A novel 2-step process for the management of inpatient beta-lactam allergy labels

BACKGROUND

Inpatient beta-lactam allergy labels may increase the unnecessary use of aztreonam and non-beta-lactam antibiotics, which can then lead to more adverse events and increased health care costs, OBJECTIVE: To assess the impact of a novel 2-step process (medication history review followed by risk stratification) on rates of beta-lactam delabeling, aztreonam use, and desensitizations on pediatric, adult, and obstetrics inpatients at a tertiary academic center.

METHODS

We prospectively collected data on 700 patients who received inpatient consultation from the Beta-Lactam Allergy Evaluation Service between August 2021 and July 2022. Patients were delabeled either by medication review alone, drug challenge alone if with a low-risk history, or penicillin skin test followed by drug challenge if with a high-risk history. Generalized linear regression modeling was used to compare aztreonam days of therapy in the intervention year with the 2 prior years. Drug desensitizations were assessed by electronic chart review.

RESULTS

Most of the patients (n = 656 of 700, 94%) had more than or equal to 1 beta-lactam allergy label removed, clarified, or both; 77.9% of these patients (n = 511 of 656) had 587 beta-lactam allergy labels removed. Nearly one-third (n = 149, 27.6%) had 162 allergy labels removed solely by medication history review. All 114 penicillin skin tests performed had negative results, and 98% (8 of 381) of the patients who underwent any drug challenge passed. Only 5.7% of the delabeled patients were relabeled. There was a 27% reduction in aztreonam use (P = .007). Beta-lactam desensitizations were reduced by 80%.

CONCLUSION

A full-time inpatient beta-lactam allergy service using medication history review and risk stratification can safely and effectively remove inpatient beta-lactam allergy labels, reduce aztreonam use, and decrease beta-lactam desensitizations.

Repositioning Glibenclamide in cardiac fibrosis by targeting TGF-β1-pSmad2/3-NLRP3 cascade

The proposed objective of this study is to attenuate cardiac fibrosis by inhibiting NLRP3 inflammasome and related genes in uninephrectomized-DOCA fed rat model. Cardiac fibrosis was induced in male Sprague Dawley rats by uninephrectomy and by subsequent administration of deoxycorticosterone acetate (DOCA) every 4th day till 28 days along with 1% NaCl in drinking water. Further, the animals in treatment groups were treated with Glibenclamide (10, 20 and 40 mg/kg) for 28 days which was selected based on docking study. Interim analysis was carried out on the 14th day to assess the hemodynamic parameters. On the 28th day, anthropometric, hemodynamic, biochemical and oxidative stress parameters, gene expression (TGF-β1, pSmad 2/3, NLRP3, IL-1β and MMP-9), ex vivo Langendorff studies and Masson's trichrome staining of heart was carried out. Results were interpreted using ANOVA followed by post hoc Bonferroni test. Glibenclamide treatment significantly reduced the increase in blood pressure. Furthermore, the ECG patterns of the treatment groups displayed a lower frequency of the slow repolarizing events seen in the model animals. Moreover, Glibenclamide treatment demonstrated normal LV function as evidenced by a significant decrease in LVEDP. Besides, this intervention improved the anthropometric parameters and less collagen deposition in Masson's trichrome staining. The cascade of TGF-β1-pSmad2/3-NLRP3 was downregulated along with suppression of IL-1β. Our study repositioned anti-diabetic drug Glibenclamide to treat cardiac fibrosis by inhibiting the TGF-β1-pSmad2/3-NLRP3 cascade.

Fabrication and In Vitro Evaluation of Febuxostat Tablet for Obtaining Biphasic Drug Release Profile

Aim and Objective The primary aim of the present investigation was to adopt the concept of quality by design (QbD) for developing Febuxostat matrix tablets containing a novel combination of polyethylene oxide (PEO), pre-gelatinized starch (PGS) and lactose for obtaining biphasic drug release. Experimental work Febuxostat-containing matrix tablets were prepared by direct compression using 32 full factorial designs. The tablets were prepared with varying amounts of PEO WSR 301 to PGS and lactose to obtain the desired release pattern. The chosen responses were cumulative % drug released at 1, 6 and 12 hours. The evaluation of tablets was done for pre and post-compressional parameters. Compared with the marketed tablet, the optimized formulations were selected based on in vitro drug release. Dose dumping was checked in the dissolution medium containing up to 40% alcohol. Result and discussion The results of the dissolution study indicated that the batch containing a 1:1 ratio of PEO WSR 301 and PGS (15 mg each) and 20 mg of Lactose showed fast initial drug release to imitate the pharmacological action followed by sustained drug release effect. The use of Lactose facilitated immediate drug release, while PEO WSR 301 and PGS exhibited the opposite effect on cumulative drug release. The results of the 32 Factorial design revealed that the concentration of Lactose is a critical parameter. Dose dumping was not observed in the alcoholic dissolution medium. Kinetic equations were fitted to the dissolution data after 1 hour of the dissolution study. Conclusion The type (soluble or swellable) and the concentration of excipients (low or high) dictate the tablets' drug release. The study's outcome revealed that the most critical material attribute is the amount of lactose. The novel combination of PEO, PGS and lactose can bypass existing patents and give more industrial applicability.

Reducing overuse of antibiotics at discharge home: A single-center mixed methods pilot study

Background:

Antibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge.

Methods:

From May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (eg, duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre versus postintervention antibiotic use at discharge in intervention versus control groups was assessed using logistic regression models controlling for patient characteristics.

Results:

Pharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per time-out) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention.

Conclusions:

A pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Identification of Critical Factors Influencing the In-Vitro Dissolution o f Bicalutamide Tablets Prepared Using Madg Technique

This study was aimed to utilize the Moisture Activated Dry Granulation (MADG) technique to formulate Bicalutamide tablet and identify critical factors influencing its dissolution. The Bicalutamide inclusion complex was formed using the kneading method. Aeroperl 300 was selected as an adsorbent, polyvinylpyrrolidone (PVP) K30 as a binder, Microcrystalline Cellulose (MCC) and Lactose Monohydrate (LMH) in1:1 ratio as fillers. Croscarmellose sodium (CCS) and neusilin were used as disintegrating agents, as they did not affect the disintegration time when hardness and compression force increased. Box Behnken experimental design was used to optimize formulations and was evaluated for pre and post-compression parameters. The optimized formulation was compared with the marketed and wet granulation formulation. In addition, the short term stability testing of the optimized batch was performed. The optimized inclusioncomplex of hydroxypropyl beta-cyclodextrin (HP-ß-CD) was selected based on a phase solubility study in 1:1 ratio with drug toimprove solubility. The optimized batch was prepared by MADG at granulator speed of 540rpm, using 4.30 % PVPK30, and 1.5 % Aeroperl 300. It showed a disintegration time of 208.33 sec.Percentage drug release was 95.02 % in 30 mins, and hardness 5.4 kg/cm2. The stability study results confirmed the stability of the tablets. The Bicalutamide tablet was successfully formulated using the MADG technique. The parameters affecting the in-vitro dissolution were identified and optimized, leading to better bioavailability. Keywords: Bicalutamide, Moisture Activated Dry Granulation technology (MADG), hydroxypropyl beta-cyclodextrin (HP-β-CD), Box Behnken design (BBD), Croscarmellose sodium

Systematic Formulation Approach for Development and Evaluation of Cefixime G ranules for Pediatric Application

The present study was aimed to apply quality by design to develop stable and flexible pediatric granules of BCS class II drug Cefiximeto improve dissolution profile using Soluplus®. Thegranules were prepared by employing the wet granulation technique. The concentration of Soluplus®(X1), Croscarmellose sodium(X2), Sodium bicarbonate(X3) were identified as critical material attributes(CMA). The critical quality attribute (CQA) are percentage drug release in 20 minutes (Y1) and dispersion time (Y2). All 17 batches were evaluated for micromeritics properties, drug content, particle size distribution, dispersion time, granules' strength/friability, In vitro drug release, comparison with marketed product and stability study. All 17 batches from the Box Behnken showed all the test results values within limits, indicating that the prepared granules were of standard quality. The optimized batch of granules showed 94.45±0.26% drug release in 20min, while the dispersion time was 90.85±0.04 sec and the similarity factor (f2) was 56.39 to marketed product (ZIPRAX). In addition, the optimized batch exhibited no significant change in drug content, dispersion time, in vitro drug release after storage at 40°C ±2°C and 75% RH ± 5% RH for one month. The formulated granules showed better drug release and dispersion time. The granules can be reconstituted with water to prepare dispersion of the drug just before use to improve compliance of paediatric patients. Keywords: Cefixime, granules, Quality by design, Box Behnken design, Soluplus®, Design space

Overdiagnosis of urinary tract infection linked to overdiagnosis of pneumonia: a multihospital cohort study

Urinary tract infection (UTI) and community-acquired pneumonia (CAP) are the most common infections treated in hospitals. UTI and CAP are also commonly overdiagnosed, resulting in unnecessary antibiotic use and diagnostic delays. While much is known individually about overdiagnosis of UTI and CAP, it is not known whether hospitals with higher overdiagnosis of one also have higher overdiagnosis of the other. Correlation of overdiagnosis of these two conditions may indicate underlying hospital-level contributors, which in turn may represent targets for intervention. To evaluate the association of overdiagnosis of UTI and CAP, we first determined the proportion of hospitalised patients treated for CAP or UTI at 46 hospitals in Michigan who were overdiagnosed according to national guideline definitions. Then, we used Pearson's correlation coefficient to compare hospital proportions of overdiagnosis of CAP and UTI. Finally, we assessed for 'diagnostic momentum' (ie, accepting a previous diagnosis without sufficient scepticism) by determining how often overdiagnosed patients remained on antibiotics on day 3 of hospitalisation. We included 14 085 patients treated for CAP (11.4% were overdiagnosed) and 10 398 patients treated for UTI (27.8% were overdiagnosed) across 46 hospitals. Within hospitals, the proportion of patients overdiagnosed with UTI was moderately correlated with the proportion of patients overdiagnosed with CAP (r=0.53, p<0.001). Over 80% (81.8% (n=952/1164) of UTI; 89.9% (n=796/885) of CAP) of overdiagnosed patients started on antibiotics by an emergency medicine clinician remained on antibiotics on day 3 of hospitalisation. In conclusion, we found overdiagnosis of UTI and CAP to be correlated at the hospital level. Reducing overdiagnosis of these two common infections may benefit from systematic interventions.

Optimization and validation of polyherbal formulation by applying Box-Behnken design for the treatment of Inflammatory bowel disease in experimental animals

Background:

The use of herbal medicine in inflammatory bowel disease (IBD) had been increased significantly. Allopathic treatment of IBD leads too many side effects therefore use of the herbal formulation is promising. Aegle Marmelos, Bombax malabericum, and Hollarrhena antidysentrica plants have been used to treat IBD.

Objective:

To evaluate a designed polyherbal formulation in experimentally induced inflammatory bowel disease in rats and To validate mathematical model derived by Box-Behnken experimental design for optimized polyherbal formulation for the treatment of IBD in experimental rats by checkpoint analysis.

Method:

Three-level Box-Behnken design was selected to optimize the dose. Polyherbal formulation consist of plant extract of Aegle Marmelos (X1), Bombax malabericum (X2), and Hollarrhena antidysentrica (X3) in different ratios were selected as independent variable. Polynomial equations were established based on Analysis of variance (ANOVA). To validate the chosen polynomial equation checkpoint analysis were performed. The percentage of predictive error is presented.

Results:

ANOVA reveals that X2 plant does not have any significant impact on the response surface. The checkpoint batch showed the experimental value of CMDI and Disease activity index (DAI) as 1.33 and 0.66 respectively. It is worthwhile to note that the observed values were quite close to the calculated values of CMDI. A little difference in the value of DAI may be attributed to the inherent variation observed in animal studies.

Conclusion:

From this study, it was concluded that a dose of Aegle marmelos 100 mg/kg, a dose of Bombax malabericum 300 mg/kg, and a dose of Holarrhena antidysentrica 200 mg/kg will always be effective in IBD patients.

Design of Experiment Approach to Assess the Effect of Formulation Variables on Extrusion and Spheronization of Telmisartan and Cilostazol Loaded Pellets and its Pharmacokinetic Study

Background:

Solubility is an important parameter that affects the availability of drug in systemic circulation. Drugs having poor solubility belonging to BCS class II eventually result in lower dissolution and bioavailability. Hence, improvement of solubility is a challenging task. Hence the present work focuses on using solid dispersion and inclusion complex approach for both telmisartan and cilostazol belonging to BCS Class II drugs.

Objective:

The present study was carried out to improve apparent solubility of telmisartan and cilostazol (BCS-Class II drugs) and optimization as pellets along with its pharmacokinetic study.

Methods:

Phase solubility study was carried out to screen the excipients such as, PVPK30, PVA, HPMC E5 and β-CD. Solvent evaporation method was adopted to prepare the solid dispersions and inclusion complex of both drugs. Pellets were optimized by extrusion spheronization method using 32 factorial design and characterized by morphology, drug content, DSC, FTIR, XRD, SEM, in- -vitro studies and drug content study.

Results:

Phase solubility study showed improved apparent solubility of telmisartan with HPMC E5 (1:3) by solid dispersion and cilostazol with β-CD (1:3) using inclusion complexation method. Drug characterization did not reveal any incompatibility. Formulation was optimized on the basis of acceptable pellet properties, including acceptable spherical shape and micromeritics properties. The percent friability of all batches was found to be less than 1%. The optimized pellets of both drugs prepared with micro crystalline cellulose provided desirable maximum release with acceptable release profile.

Conclusion:

The formulated pellets when studied in vivo showed superior pharmacokinetic profile. The drawback associated with apparent solubility and bioavailability of both drugs can thus be alleviated by use of novel pellet formulation.

A validated HPTLC method for quantification of cordifolioside A, 20-β-hydroxyecdysone and columbin with HPTLC–ESI–MS/MS characterization in stems of Tinospora cordifolia

The objective of the present work was to develop a simple, specific, and fast high-performance thin-layer chromatographic (HPTLC) method to identify and quantify cordifolioside A, 20-β-hydroxyecdysone and columbin with HPTLC‒electrospray ionization‒tandem mass spectrometry (ESI‒MS/MS) for characterization in Tinospora cordifolia stem extracts. Chromatographic development was performed using a HPTLC aluminum plate, pre-coated with silica gel 60 F₂₅₄ with hexane‒chloroform‒methanol‒formic acid as the mobile phase. Densitometric quantification for 20-β-hydroxyecdysone and cordifolioside A was performed at 254 nm and for columbin at 600 nm after derivatization with anisaldehyde‒sulfuric acid. The optimized mobile phase resulted in chromatographic separation of peaks for cordifolioside A, 20-β-hydroxyecdysone, and columbin at R_F of 0.12, 0.47, and 0.86, respectively. The linear concentration range was found to be 750‒2250 ng/band for 20-β-hydroxyecdysone and cordifolioside A and 675‒1875 ng/band for columbin with (r² > 0.99). The methodology showed good recoveries as 98.96‒101.43% for cordifolioside A, 98.15‒101.56% for 20-β-hydroxyecdysone, and 98.06‒98.80% for columbin. The limit of detection was found for columbin, 20-β-hydroxyecdysone, and cordifolioside A as 53.86 ng/band, 40.90 ng/band, and 107.05 ng/band, while the limit of quantification was found to be 163.21 ng/band, 123.94 ng/band, and 324.38 ng/band, respectively. The relative standard deviation for precision and robustness study for all the markers was found to be within 2%. Three markers were identified and confirmed in T. cordifolia stem extracts by ESI‒MS/MS. Compounds were assigned as norditerpene furan glycosides, ecdysteroids, and diterpenoid furanolactone: cordifolioside A (m/z = 527 [M + Na]⁺; UV λ_max 221 nm), 20-β-hydroxyecdysone (m/z = 481.30 [M + H]⁺; UV λ_max 247 nm), and columbin (m/z = 359 [M + H]⁺; UV λ_max 210 nm). The optimized method was found accurate, reproducible, robust, and specific and can be applied for the quantification of cordifolioside A, 20-β-hydroxyecdysone, and columbin for quality control of extracts of T. cordifolia.

Variation in COVID-19 characteristics, treatment and outcomes in Michigan: an observational study in 32 hospitals

OBJECTIVE

To describe patient characteristics, symptoms, patterns of care and outcomes for patients hospitalised with COVID-19 in Michigan.

DESIGN

Multicentre retrospective cohort study.

SETTING

32 acute care hospitals in the state of Michigan.

PARTICIPANTS

Patients discharged (16 March-11 May 2020) with suspected or confirmed COVID-19 were identified. Trained abstractors collected demographic information on all patients and detailed clinical data on a subset of COVID-19-positive patients.

PRIMARY OUTCOME MEASUREMENTS

Patient characteristics, treatment and outcomes including cardiopulmonary resuscitation, mortality and venous thromboembolism within and across hospitals.

RESULTS

Demographic-only data from 1593 COVID-19-positive and 1259 persons under investigation discharges were collected. Among 1024 cases with detailed data, the median age was 63 years; median body mass index was 30.6; and 51.4% were black. Cough, fever and shortness of breath were the top symptoms. 37.2% reported a known COVID-19 contact; 7.0% were healthcare workers; and 16.1% presented from congregated living facilities.During hospitalisation, 232 (22.7%) patients were treated in an intensive care unit (ICU); 558 (54.9%) in a 'cohorted' unit; 161 (15.7%) received mechanical ventilation; and 90 (8.8%) received high-flow nasal cannula. ICU patients more often received hydroxychloroquine (66% vs 46%), corticosteroids (34% vs 18%) and antibiotic therapy (92% vs 71%) than general ward patients (p<0.05 for all). Overall, 219 (21.4%) patients died, with in-hospital mortality ranging from 7.9% to 45.7% across hospitals. 73% received at least one COVID-19-specific treatment, ranging from 32% to 96% across sites.Across 14 hospitals, the proportion of patients admitted directly to an ICU ranged from 0% to 43.8%; mechanical ventilation on admission from 0% to 12.8%; mortality from 7.9% to 45.7%. Use of at least one COVID-19-specific therapy varied from 32% to 96.3% across sites.

CONCLUSIONS

During the early days of the Michigan outbreak of COVID-19, patient characteristics, treatment and outcomes varied widely within and across hospitals.

Demonstration of Advanced Data Mining Tools for Optimization of Pellets Employing Modified Extrusion-pelletization Technique

Background:

The multi particulate drug delivery system is preferred due to its numerous advantages but the batch to batch consistency and to achieve desired physical properties are the major challenges in the formulation of such dosage form.

Objective:

The objective of the present study was to explore the concept of quality by design for the development of galantamine HBr controlled release pellets using a modified palletization technique.

Methods:

Compritol 888 and Ethocel were chosen as hydrophobic release retardants, while Avicel was chosen as pelletization aid. A compatibility study was conducted between the drug and excipients. Drug loaded extrudes were prepared by using a mixture of isopropyl alcohol, and dichloromethane. Before converting the wet extrudes into pellets, pregelatinized starch was sprinkled on them to improve the physical properties of the pellets. The pellets were characterized for size, shape, and flow. The critical evaluation parameter was the drug dissolution pattern in distilled water. The dissolution data were treated with advanced data mining techniques. The in-vivo profile was predicted employing pharmacokinetic parameters of the drug and in-vitro drug release data of optimized batch pellets.

Results:

The failure mode and effect analysis revealed that the amount of Compritol 888 ATO and Ethocel were the most critical formulation parameters. The results of FTIR and DSC revealed compatibility between the drug and the excipients. The spherical pellets exhibited good flow. The drug dissolution studies of the batches, prepared according to the central composite design, revealed modified drug release. Multiple regression analysis and analysis of variance were performed to identify statistically significant factors. Contour plots demonstrated the impact of the amount of Compritol 888 and ethyl cellulose. The Design-Expert software was used to identify optimized formulation. The predicted in-vivo plasma concentration-time profile revealed the modified drug release up to 12h.

Conclusions:

Compritol and Ethocel were able to retard the drug release up to 12 hrs in distilled water. The innovative finding of this study is the use of a dry binder (pregelatinized starch) to improve the characteristics of pellets. Other dry binders are expected to show a similar effect. The newer processing technique can be of use in the industry.

Lansoprazole a Proton Pump Inhibitor Prevents IBD by Reduction of Oxidative Stress and NO Levels in the Rat

The inflammatory disease’s increased prevalence leads to a major concern around the world. Still, there is a lack of effective and successful therapy in the reversal of Inflammatory Bowel Disease (IBD) symptoms. Whereas, reactive oxygen species (ROS) production and muddled defense capacity of antioxidants in IBD subjects reported several times. Many proton pump inhibitors have been reported previously for their anti-inflammatory effect. The present study is aimed to assess the ameliorative effect of lansoprazole in experimentally induced IBD in rats. Thirty-six female Sprague Dawley rats were divided equally into six groups based on their body weight. Lansoprazole (1, 5, and 10 mg/kg, p.o.) and 5-aminosalicylate (5-ASA, 100 mg/kg, p.o.) served as standard control respectively, given for 18 days once a day. On the 11th day of the study, colitis was induced by intrarectal instillation of 2, 4-Dinitrobenzene sulfonic acid (DNBS), and treatment was continued for the next 7 days. Administration of lansoprazole (at 5 and 10 mg/kg) significantly reduced DAI (Disease Activation Index) and CMDI (Colon Macroscopic Damage Index); which further justifies a reduction in colon inflammation grades, as well as histopathological changes, and reflected by the stalling of body weight. The anti-inflammatory effects were indicated by lowered MPO (myeloperoxidase) and SOD (superoxide dismutase) in colon tissue as well as restores colonic NO (nitric oxide) level. The study shows lansoprazole improved DAI and CMDI scores, reduction of neutrophil infiltration, and an improved antioxidant status indicating an anti-ulcerative effect in DNBS-induced experimental colitis that is comparable with 5-ASA treatment.

UV-spectrophotometry-assisted chemometric methods for simultaneous determination of ambroxol hydrochloride and doxofylline in pharmaceutical formulation

Two methods, ratio spectra derivative method and partial least squares regression (PLS) were developed for the simultaneous estimation of ambroxol hydrochloride and doxofylline in combined dosage form. In the first method, ratio spectra derivative method, analytical signals were measured at the wavelengths corresponding to either maximums or minimums for both drugs in the first derivative spectra of the ratio spectra obtained by dividing the standard spectrum of one of two drugs in water. Partial least squares regression (PLS) was used for data analysis of and the parameters of the chemometry procedures were optimized. In this study, the simultaneous determination of ambroxol hydrochloride and doxofylline in pharmaceuticals by chemometric approaches using UV spectrophotometry has been reported. Spectra of ABH and DOX were recorded at several concentrations within their linear ranges between 2-12 μg/mL and 15-40 μg/mL respectively and applied to pharmaceutical formulation, tablet, with no interference with excipients as indicated by the results of the recovery study. The proposed methods are simple, rapid and can be easily used in the quality control of drugs as alternative analytical tools.

Systematic Development of Bicalutamide Immediate Release Pellets Using Aeroperl and Non-MCC Extruder Aid

Background:

The Microcrystalline Cellulose is called as a gold standard for the manufacture of pellets. The poor disintegration leads to incomplete drug release that restricts the use of MCC in the immediate-release formulation.

Objective:

The present work aims to explore non-MCC extruder aid for pellet formulation and solubility modulation potential of Aeroperl® 300 Pharma.

Methods:

Bicalutamide (BCL) was selected as a model BCS class-II drug. The solubility of BCL was assessed in different vehicles such as polyethylene glycol, propylene glycol, and Tween by carrying out phase solubility study. The suitable vehicle was selected based on the higher solubility of BCL. The vehicle was further adsorbed on newer adsorbent Aeroperl® 300 Pharma to formulate liquisolid granules. The liquisolid granules were further incorporated into the pellet using mannitol and microcrystalline cellulose as an extruder aid. Box-Behnken design was adopted for the optimization of formulation considering MCC: mannitol ratio, the concentration of HPMC and spheronizer speed as independent factors whereas drug release at 30 min, disintegration time and aspect ratio were selected as dependent variables. The pellets were evaluated for different evaluation parameters.

Results:

Propylene glycol was selected for the formulation of liquisolid technique based on the results of the phase solubility study. Propylene glycol containing BCL was adsorbed on Aeroperl 300 Pharma. The optimized batch was selected exploring the Design-Expert software by considering the limits of different responses. Pellet had excellent flowability. Friability was found to be within the range (<1%). Pellets were found to be spherical and had pores on the surfaces.

Conclusion:

Liquisolid granules containing newer solubilizer Aeroperl was found to be a promising approach for the improvement in the solubility of the drug. The use of mannitol with MCC has a profound effect on disintegration time, without altering flow property and other parameters. No patents were reported on the combination of Bicalutamide, mannitol and Aeroperl. The critical finding of the present work is to use mannitol as an extruder aid to fasten the disintegration leads to complete drug release within a short period of time. Aeroperl and Mannitol, MCC: mannitol ratio, the concentration of HPMC and spheronizer speed were found to be significant and had the potential effect in pellet formulation.

Exploring of Taguchi Design in the Optimization of Brinzolamide and Timolol Maleate Ophthalmic in-situ Gel Used in Treatment of Glaucoma

Objective:

The present research work focuses on experimental design assisted In-situ gel for fixed dose combination.

Significance:

Brinzolamide(BZ) BCS class II drug and Timolol Maleate (TM), a BCS class I drug is formulated for obtaining the sustained effect, increased ocular bioavailability and reduction of dose leading to better patient compliance.

Methods:

The material attributes were gelrite, hydroxy propyl methyl cellulose K4M(HPMC K4M) and HP-β-CD and critical quality attributes identified were gel strength, mucoadhesive index and percentage of drug release of both drugs. BZ and TM were successfully formulated in ion-triggered In-situ gelling system using Taguchi design with minimum trials.

Results:

The final optimized formula 0.5 %w/v gelrite, 0.5 %w/v HPMC K4M, 1:2.5 Ratio of drug to HP-β-CD as well as 150rpm stirring rate exhibited acceptable results with enhanced solubility of BZ. The pharmacodynamic study revealed a decrease in intraocular pressure for In-situ gel (17.3) compared to conventional marketed suspension. Moreover, delayed mean residence time and high AUC (61.237 and 4523.65) of In-situ gel indicates prolonged residence time with sustained release.

Conclusion:

In conclusion, excellent ocular tolerance and longer action of gelrite and HPMC K4M. In-situ gel for BZ and TM can be explored as potential alternative to marketed formulation reducing the frequency of administration and improving patient compliance in glaucoma.

The Association of Antibiotic Stewardship With Fluoroquinolone Prescribing in Michigan Hospitals: A Multi-hospital Cohort Study

BACKGROUND

Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown.

METHODS

This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015-September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship.

RESULTS

There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003).

CONCLUSIONS

Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing.

Formulation of Dry Powder Inhaler of Anti-tuberculous Drugs Using Spray Drying Technique and Optimization Using 23 Level Factorial Design Approach

Background:

Targeting anti-tubercular therapeutics to alveolar macrophages using microparticles technology mainly focuses on increasing local concentrations of therapeutics and potentially reducing the frequency of dosing requirements. Rifampicin (RIF), Ofloxacin (OFX) and Ethambutol (ETH) combination show synergism.

Objective:

In light of the above facts, the focus of the present study was to develop and characterize novel Dry powder Inhaler formulation incorporating novel drug combination as a pulmonary delivery for the effective eradication of Tuberculosis.

Method:

Biodegradable microparticles containing RIF, OFX and ETH were prepared by a spray drying technique using PLGA polymer through the critical process as well as polymer attributes were screened and optimized using 23 factorial design. The identified critical process parameters (CPP’s) viz. Inlet temperature, Aspiration rate, and feed rate were selected as independent variables while percentage yield, percentage entrapment efficiency, and particle size were selected as a response. The formulated microparticles were evaluated for particle size, drug-polymer compatibility study, aerodynamic behavior, morphology, particle size distribution, crystallinity, residual solvent content, in-vitro drug release study, and stability study.

Results:

By choosing the optimum spray drying conditions maximum yield of 73%, entrapment efficiency of 86% and particle size of 1.4 μm was attained of the optimized batch. Thus the results revealed that spherical microparticles are suitable for inhalation and sustained release for 12 h.

Conclusion:

The successful formulation and evaluation of dry powder could be used as an enhanced therapeutic alternative of the standard oral anti-tubercular regimen, rescuing oral dosing, shortening drug regimen and limiting toxicity. This will ultimately improve patient compliance and diminish the prevalence of MDR resistance.

Systematic Scrutinisation of Vital Factors for Fabrication and Evaluation of PGS-MCC Based Drug Loaded Pellets by Extrusion Spheronization Technique

Objective:

The prime objective was to formulate pellet formulation incorporating a newer extrusion- pelletisation aid, Pregelatinised Starch (PGS) and to scrutinise the factors that can affect the quality of the pellets and to overcome the slower disintegration of Microcrystaline Cellulose (MCC).

Methods:

Pellets were prepared initially using PGS, MCC, water, ethanol, HPMC K 4 M and Febuxostat was employed as model drug. Optimisation of formulation was done by employing Quality by design (QbD) and Design of experiment (DoE) approach. Ratio of PGS and MCC, ratio of binder and spheronisation speed were selected as independent variables and disintegration time and % cumulative drug release as dependent variables. In vitro in vivo correlation of the optimised batch was carried out using Wagner nelson method. Incompatibility studies have indicated compatibility of drug and excipients.

Results:

From the experiments, it was proved that the batch comprising 3:1 ratio of PGS and MCC, 1:1 binder solution and 1500 speed yielded good pellets with decreased disintegration time and improved dissolution rate as compared to pure Febuxostat. IVIVC studies indicated one to one correlation between in vitro and in vivo parameters.

Conclusion:

Pellets with good quality, minimum disintegration time and improved dissolution of model drug were successfully prepared with maximum amount of PGS. Optimisation using QbD approach was worth fruitful that affected the quality of pellets.

Development of Biodegradable Injectable In situ Forming Implants for Sustained Release of Lornoxicam

OBJECTIVE

The focus of this study was to develop in situ injectable implants of Lornoxicam which could provide sustained drug release.

METHODS

Biodegradable in situ injectable implants were prepared by polymer precipitation method using polylactide-co-glycolide (PLGA). An optimized formulation was obtained on the basis of drug entrapment efficiency, gelling behavior and in vitro drug release. The compatibility of the formulation ingredients were tested by Fourier transform infrared (FT-IR) spectroscopy, and differential scanning colorimetry (DSC). SEM study was performed to characterize in vivo behavior of in situ implant. Pharmacokinetic study and in vivo gelling study of the optimized formulation were performed on Sprague-Dawley rats. Stability testing of optimized formulation was also performed.

RESULTS

The drug entrapment efficiency increased and burst release decreased with an increase in the polymer concentration. Sustained drug release was obtained up to five days. SEM photomicrographs indicated uniform gel formation. Chemical interaction between the components of the formulation was not observed by FT-IR and DSC study. Pharmacokinetic studies of the optimized formulation revealed that the maximum plasma concentration (Cmax), time to achieve Cmax (Tmax) and area under plasma concentration curve (AUC) were significantly higher than the marketed intramuscular injection of lornoxicam. Stability study of optimized batch showed no change in physical and chemical characteristics.

CONCLUSION

Lornoxicam can be successfully formulated as in situ injectable implant that provides long-term management of inflammatory disorders with improved patient compliance.

Analytical QbD: Designing Space for HPLC Method Operable Region for Estimation of Preservatives in Herbal Formulation

Background:

Quantification of preservatives in herbal formulation, simultaneously by high performance liquid chromatography analysis is very complex and involves series of steps including sample preparation, selection of suitable mobile phase and its validation for routine applications. </P><P> Introduction: Application of Quality by Design (QbD) in the development of novel, simple, accurate and precise RP-HPLC method for concurrent quantification of quaternary preservatives in herbal formulation, focusses on development of robust method.

Methods:

Isocratic analysis was carried out using C18 column at 231 nm. Risk assessment studies were executed to determine the critical method parameters which were defined as acetonitrile volume in the mobile phase, volume of injection and orthophosphoric acid concentration in the mobile phase. The effect of the critical method parameters on critical method attributes, i.e. retention time, resolution and chromatographic optimization function was further evaluated by means of central composite design and the optimal conditions were determined through derringer’s desirability approach of multi-criteria decision making technique.

Results:

The method was statistically validated according to ICH guidelines having good resolution using optimized mobile phase, acetonitrile: 0.11% orthophosphoric acid in water (12.30: 87.70 % v/v) giving acceptable retention time i.e. 3.7128 ± 0.0138 of bronopol, 4.5106 ± 0.00542 of sodium propyl paraben, 10.7228 ± 0.029 of sodium benzoate and 12.252 ± 0.027 of sodium methyl paraben.

Conclusion:

Hence, the QbD based method development assisted in generating a design space with knowledge of all method performance characteristics leading to a better understanding of the method, and achieving desirable method quality.

234. Improving Antimicrobial Prescribing and Rate of Infectious Diseases Consult Utilizing a Best-Practice Alert and Targeted Education for Staphylococcus aureus Bacteremia

Background

Delays in time to appropriate management and antimicrobial therapy in patients with Staphylococcus aureus bacteremia (SAB) lead to dramatic increases in mortality, cost, and length of hospital stay. This study assesses the impact of antimicrobial stewardship pharmacist (ASP)-led Verigene education sessions paired with a physician targeted EPIC best practice alert (BPA) on time to appropriate therapy and rate of infectious diseases (ID) consult for patients SAB.

Methods

This single-center pre–post study included adult patients with SAB from October 2016 through January 2018. A BPA was implemented in August 2017, and fired for any patient with SAB and no ID consult. The BPA provided four recommendations: (1) repeat blood cultures till clearance, (2) obtain ID consult, (3) start vancomycin for SAB with mecA gene (i.e., MRSA) and nafcillin or cefazolin for SAB without mecA gene (i.e., MSSA), and (4) obtain echocardiogram. The ASP also provided education on antimicrobial therapy choices and optimization to clinical pharmacists and ID physicians. The hospital utilized Verigene Gram-positive blood culture nucleic acid test during both study periods and ASP review of SAB cases without an ID consult in the preintervention phase. The primary outcome was time to appropriate therapy defined as the time a positive blood culture was drawn to the time of first appropriate antibiotic administration.

Results

A total of 223 patients with SAB were included; 134 were in the 10-month historic group (October 2016–July 2017) and 89 were in the 5-month postintervention (PI) group (August 2017–January 2018). The BPA fired for 86% (n = 77) of patients in the PI group. Average time to appropriate therapy for all SAB patients and patients with MSSA significantly improved following the intervention (35.1 vs. 20.4 hours, P = 0.004; 53.2 vs. 30.3 hours, P = 0.001). During the intervention phase, therapy was more frequently changed between the time of Verigene results and antibiotic susceptibilities (77.6% vs. 86.5%, P = 0.254). The rate of ID consult also significantly improved following the intervention (89.6% vs. 97.8%, P < 0.02).

Conclusion

Implementing an SAB BPA and education on interpretation of Verigene results for SAB significantly improved time to appropriate therapy for all patients with SAB, patients with MSSA bacteremia, and rate of ID consult.

Disclosures

All authors: No reported disclosures.

1870. Excess Antibiotic Duration in Patients Hospitalized for Pneumonia: A Multi-Hospital Cohort Study

Vaughn VM, Flanders SA, Chopra V, Conlon A, Malani A, Thyagarajan R, Hsaiky L and Gandhi T

216. Step-down Therapy With Oral Fluoroquinolones vs. Oral β-Lactams for Hospitalized Adult Patients with Community-Acquired Pneumonia: A Multi-Hospital Cohort Study

Background

Community-acquired pneumonia (CAP) guidelines recommend transition to an oral (PO) β-lactam (BL) regimen or fluoroquinolone (FQ) when patients are clinically stable. Due to collateral damage associated with FQs, stewardship efforts often focus on reducing initial FQ use for CAP therapy. We hypothesized that FQ use remains prevalent in CAP treatment despite initial intravenous (IV) BL therapy, and examined factors associated with switching to a PO BL vs. an FQ and the impact on outcomes.

Methods

In this retrospective cohort study, data were collected from January 2016 through February 2018 on non-ICU medical patients admitted with CAP at 46 Michigan hospitals. Patients were included if they received IV BL (ceftriaxone or ampicillin-sulbactam) plus macrolide/doxycycline by hospital day 2 and switched to a PO respiratory FQ or BL by therapy day 4. Exclusions included positive culture, concomitant infection, HCAP, unstable on day 4, or severe immune deficiency. Data were analyzed using logistic generalized estimating equation models, accounting for hospital-level clustering; outcomes were adjusted using the inverse probability of treatment weighting by propensity scores.

Results. Of 555 included patients, 54.4% were switched to a PO BL vs. 45.6% to an FQ by day 4 of therapy. The groups had similar durations of therapy (8 days), time to clinical stability, prior antibiotics, and COPD, but the BL group was older, with a higher Pneumonia Severity Index, CURB-65, and more cardiovascular (CV) disease (Figure 1). In multivariable analysis, CV disease and higher CURB-65 were more common and diabetes (DM) less common in the PO BL group (Figure 2). Sharing antibiotic use data with providers were associated with less FQ use (83.1% vs. 70.8%, OR 0.51, 95% CI 0.27, 0.97, P = 0.04). On adjusted analysis there were no differences in patient outcomes (Figure 3).

Conclusion. Among CAP patients started on an IV BL regimen, nearly half were switched to a PO FQ by therapy day 4, including more patients with DM. Although there were sicker patients in the BL group, there were no differences in outcomes between cohorts. To reduce FQ use, stewardship programs should share antibiotic use data and provide guidance for step-down therapy in clinically stable CAP patients.

Disclosures

All authors: No reported disclosures.

A Multicenter Stewardship Initiative to Decrease Excessive Duration of Antibiotic Therapy for the Treatment of Community-Acquired Pneumonia (CAP)

Background

Hospitals have implemented multifaceted approaches to quickly identify CAP, start timely therapy, and reduce hospital readmission, yet there has been minimal focus on providing appropriate duration of therapy. The IDSA CAP guidelines recommend 5 days of antibiotic therapy for patients that are clinically stable and quickly defervesce. However, previous publications suggest duration of therapy for CAP may be unnecessarily prolonged.

Methods

The objective of this multicenter, quasi-experimental study of hospitalized patients with CAP was to assess the impact of a prospective 6-month stewardship intervention on total duration of antibiotic therapy and associated clinical outcomes. All centers updated institutional CAP guidelines to promote IDSA-concordant durations of therapy and provided education to pharmacists and prescribers. Daily patient-specific prospective audit and feedback was provided by infectious diseases stewardship pharmacists to optimize compliance with guideline recommendations.

Results

A total of 600 patients were included (307 in the historic control group and 293 in the stewardship intervention group). The stewardship intervention led to significantly increased rates of compliance with IDSA duration of therapy recommendations (5.6% vs. 41.4%, P&lt; &lt; 0.01) and significantly reduced the duration of therapy for CAP (9 vs. 6 days, P &lt; 0.01). Inappropriate days of antibiotic therapy was reduced in the intervention group (4 vs. 1.6 days, P &lt; 0.01), and total avoidance of 720 excessive days of antibiotic therapy. Clinical outcomes, including mortality, length of hospitalization, readmission to hospital with pneumonia, presentation to the ER/clinic with pneumonia within 30 days of discharge, and incidence of C. difficilecolitis, were not different between groups.

Conclusion

This multicenter evaluation of a prospective stewardship intervention in hospitalized CAP patients reduced the total duration of antibiotic therapy and increased compliance with guideline-concordant duration of therapy without adversely affecting patient outcomes.

This project was funded through a competitive stewardship grant provided by Merck & Co.

Disclosures

A. Huang, Merck: Grant Investigator, Research grant; C. Nguyen, Merck: Grant Investigator, Research grant; J. Grieger, Merck: Grant Investigator, Research grant; S. Revolinski, Merck: Grant Investigator, Research grant; J. Li, Merck: Grant Investigator, Research grant; M. Mack, Merck: Grant Investigator, Research grant; J. N. Wainaina, Merck: Grant Investigator, Research grant; G. Eschenauer, Merck: Grant Investigator, Research grant; T. Patel, Merck: Grant Investigator, Research grant; V. Marshall, Merck: Grant Investigator, Research grant; J. Nagel, Merck: Grant Investigator, Research grant

Modelling the Expected Net Benefits of Interventions to Reduce the Burden of Medication Errors

Objectives

The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors.

Methods

A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE.

Results

The model predicts annual health service costs of between £0.3 million and £1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around £31.5 million for CPOE over a five-year time horizon.

Conclusions

The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

Coordinated, systemwide efforts necessary to accelerate progress against preventable harm

Preventable harm in healthcare is a leading cause of death in America and should be tackled as a public health crisis with its own coordinated response.

Assessing the impact of a program for late surgical intervention in early-blind children

OBJECTIVE

Many blind children in the developing world are unable to obtain timely treatment due to lack of financial and medical resources. Can public health programs that identify and treat such children several years after the onset of blindness enhance their quality of life? The notion that visual development is subject to an early 'critical period' argues against this possibility. However, there are inadequate empirical data from humans on this issue. To address this need, we examined the quality of life of children living in India and who were treated for early-onset blindness (before one year of age), due to cataracts or corneal opacities.

STUDY DESIGN

Survey study.

METHODS

As part of an ongoing scientific effort named Project Prakash, we screened over 40,000 children in rural northern India to identify those suffering from early-onset blindness. They were provided eye surgeries in a tertiary care ophthalmic center in New Delhi. We subsequently surveyed 64 Prakash children, ranging in age from 5 to 22 years and obtained their responses on a multi-dimensional quality of life questionnaire.

RESULTS

Nearly all of the subjects indicated that their quality of life had improved after treatment. Children reported marked enhancement in their mobility, independence, and safety, and also in social integration. Surprisingly, we found no significant correlations between quality of life metrics and factors such as age at treatment, gender, time since treatment, and pre-surgery and post-surgery acuity.

CONCLUSIONS

A key question for public health policy makers is whether a program of surgical intervention for older blind children is likely to be beneficial, or if the resources are better spent on rehabilitation via vocational training and assistive devices. The marked improvements in quality of life we find in our data strongly argue for the provision of surgical care regardless of a child's age.

Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration

BACKGROUND

Copy and paste functionality can support efficiency during clinical documentation, but may promote inaccurate documentation with risks for patient safety. The Partnership for Health IT Patient Safety was formed to gather data, conduct analysis, educate, and disseminate safe practices for safer care using health information technology (IT).

OBJECTIVE

To characterize copy and paste events in clinical care, identify safety risks, describe existing evidence, and develop implementable practice recommendations for safe reuse of information via copy and paste.

METHODS

The Partnership 1) reviewed 12 reported safety events, 2) solicited expert input, and 3) performed a systematic literature review (2010 to January 2015) to identify publications addressing frequency, perceptions/attitudes, patient safety risks, existing guidance, and potential interventions and mitigation practices.

RESULTS

The literature review identified 51 publications that were included. Overall, 66% to 90% of clinicians routinely use copy and paste. One study of diagnostic errors found that copy and paste led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. Copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart. Existing guidance identified specific responsibilities for authors, organizations, and electronic health record (EHR) developers. Analysis of 12 reported copy and paste safety events was congruent with problems identified from the literature review.

CONCLUSION

Despite regular copy and paste use, evidence regarding direct risk to patient safety remains sparse, with significant study limitations. Drawing on existing evidence, the Partnership developed four safe practice recommendations: 1) Provide a mechanism to make copy and paste material easily identifiable; 2) Ensure the provenance of copy and paste material is readily available; 3) Ensure adequate staff training and education; 4) Ensure copy and paste practices are regularly monitored, measured, and assessed.

Salting-Out Assisted Liquid-Liquid Extraction for Quantification of Febuxostat in Plasma Using RP-HPLC and Its Pharmacokinetic Application

A rapid and sensitive reversed-phase high-performance liquid chromatography (HPLC) method using novel salting-out assisted liquid-liquid extraction technique has been developed for the quantitative determination of febuxostat (FEB), used for the treatment of gout, in rat plasma. The method was validated according to US FDA guideline. Separation was achieved using a Phenomenex Luna-C₁₈ (250 × 4.60 mm, 5 µm) column and mobile phase composed of potassium dihydrogen orthophosphate buffer 25 mM, adjusted to pH 6.8 with triethylamine:methanol in a ratio of 35:65 (v/v) showing retention time 5.56 and 8.86 min for FEB and internal standard, respectively. The optimal salting-out parameters; 1 mL of acetonitrile and 200 µL of 2 M ammonium acetate salt showed extraction recovery >90% for FEB from plasma. This extraction procedure afforded clear samples resulting in convenient and cost-saving procedure and showed good linear relationship (r > 0.9997) between peak area ratio and concentration from 0.3 to 20 µg/mL. The results of pharmacokinetic study showed that absorption profile of spherical agglomerate of FEB compared to marketed formulation was higher indicating greater systemic absorption. In conclusion, the developed SALLE-HPLC method with simple ultraviolet detection offered a number of advantages including good quantitative ability, wide linear range, high recovery, short analysis time as well as low cost.

Effect of Cyperus Rotundus on Cytokine Gene Expression in Experimental Inflammatory Bowel Disease

BACKGROUND

The protective effect of the chloroform extract of Cyperus rotundus (CHCR) is attributed to its anti-inflammatory and antioxidant activities. Cytokines, important regulators of inflammation and repair, play a key role in the pathogenesis of inflammatory bowel disease (IBD). Targeting these cytokines can effectively ameliorate the symptoms of IBD. The aim of the present study was to unravel the molecular mechanism through cytokine regulation in rats in experimental IBD.

METHODS

Sprague Dawley rats were randomly allocated to 5 groups (n=6). Group I served as the normal control. Group II served as the vehicle control and received 50% ethanol intracolonically on day 11 of the study. Group III served as the model control. Group IV and Group V were given standard drug 5-aminosalicylic acid (100 mg/kg) and CHCR (800 mg/kg), respectively, for 18 days once a day orally. Colitis was induced with dinitrobenzene sulfonic acid (180 mg/kg in 50% ethanol) intracolonically in groups III-V on day 11 of the study. On day 18, the rats were euthanized and colon tissues were removed for IL-4, IL-6, IL-12, and IFN-gamma gene expression studies using quantitative RT-PCR.

RESULTS

The expression levels of proinflammatory cytokines IL-4, IL-6, IL-12, and IFN-gamma were upregulated in the model control rats. Pretreatment with 5-aminosalicylic acid (100 mg/kg) and CHCR (800 mg/kg) significantly decreased the fold of the expression of the above cytokines.

CONCLUSION

CHCR acts as a molecular brake and downregulates the expression of proinflammatory cytokine genes; this is beneficial for reducing the severity of the experimental IBD. Thus, Cyperus rotundus is a safe, economical, and effective alternative for the treatment of patients with IBD.

Inhibition of RhoA/Rho kinase by ibuprofen exerts cardioprotective effect on isoproterenol induced myocardial infarction in rats

Myocardial infarction (MI) and hypertension are the leading cause of death worldwide so protection of heart is focus of intense research. Rho-kinase, a downstream effector of protein involved in MI and hypertension, is inhibited by ibuprofen. This study aims to elucidate cardioprotective effect of ibuprofen in rats. MI was produced in rats with 85mg/kg isoproterenol (ISO) administered s.c. twice at an interval of 24h. The rats were randomized into six groups: (I) Normal; (II) ISO; (III) ISO + ascorbic acid (250mg/kg p.o.); (IV-VI) ISO + ibuprofen (30, 60 and 90mg/kg p.o). After the completion of the study period of 21 days, cardiac function and biomarkers were assessed. Pre-treatment with ibuprofen (30, 60 and 90mg/kg p.o) ameliorated high BP and left ventricular dysfunction, furthermore it prevented the rise in CKMB, LDH and α-HBDH, suggesting the effect of ibuprofen in maintenance of cell membrane integrity. In addition, it also prevented alteration in the levels of electrolytes, ATPase activity and antioxidant status. Ibuprofen suppressed ISO-induced ROCK-1 mRNA expression and histological changes. Ibuprofen provided cardioprotection in a model of myocardial infarction, by restoring most of the altered physical, physiological, biochemical, haemodynamic parameters, antioxidant status, and histological changes and by inhibiting ROCK-1 mRNA expression.

An Online Learning Module to Increase Self-Efficacy and Involvement in Care for Patients With Advanced Lung Cancer: Research Protocol

Background

Improving patient care for individuals with lung cancer is a priority due to the increasing burden of the disease globally. One way this can be done is by improving patient self-management capabilities through increasing their self-efficacy. This can improve positive outcomes for patients with chronic conditions and increase their ability to manage the challenges of such illnesses. Unfortunately, patients with chronic conditions often struggle to travel far from home to engage with patient education events, a common means of improving self-efficacy. The development of more accessible tools for improving patient self-efficacy is required to increase quality of life for patients with chronic conditions.

Objective

To evaluate the feasibility of delivering symptom identification and management information to patients with advanced lung cancer using an online program.

Methods

This article describes a pre-post test study to evaluate a Qstream online learning platform to improve patient self-efficacy for managing advanced lung cancer symptoms. Undertaking this program should increase participant knowledge about the side-effects they may experience as a result of their treatment and in turn increase help-seeking behavior and self-efficacy for the participant cohort. Quantitative data collected by the Qstream platform on the completion rates of participants will be used as a tool to evaluate the intervention. Additionally, validated scales will be used to collect data on patient self-efficacy. Qualitative data will also be collected via an exit survey and thematic content analysis of semi-structured interviews.

Results

The research is in the preliminary stages but thus far a protocol has been approved in support of the project. Additionally, advisory committee members have been identified and initial meetings have been undertaken.

Conclusions

Development of new approaches for increasing patient understanding of their care is important to ensure high quality care continues to be delivered in the clinical setting.