tramadol administration. The experiments were conducted on eight male Wistar rats (250-300 g). After ophthalmic examination, epithelial cell layers in the central cornea were wounded. Rats received 30 μL of tramadol hydrochloride in one eye (Group Tramadol) and the same volume of vehicle in the other (Group Control) every 12 h for 7 days. Both eyes were stained with fluorescein dye, photographed, and wound area was calculated every 8 h until complete healing was observed. Eye blink frequency and corneal reflex tests were measured before and after drug administrations. After 7 days, slit lamp biomicroscopy, fundoscopy, Goldmann applanation tonometry, and histological evaluation were performed. There was no difference in the corneal wound healing rates between the tramadol and control groups. Reduction in wound area over time was also similar; group-time interaction was insignificant (F = 738.911; p = 0.225). Tramadol application resulted in blinking and blepharospasm for 30 s, but vehicle did not. Corneal reflex was intact and eye blink frequency test results were similar in all measurement times in both groups. Slit lamp biomicroscopy, fundoscopy, and intraocular pressures were within normal range. Corneal cells appeared unaffected by the repeated doses of tramadol for 7 days. Topical tramadol application on the cornea did not cause any side effect, except for initial temporary blinking and blepharospasm. Corneal wound healing was not affected, either.

Topical delivery of aqueous micellar resolvin E1 analog (RX-10045)

PURPOSE

The primary objective of this study were to optimize aqueous micellar solution of isopropyl ester prodrug of resolvin (RX-10045), study in vivo ocular compatibility and tissue distribution following topical administration.

METHODS

An optimized ratio of hydrogenated castor-oil and octoxynol-40 (1.0:0.05 wt%) was prepared to entrap RX-10045 in the hydrophobic core of micelles. RX-10045 aqueous micelles were subjected to characterization. In vitro stability studies were performed at 4 °C, 25 °C and 40 °C. In vivo studies were conducted in New Zealand albino rabbits following topical drop administration.

RESULTS

Aqueous RX-10045 micellar solutions were successfully prepared. Micelles had a mean diameter of ∼12 nm with low negative surface charge. RX-10045 demonstrated high stability in citrate buffer (0.0 1M) at 40 °C. Hackett-McDonald ocular irritation scores were extremely low comparable to negative control. No significant difference in intraocular pressure was noted. Electroretinography studies did not reveal any retinal damage after multiple dosing of RX-10045 micellar solution. Ocular tissue distribution studies demonstrated appreciable drug concentrations in anterior ocular tissues. Moreover, RX-10008 (active metabolite of RX-10045) was detected in retina/choroid upon topical drop instillation.

CONCLUSIONS

A clear, stable, aqueous 0.1% RX-10045 micellar formulation was successfully prepared. Micellar solution was well-tolerated and did not have any measurable tissue damage in rabbit ocular tissues. Micelles appear to follow conjunctival/scleral pathway to reach back-of-the-eye tissue (retina). Topical aqueous formulations may be employed to treat posterior ocular diseases. Such micellar topical formulations may be more patient acceptable over invasive routes of administrations such as intravitreal injection/implants.

Scrolls: novel microparticulate systems for enhanced delivery to/across the skin

We describe the scroll system as a new microparticulate structured delivery system for enhanced delivery to/across the skin. The basic components of the scroll system are non-ionic surface active of the type of alkyl polyglycol ethers and a glycol. The unique structures are preserved with addition of various ingredients such as polymers, vegetable oils, pharmaceuticals, and permeation enhancers but are dismissed when amphiphile is withdrawn. The microparticles have a unique scroll structure with multiple "wrapping." Besides enabling superior permeation of drugs into/across the skin, the drugs delivered by scroll systems were more effective in vitro and in vivo compared to controls. Model drugs presented high entrapment capacity in scroll systems. The systems are stable over time and are safe for skin application. In order to form, they require a small number of ingredients, simple preparation method, and are environment friendly. The scroll systems may be new potential tools in the dermal/transdermal pharmaceutical and cosmetic industry.

Effect of a topical nonsteroidal anti-inflammatory agent (0.1 % pranoprofen) on acute central serous chorioretinopathy

PURPOSE

To investigate the effects of topical pranoprofen 0.1 % on acute central serous chorioretinopathy (CSC).

METHODS

The medical records of 52 cases (52 patients) of CSC were retrospectively reviewed. Twenty-six patients were treated with topical pranoprofen 0.1 % (treatment group) and 26 patients did not receive treatment (control group). Baseline and follow-up values for visual acuity, subfoveal choroidal thickness (SCT), subretinal fluid (SRF) maximum height, and central macular thickness (CMT) were examined and compared between groups.

RESULTS

In the treatment group, mean SCT decreased from 365.5 ± 52.9 μm at baseline to 288.9 ± 36.1 μm at 6 months after initiation of treatment (p = 0.005). Both SRF maximum height and CMT were also decreased from baseline at 1 month (SRF maximum height, baseline: 221.5 ± 108.4, 1 month: 97.7 ± 54.3 μm, p = 0.002; CMT, baseline: 403.9 ± 114.6, 1 month: 270.1 ± 37.9 μm, p = 0.003). In the control group, SCT decreased throughout the follow-up period, but the change was not significant. Subretinal fluid maximum height and CMT were significantly decreased after 3 months in the control group (SRF, baseline: 265.4 ± 112.4 μm, 6 months: 64.8 ± 116.9 μm, p = 0.005; CMT, baseline: 459.1 ± 104.9 μm, 6 months: 304.6 ± 92.8 μm, p < 0.001). Visual acuity was improved from baseline in both groups after 6 months, but the improvement was only significant in the treatment group (p = 0.002). The rate of disease recurrence was lower in the treatment group (23 %) than in the control group (38 %), but this difference between groups was not statistically significant (p = 0.229, chi-square test).

CONCLUSIONS

Topical pranoprofen 0.1 % was effective in treating acute CSC, as demonstrated by an increase in visual acuity and a decrease in SRF, SCT, and CMT after treatment. These results suggest that topical pranoprofen 0.1 % may be useful in treating patients with acute CSC.

The Role of Topical Brimonidine Tartrate Gel as a Novel Therapeutic Option for Persistent Facial Erythema Associated with Rosacea

Rosacea is a chronic inflammatory skin condition that commonly presents with persistent facial erythema with or without the coincident presence of flushing, telangiectasias, inflammatory papules or pustules, phymatous changes, or ocular involvement. Patients often present with a constellation of various signs and symptoms of the disease, and an individualized treatment plan should be tailored to a patient's unique clinical presentation. Previously available medications for rosacea have all targeted the inflammatory erythematous papules and pustules frequently associated with the disease, leaving a therapeutic gap for the common manifestation of persistent facial erythema. Brimonidine tartrate 0.33% gel was approved by the US Food and Drug Administration in August 2013 as the first medication available for the topical treatment of persistent facial erythema associated with rosacea. Brimonidine gel is a highly selective α2-adrenergic receptor agonist with potent vasoconstrictive effects, which leads to significant reduction of persistent facial erythema in the majority of patients when applied once daily. Based on large-scale clinical trials and post-marketing reports, brimonidine gel has maintained a good safety profile with a minority of patients experiencing adverse effects from its use, most of which are cutaneous in nature, mild-to-moderate in degree, occur early after initiation of treatment, often resolve spontaneously with continued use, and generally resolve after discontinuation of use. Among the reported adverse effects, two distinct manifestations of worsened erythema have been described. Brimonidine gel can be integrated into a treatment regimen along with concomitant therapies for facial papules and pustules with no increased risk of adverse events with combination therapy. Education about optimal application methods, setting reasonable expectations for treatment, and minimizing inflammation are important factors for the successful use of brimonidine gel as part of a patient's overall rosacea treatment regimen.

Rapid, sensitive and selective HPLC-MS/MS method for the quantification of topically applied besifloxacin in rabbit plasma and ocular tissues: Application to a pharmacokinetic study

Besifloxacin is a fourth-generation broad-spectrum fluoroquinolone registered for the topical treatment of bacterial conjunctivitis. In this study, a rapid, sensitive and selective liquid chromatography tandem mass spectrometry (LC-MS/MS) method was developed for quantification of besifloxacin in rabbit plasma and ocular tissues using nateglinide as the internal standard (IS). The analyte and IS were separated on a Sepax GP-Phenyl column by isocratic elution with methanol-acetonitrile-5 mM ammonium formate-formic acid (29:55:16:0.1, v/v/v/v) as the mobile phase at a flow rate of 1.2 mL/min, and the total run time was 3.0 min. An electrospray ionization (ESI) source was applied and operated in the positive ion mode; multiple reaction monitoring (MRM) mode was used for quantification, and the monitored transitions were 394.2→377.1 for besifloxacin and m/z 318.3→166.1 for the IS. The calibration curve was linear over the range of 0.103-206 ng/mL for plasma and 2.06-2060 ng/mL for tears, aqueous humor, conjunctiva and cornea with correlation coefficient (r) greater than 0.99. The lower limit of quantification (LLOQ) for besifloxacin was 0.103 ng/mL for plasma and 2.06 ng/mL for other ocular tissues with good accuracy and precision. Intra- and inter-batch precision were both lower than 15% and accuracy ranged from 85% to 115% at all QC levels. The method was successfully applied to the pharmacokinetic study of besifloxacin in rabbit plasma and ocular tissues after single and multiple topical administrations.

Efficacy and Safety of Calcipotriol/Betamethasone Dipropionate Ointment for the Treatment of Trachyonychia: An Open-Label Study

Background

Despite efforts to treat trachyonychia, there is no promising treatment modality.

Objective

This study evaluated the efficacy and safety of calcipotriol plus betamethasone dipropionate ointment on trachyonychia.

Methods

A total of 39 patients with 432 nails affected by trachyonychia were enrolled. All patients applied calcipotriol/betamethasone ointment once daily without occlusion for 6 months. Outcome measures were assessed by physician's global assessment (degree of roughness: 0, clear; 1, mild; 2, moderate; 3, marked; 4, severe) at all time points.

Results

After 6 months of therapy, 98.6% (426/432) of nails showed significant clinical improvement; 4.2% were completely free from nail lesions. The mean physician global assessment score decreased significantly from 3.5 to 1.7 points (p< 0.05). No serious side effects were reported, except mild pruritus and erythema in 2 patients.

Conclusion

This is the first study to prospectively evaluate the efficacy and safety of calcipotriol/betamethasone ointment for the treatment of trachyonychia. The results indicate topical calcipotriol/betamethasone is an effective and safe treatment for symptom improvement of trachyonychia.

Topical therapies for skin cancer and actinic keratosis

The global incidence of skin cancer and actinic keratosis (AK) has increased dramatically in recent years. Although many tumours are treated with surgery or radiotherapy topical therapy has a place in the management of certain superficial skin neoplasms and AK. This review considers skin physiology, non-melanoma skin cancer (NMSC), the relationship between AK and skin cancer and drugs administered topically for these conditions. The dermal preparations for management of NMSC and AK are discussed in detail. Notably few studies have examined drug disposition in cancerous skin or in AK. Finally, recent novel approaches for targeting of drugs to skin neoplasms and AK are discussed.

Topical and transdermal delivery of caffeine

Caffeine is administered topically and transdermally for a variety of pharmaceutical and cosmetic applications and it is also used as a model hydrophilic compound in dermal risk assessment studies. This review considers the physicochemical and permeation properties of caffeine with reference to its delivery to and through the skin. Since it has been used as a model compound the findings have implications for the delivery of many hydrophilic compounds having similar properties. Various passive and active formulation strategies to promote enhanced skin permeation of caffeine are considered. Models to study percutaneous caffeine penetration are also discussed in detail.

Comparing the effect of topical anesthesia and retrobulbar block with intravenous sedation on hemodynamic changes and satisfaction in patients undergoing cataract surgery (phaco method)

BACKGROUND

Cataract is one of the most common surgical procedures in the elderly. In most cases, the elderly have cardiac ischemia or chronic coronary diseases, which would lead to more ischemic events during general anesthesia. Therefore, surgeons and anesthetists prefer regional aesthesia to the general one owing to its more advantages and less complications.

OBJECTIVES

Therefore, this study aimed to compare topical method and retrobulbar block for pain intensity, patient's satisfaction, hemodynamic changes and intra and postoperative complications.

PATIENTS AND METHODS

In a single-blinded clinical trial, 114 patients scheduled for cataract surgery, aged 50 to 90 years with ASA physical status of I-III, were randomly assigned to two groups under monitored anesthesia care as topical anesthesia and retrobulbar block. After the injection of intravenous sedation, which was the combination of midazolam 0.5-1 mg with fentanyl 0.5-1 µ/kg, patients received retro bulbar block or topical anesthesia. During the operation, heart rate, systolic and diastolic blood pressure, mean arterial blood pressure and arterial saturation of O2were measured every five minutes. In addition, pain (VAS) and satisfaction (ISAS) scores were recorded every 15 minutes, then at recovery and one hour after the ending of operation in the ward. Findings were statistically analyzed using SPSS 16.

RESULTS

In this study, no significant association was found between age, gender, education and physical condition of patients in both topical and retro bulbar block groups. Comparison of pain based on VAS, satisfaction based on ISAS score and MAP in the studied periods had no significant differences between the two groups of patients undergoing cataract surgery. However, significant differences were found between the two groups (P = 0.045, 0.02, 0.042 and P < 0.05) regarding heart rate, systolic and diastolic blood pressure and arterial oxygen saturation percentage after 20-30 minutes of the operation.

CONCLUSIONS

Both methods, topical and retro bulbar block had similar impression in cataract surgery regarding analgesia and patient satisfaction. However, in non-complicated cataract surgeries with short duration, topical anesthesia may be the preferable method, because of non-invasiveness, appropriate analgesia, patient satisfaction and hemodynamic stability.

Miconazole buccal gel and risk for systemic bleeding: how certain topical formula can interfere with anticoagulants

The association of miconazole and oral anticoagulants should be carried out with great caution because of potentially serious side effects. This phenomenon is well known in the case of systemic administration of miconazole, but there is limited awareness that also topical oral administration of miconazole can provoke these effects. In this paper we describe four patients followed at the Cardiology Department of the Ghent University Hospital, who used an oral mucosal miconazole preparation, and who developed an increased international normalized ratio.

Topical simvastatin promotes healing of Staphylococcus aureus-contaminated cutaneous wounds

Cutaneous wounds are prompt to be contaminated by bacteria, but the clinical benefits of applying antibiotics and antiseptics in wound management have not been proven. Statins are 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors commonly used to lower cholesterol levels. Studies indicated that statins, especially simvastatin, promote wound healing in experimental models. As Staphylococcus aureus is one of the most important microorganism responsible for wound infections, the aims of this study were to characterise the anti-staphylococcal activity of simvastatin and to evaluate the application of simvastatin as a topical therapy for S. aureus-contaminated wounds. In the present study, simvastatin was bacteriostatic against S. aureus at sub-inhibitory concentrations up to 8 hours after exposure. Further increased concentrations of simvastatin above the minimal inhibitory concentration (MIC) did not enhance the growth inhibitory effect. By contrast, the ability of simvastatin to inhibit S. aureus biofilm formation was concentration dependent. Topical application of simvastatin at its MIC against S. aureus accelerated the healing and bacterial clearance of S. aureus-contaminated wounds in an excisional mice wound model. This effective concentration is well below the safe concentration for topical use. Collectively, topical application of simvastatin has the potential as a novel modality for managing wound infections and promoting wound healing.

Evaluation of topical application and systemic administration of rosuvastatin in preventing epidural fibrosis in rats

BACKGROUND CONTEXT

Epidural fibrosis is a major challenge in spine surgery, with some patients having recurrent symptoms secondary to excessive formation of scar tissue resulting in neurologic compression. One of the most important factors initiating the epidural fibrosis is assumed to be the transforming growth factor-1β (TGF-1β). Rosuvastatin (ROS) has shown to demonstrate preventive effects over fibrosis via inhibiting the TGF-1β.

PURPOSE

We hypothesized that ROS might have preventive effects over epidural fibrosis through the inhibition of TGF-1β pathways.

STUDY DESIGN

Experimental animal study.

METHODS

Forty-eight adult male Wistar Albino rats were equally and randomly divided into four groups (laminectomy, spongostan, topical ROS, and systemic ROS). Laminectomy was performed at the L3 level in all rats. Four weeks later, the extent of epidural fibrosis was assessed both macroscopically and histopathologically.

RESULTS

Our data revealed that topical application and systemic administration of ROS both were effective in reducing epidural fibrosis formation. Furthermore, the systemic administration of ROS yielded better results than topical application.

CONCLUSIONS

Both topical application and systemic administration of ROS show meaningful preventive effects over epidural fibrosis through multiple mechanisms. The results of our study provide the first experimental evidence of the preventive effects of ROS over epidural fibrosis.

Animal models for cutaneous vaccine delivery

Main challenges in skin vaccination are overcoming the stratum corneum (SC) barrier and targeting the antigen presenting cells (APC) in the epidermis and the dermis. For this purpose many delivery techniques are being developed. In vivo immunogenicity and safety studies in animals are mandatory before moving to clinical trials. However, the results obtained in animals may or may not be predictive for humans. Knowledge about differences and similarities in skin architecture and immunology within a species and between species is crucial. In this review, we discuss variables, including skin morphology, skin barrier function, mechanical properties, site of application and immunology, which should be taken into account when designing animal studies for vaccination via the skin in order to support the translation to clinical trial outcomes.

Peptides as skin penetration enhancers: mechanisms of action

Skin penetrating peptides (SPPs) have garnered wide attention in recent years and emerged as a simple and effective noninvasive strategy for macromolecule delivery into the skin. Although SPPs have demonstrated their potential in enhancing skin delivery, they are still evolving as a new class of skin penetration enhancers. Detailed studies elucidating their mechanisms of action are still lacking. Using five SPPs (SPACE peptide, TD-1, polyarginine, a dermis-localizing peptide and a skin penetrating linear peptide) and a model hydrophobic macromolecule (Cyclosporine A, CsA), herein we provide a mechanistic understanding of SPPs. To evaluate the mechanism and safety of SPPs, their effects on skin lipids, proteins and keratinocyte cells were evaluated. Three SPPs (SPACE, Polyarginine and TD-1) significantly enhanced CsA penetration into the skin. SPPs did not alter the skin lipid barrier as measured by skin resistance, transepidermal water loss (TEWL) and Fourier transform infrared (FTIR) spectroscopic analysis. In contrast, SPPs interacted with skin proteins and induced changes in skin protein secondary structures (α-helices, β-sheet, random coils and turns), as evaluated by FTIR analysis and confirmed by in-silico docking. SPPs enhanced CsA skin penetration, via a transcellular pathway, enhancing its partitioning into keratin-rich corneocytes through concurrent binding of SPP with keratin and CsA. Interaction between SPP and keratin best correlated with measured CsA skin transport. Many SPPs appeared to be safe as shown by negligible effect on skin integrity, nominal skin irritation potential and cytotoxicity. Among the peptides tested, SPACE peptide was found to be least toxic to keratinocytes, and among the most effective at delivering CsA into the skin.

Topical use of antithrombotics: review of literature

While antithrombotics are usually administered intravenously, subcutaneously or orally, there are a number of publications reporting topical application of anticoagulation therapy. This paper aims to review the available literature regarding clinical conditions, the details of the topical antithrombotic treatment, as well as positive or adverse effects in an attempt to ascertain the safety and efficacy of this form of treatment. Published literature was searched to identify publications reporting the use of antithrombotic treatments administered via topical application between 1st January 1990 and 1st January 2013. There were 43 studies reported in 10 different clinical conditions. Majority of the studies were randomized controlled trials (51.2%), prospective studies (18.6%) or case reports (11.6%). The clinical conditions in which topical antithrombotics were administered included: microangiopathy, acute haemorrhoids, periodontitis, dermatitis, burns, ocular conditions and surgery, blunt force impact, scars, as well as clinical conditions associated with superficial venous thrombosis (SVT). The most commonly used topical antithrombotic was heparin (79.1% of studies). The respective dosage of different antithrombotics varied depending on specific clinical conditions. While most studies reported mean improvements or resolution of symptoms/condition in patients, the patient outcomes were variable. This review demonstrates that topical antithrombotic treatment is used according to a wide variety of protocols, with a subsequent variability in patient outcomes. Specific guidelines for the use of topical antithrombotics should be developed to standardize this form of treatment and ensure the best possible outcomes for patients.

Efficacy and Tolerability of Steroid-Free, Over-the-Counter Treatment Formulations in Infants and Children With Atopic Dermatitis

Background

Two steroid-free, over-the-counter skin protectant products have been developed for the care and treatment of atopic dermatitis (AD)—Eucerin Eczema Relief Body Crème (Body Cream) for daily skin moisturization and Eucerin Eczema Relief Instant Therapy cream (Instant Therapy) for treatment of AD flare-ups. We tested the efficacy and tolerability of these formulations in infants and children with AD.

Methods

Study 1: Body Cream was applied twice daily to the lower legs of 64 children with a history of AD (aged 3 months to 12 years) for 14 days. Study 2: Instant Therapy was applied to active lesions and surrounding skin of 29 children (aged 3 months to 12 years) with active atopic lesions. Assessments were performed at baseline and Days 7 and 14. Symptoms were assessed using the Atopic Dermatitis Severity Index in Study 2.

Results

Body Cream significantly improved skin hydration and reduced itching, burning/stinging, erythema, and tactile roughness. Instant Therapy significantly improved skin hydration and AD symptoms, notably pruritus, erythema, and lichenification. Both products were safe and well tolerated.

Discussion

Body Cream and Instant Therapy were effective and well tolerated in the treatment of AD in children. These products provide steroid-free, nonprescription therapy for the maintenance and treatment of acute eczema and were proven effective and safe in infants as young as 3 months.

Comparison of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled and prospective cohort trials

BACKGROUND

There has been much debate and controversy about the optimal regimen of tranexamic acid in primary total knee arthroplasty. The purpose of this study was to undertake a meta-analysis to compare the efficacy of topical and intravenous regimen of tranexamic acid in primary total knee arthroplasty.

METHODS

A systematic review of the electronic databases PubMed, CENTRAL, Web of Science, and Embase was undertaken. All randomized controlled trials and prospective cohort studies evaluating the effectiveness of topical and intravenous tranexamic acid during primary total knee arthroplasty were included. The focus of the analysis was on the outcomes of blood loss, transfusion rate, and thromboembolic complications. Subgroup analysis was performed when possible.

RESULTS

Of 328 papers identified, six trials were eligible for data extraction and meta-analysis comprising 679 patients (739 knees). We found no statistically significant difference between topical and intravenous administration of tranexamic acid in terms of blood loss, transfusion requirements and thromboembolic complications.

CONCLUSIONS

Topical tranexamic acid has a similar efficacy to intravenous tranexamic acid in reducing both blood loss and transfusion rate without sacrificing safety in primary total knee arthroplasty.

LEVEL OF EVIDENCE

II.

A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

Topical NSAID formulations

OBJECTIVE

This article reviews topical nonsteroidal anti-inflammatory drug (NSAID) formulations available in the United States, including advantages and disadvantages, therapeutic usefulness, adverse effects, and formulation considerations.

RESULTS

In the United States, several topical NSAID products are approved to treat painful conditions including diclofenac sodium 1% gel (Voltaren Gel®; Endo Pharmaceuticals), diclofenac sodium topical solution 1.5% w/w in 45.5% dimethyl sulfoxide (PENNSAID®; Mallinckrodt, Inc.), and diclofenac epolamine 1.3% (Flector Patch®; Alpharma Pharmaceuticals LLC, a subsidiary of Pfizer, Inc.). Recent studies suggest topical diclofenac preparations are effective for osteoarthritis pain and suggest the efficacy of topical formulations is similar to that achieved with oral NSAID formulations. All NSAID formulations contain the same boxed warnings regarding cardiovascular and renal toxicity; however, topical NSAIDs are proposed to have a more favorable safety profile than oral NSAIDs due to the low serum concentrations achieved with topical NSAID formulations.

CONCLUSIONS

Topical NSAIDs have been shown to be beneficial from both a therapeutics and adverse effect perspective, and are increasingly recommended in treatment guidelines.

Choice of wound care in diabetic foot ulcer: A practical approach

Diabetic foot ulcers are the consequence of multiple factors including peripheral neuropathy, decreased blood supply, high plantar pressures, etc., and pose a significant risk for morbidity, limb loss and mortality. The critical aspects of the wound healing mechanism and host physiological status in patients with diabetes necessitate the selection of an appropriate treatment strategy based on the complexity and type of wound. In addition to systemic antibiotics and surgical intervention, wound care is considered to be an important component of diabetic foot ulcer management. This article will focus on the use of different wound care materials in diabetic foot. From a clinical perspective, it is important to decide on the wound care material depending on the type and grade of the ulcer. This article will also provide clinicians with a simple approach to the choice of wound care materials in diabetic foot ulcer.

[Topical anesthesia in flexible nasofibrolaryngoscopy]

INTRODUCTION

The emergence of flexible nasofibrolaryngoscopy in recent decades has facilitated the development of Otolaryngology and the nasofibrolaryngoscope has become an essential diagnostic tool for the otolaryngologist. However, its use is not without discomfort for the patient, which is why various options for topical anaesthesia have been proposed during the development of the technique.

MATERIAL AND METHODS

This was a prospective, double blind, crossover study in patients with no history of nasal disease, through which we compared the use of topical anaesthetic (Lidocaine) + epinephrine, oxymetazoline and placebo. Using a visual analogue scale, the degree of discomfort was assessed during each scan.

RESULTS

We evaluated 18 patients, 10 women (55.6%) and 8 men (44.4%), with a mean age of 28±4 years. The degree of disturbance generated by the scan with the application of lidocaine-epinephrine was 1.94; with oxymetazoline it was 3.78, and with placebo, 4.61. When the lidocaine-epinephrine solution was compared with oxymetazoline, there was a statistical significance in favour of lidocaine-epinephrine (P<0.05). When we compared the use of lidocaine-epinephrine with the placebo, the result was also statistically significant in favour of lidocaine-epinephrine (P<0.05).

CONCLUSIONS

In this study we demonstrated that using lidocaine associated with epinephrine as a topical anaesthetic prior to flexible nasofibrolaryngoscopy decreases pain and feeling of discomfort for the patient. Consequently, we can recommend the use of topical nasal anaesthesia when performing this exploration.

Pharmacokinetics and metabolism of eprinomectin in cats when administered in a novel topical combination of fipronil, (S)-methoprene, eprinomectin and praziquantel

Four studies were conducted to determine the pharmacokinetic characteristics and in vitro metabolism of eprinomectin, a semi-synthetic avermectin, in cats. Pharmacokinetic parameters including bioavailability of eprinomectin were determined in a parallel study design comprised of one group of eight cats which were treated once topically at 0.12 mL/kg bodyweight with BROADLINE(®), a novel combination product (fipronil 8.3% (w/v), (S)-methoprene 10% (w/v), eprinomectin 0.4% (w/v) and praziquantel 8.3% (w/v)), delivering a dose of 0.5mg eprinomectin per kg body weight, and a group of six cats which received 0.4% (w/v) eprinomectin at 0.4 mg/kg bodyweight once by intravenous injection. For cats treated by topical application, the average eprinomectin (B1a component) maximum plasma concentration (Cmax) was 20 ng/mL. The maximum concentrations were reached 24h after dosing in the majority of the animals (six of eight cats). The average terminal half-life was 114 h due to slow absorption ('flip-flop' kinetics). Following intravenous administration the average Cmax was 503 ng/mL at 5 min post-dose, and the mean elimination half-life was 23 h. Eprinomectin was widely distributed with a mean volume of distribution of 2,390 mL/kg, and the clearance rate was 81 mL/h/kg. Mean areas under the plasma concentration versus time curves extrapolated to infinity were 2,100 ngh/mL and 5,160 ngh/mL for the topical and intravenous doses, respectively. Topical eprinomectin was absorbed with an average absolute bioavailability of 31%. In a second parallel design study, the dose proportionality of eprinomectin after single topical administration of BROADLINE(®) was studied. Four groups of eight cats each were treated once topically with 0.5, 1, 2 or 5 times the minimum recommended dose of the combination, 0.12 mL/kg bodyweight. Based on comparison of areas under the plasma concentration versus time curves from the time of dosing to the last time point at which eprinomectin B1a was quantified, and Cmax, dose proportionality was established. In addition, the metabolic pathway of eprinomectin using cat liver microsomes, and plasma protein binding using cat, rat, and dog plasma were studied in vitro. Results of the analyses of eprinomectin B1a described here showed that it is metabolically stable and highly protein bound (>99%), and thus likely to be, as with other species, excreted mainly as unchanged parent drug in the feces of cats.

Efficacy of a novel topical combination of fipronil, (S)-methoprene, eprinomectin, and praziquantel, against the ticks, Ixodes ricinus and Ixodes scapularis, on cats

Five controlled, blinded and randomized studies were conducted to examine the efficacy of a single topical application of a combination of fipronil, (S)-methoprene, eprinomectin, and praziquantel (BROADLINE(®), Merial) against induced infestations with Ixodes ticks on cats. Three studies investigated the efficacy against Ixodes ricinus and two against Ixodes scapularis. In each study, purpose-bred cats were assigned at random to an untreated group or to a treated group. For the studies using I. ricinus, cats were infested with 50 female ticks and a similar number of males 2 days before treatment application, and weekly afterwards on between four and six occasions. For the studies using I. scapularis, cats were infested with a total of 50 ticks (approximately 25 females and 25 males) according to the same schedule as for I. ricinus. Tick counts for the evaluation of efficacy were performed 48 h after treatment and 48 h after the subsequent weekly infestations. Weekly attachment rates to untreated cats of at least 29% for I. ricinus and at least 30% for I. scapularis demonstrated consistently that the ticks were vigorous and that the attachment rates were adequate for efficacy evaluation. In the I. ricinus studies, an efficacy of at least 93% was demonstrated for up to 37 days after the treatment. In the I. scapularis studies, the efficacy level was at least 95% 30 days after the treatment. The product was well tolerated and caused no adverse reaction.

Efficacy of a novel topical combination of fipronil, (S)-methoprene, eprinomectin and praziquantel against adult and larval stages of Toxocara cati in cats

The efficacy of a novel topical combination of fipronil 8.3% (w/v), (S)-methoprene 10% (w/v), eprinomectin 0.4% (w/v), and praziquantel 8.3% (w/v) (BROADLINE(®), Merial) was evaluated against adult and larval Toxocara cati in four controlled studies. All studies included experimentally infected, purpose-bred, short-haired cats. In two studies, 22 or 20 cats harbouring patent infections as confirmed by pre-treatment faecal examination, were included. Within each study, cats were allocated to one of two groups: control or treated. In a further two studies, 30 cats were included in each; cats were allocated to one of three groups: control, treated when T. cati were expected to be either migrating third and/or fourth-stage larvae, or treated when T. cati were expected to be fourth-stage larvae. Cats allocated to the treated groups received a single topical application of the combination product at 0.12 mL/kg bodyweight (10mg fipronil+12 mg (S)-methoprene+0.5mg eprinomectin+10mg praziquantel per kg). For parasite recovery and count, cats were euthanized humanely at different intervals after treatment. In the studies targeting adult T. cati, ascarids were recovered from all controls (range 1-150) while only two worms were isolated from one treated cat. Thus, the efficacy of the novel combination was 99.4% and 100% against adult T. cati. For studies targeting larval T. cati, up to 21 worms were recovered from each of seven or eight of the control cats per study. No T. cati were recovered from the treated cats in two studies, corresponding to 100% efficacy against both, migrating third and/or fourth-stage larvae and luminal fourth-stage larvae. All cats accepted the treatment well and no adverse experiences or other health problems were observed throughout the studies.

Efficacy of a novel topical combination of fipronil, (S)-methoprene, eprinomectin and praziquantel against larval and adult stages of the cat lungworm, Aelurostrongylus abstrusus

The efficacy of a novel topical combination of fipronil 8.3% w/v, (S)-methoprene 10% w/v, eprinomectin 0.4% w/v, and praziquantel 8.3% w/v (BROADLINE(®),(1) Merial) against larval and adult Aelurostrongylus abstrusus lungworms in cats was assessed in a controlled laboratory study. The study included 48 purpose-bred, short-haired cats which were each inoculated with 225 infective A. abstrusus larvae. The cats were formed into eight blocks based on pre-treatment bodyweight and were then, within each block, randomly allocated to one of six treatment groups: untreated control; treated once when A. abstrusus were expected to be third-stage larvae (4 days post inoculation [dpi]), fourth-stage larvae (7 dpi), immature adults (14 dpi) or adult nematodes (32 dpi), or treated twice, once when A. abstrusus were expected to be third-stage larval and once again when A. abstrusus were expected to be adult nematodes (4 dpi+32 dpi). Cats weighing ≥ 0.8-2.5 kg received one 0.3 mL applicator and cats weighing >2.5-7.5 kg received one 0.9 mL applicator. For determination of the efficacy of treatments, lungworm larval counts were established on faecal samples collected from all cats 32, 39, 46, 53 and 60 dpi. At each occasion from 46 dpi on, cats treated with fipronil, (S)-methoprene, eprinomectin and praziquantel had significantly lower A. abstrusus larval counts than the untreated controls with percentage reductions of 91.6% (cats treated 14dpi; P=0.012), ≥ 98.9% (cats treated either 4 dpi, 7 dpi or 32 dpi; P<0.001) or >99.9% (cats treated 4 dpi+32 dpi; P<0.001) at 60 dpi. Thus, the novel topical combination of fipronil, (S)-methoprene, eprinomectin and praziquantel was highly effective in the prevention and treatment of A. abstrusus lungworm infection in cats.

Efficacy of a novel topical combination of fipronil, (S)-methoprene, eprinomectin and praziquantel against adult and immature stages of the cat flea (Ctenocephalides felis) on cats

The efficacy of a novel topical combination of fipronil 8.3% (w/v), (S)-methoprene 10% (w/v), eprinomectin 0.4% (w/v) and praziquantel 8.3% (w/v) (BROADLINE(®)) was tested against adult and immature stages of Ctenocephalides felis fleas in six studies. For that purpose, fleas from different colonies from North America, Germany and South Africa were used to induce infestations in cats under laboratory conditions. In each study, between 12 and 16 cats were allocated randomly to 2 groups. Cats in Group 1 were not treated and served as controls. Cats in Group 2 were treated once on Day 0 with BROADLINE(®) at the minimum recommended dosage of 0.12 mg/kg body weight. In 4 studies, all animals were infested experimentally with unfed C. felis (100 ± 5) on Days 2 (or 1), 7, 14, 21, 28 and 35. Live fleas were counted 24h post-treatment or infestation. In 2 additional studies, animals were infested at the same frequency with gravid C. felis fleas (100 ± 5) that were fed previously on an untreated host. Forty-eight hours post-infestation, flea eggs were collected, counted and incubated for the evaluation of the reduction of emergence of adults. The combined curative efficacy against adult fleas at 24h after treatment was 94.3% and the combined preventive efficacy values remained greater than 95.9% at 24h after 5 subsequent weekly infestations. In addition, the product reduced dramatically the emergence of new adult fleas for at least 5 weeks (>98.1% for one month and 93.2% at 5 weeks after infestation), demonstrating its efficiency in preventing environmental contamination by immature stages.