The Potential of Vitamin-D-Binding Protein as a Urinary Biomarker to Distinguish Steroid-Resistant from Steroid-Sensitive Idiopathic Nephrotic Syndrome in Iraqi Children

Objective: To determine the ability of uVDBP to discern SRNS from steroid-sensitive nephrotic syndrome (SSNS) in Iraqi children. Materials and Methods: This cross-sectional study enrolled children with SRNS (n=31) and SSNS (n=32) from the pediatric nephrology clinic of Babylon Hospital for Maternity and Pediatrics over three months. Patients' characteristics in terms of demographics, clinical data, and urinary investigations were collected. Quantitative analysis of uVDBP levels was undertaken via a commercially available ELISA kit. Results: The median uVDBP values were significantly higher (p-value<0.001) in the SRNS group (median=10.26, IQR=5.91 μg/mL) than in the SSNS group (median=0.953, IQR=4.12 μg/mL). A negative correlation was noted between uVDBP levels and estimated glomerular filtration rate (eGFR) (Spearman's rho coefficient= − 0.494, p=0.001). Nevertheless, the rise in uVDBP concentrations was still considerable in children with SRNS whose eGFR measurements were above 60 mL/min/1.73 m2. The study revealed a good discriminatory power for uVDBP as a predicting parameter to distinguish SRNS from SSNS (AUC= 0.909, p<0.0001. The optimal uVDBP cut-off value of 5.781 μg/mL was associated with a sensitivity of 0.839 and specificity of 0.844 to differentiate SRNS from SSNS. Conclusion: Considering its significant discriminatory strength, uVDBP can be considered as a potential marker to noninvasively distinguish children with SRNS from those with SSNS

A Cross-Sectional Study of Urinary Neutrophil Gelatinase-Associated Lipocalin and its Association with Steroid Responsiveness in Iraqi Children with Idiopathic Nephrotic Syndrome

Background: Steroid-resistant nephrotic syndrome (SRNS)is associated with serious complications and financial burdens. Studies reported increased urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels in children with idiopathic nephrotic syndrome (INS). Objectives: This study aimed to evaluate the uNGAL potential to distinguish SRNS from steroid-sensitive nephrotic syndrome (SSNS) in Iraqi children. Patients and Methods: Children with SRNS (n=31) and SSNS (n=32) were recruited from Babylon Hospital for Maternity and Pediatrics from March to June 2022. Patients' data included demographics, clinical characteristics, and urinary lab tests. The uNGAL concentrations were measured via a commercially available ELISA kit. Results: A significantly higher uNGAL median (p-value<0.001) was noted in the SRNS group (median [IQR] = 131.512 [30.28] ng/mL) than in the SSNS group (88.45 [41.6] ng/mL). The correlation between uNGAL levels and estimated glomerular filtration rate (eGFR) was negative (Spearman's rho coefficient = − 0.599, p<0.001). The discriminatory power ofuNGAL to discern SRNS from SSNS was significantly high (AUC=0.899, p<0.0001) with a sensitivity of 87.1% and specificity of 87.5% at an optimal cut-off value of 111.091 ng/mL. Conclusion: uNGAL is associated with a reliable discriminatory strength to distinguish, noninvasively, children with SRNS from those with SSNS.   Received: Jan. 2023 Accepted: Jul, 2023 Published: Oct.202

DESIGN AND CHARACTERIZATION OF CANDESARTAN CILEXETIL ORAL NANOEMULSION CONTAINING GARLIC OIL

Objective: This study was designed to prepare and characterize oil in water (o/w) nanoemulsion of candesartan cilexetil for oral administration. Preparation of candesartan cilexetil as nanoemulsion could increase its water solubility and thus could enhance its bioavailability. Methods: Aqueous titration method was used to construct the pseudo-ternary phase diagrams of nanoemulsion (NE) consisting of oil, various weight ratios of surfactant and co-surfactant (S mix), and deionized water. Different characterization techniques were conducted on the prepared nanoemulsions to obtain the optimized formula. Results: Characterizations of formula NE-4 (consists of 0.16% of candesartan cilexetil, 10% of garlic oil, 35 % of S mix (3:1) and 54.84% of deionized water) revealed the following characteristics: droplet size range (95-139 nm), polydispersity index (0.14), zeta potential value (-41.06 mV) and pH value (6.71), which are suitable for oral administration. Candesartan cilexetil in vitro release from this formula was significantly high (P&lt;0.05) and scanning probe microscopy (SPM) study confirmed that the optimized formula (NE-4) was in nano-scale. Conclusion: Nanoemulsion formula 4 (NE-4) of candesartan cilexetil is the optimized formula and it could be a promising formula for improving the water solubility of candesartan cilaxetil

Is there scope for rapid implementation of pharmacoepidemiology findings using quality improvement methods?

Background The Scottish Patient Safety Programme – Pharmacy in Primary Care collaborative has developed High Risk Medicine (HRM) Care Bundles (CB). These CBs, which are interventions that improve care processes and outcomes, focus on clinical assessment and patient education. Using quality improvement methods, these have been implemented in 28 community pharmacies in four health service regions – two focus on Warfarin and two on non-steroidal anti-inflammatories. The intent is for national roll out of a HRM CB, where a standardised process may act as a platform to accelerate uptake of pharmacoepidemiology findings into routine practice. Objective To develop a generic HRM CB process map to facilitate implementation. Methods Regional process maps were developed through data collection in four pharmacies, involving simulation of the CB process, staff interviews and documentation of resources. Following validation by the onsite pharmacist, commonalities among the process maps were collated to create a process map for each HRM. To develop a generic HRM process map, these were validated by 93% (n=26) of participating pharmacies. Consent was gained throughout. Ethical approval was not sought as this was service evaluation. Results Although some regional variation existed, the validation identified six core stages required for successful CB delivery: patient identification, clinical assessment, patients’ eligibility flagged, CB delivery, enrolling non-attending patients and documentation. The commonalities were sufficient to develop a generic process map encompassing staff and patients' journey, its integration into usual practice and resources utilised. Conclusion To maximise implementation success, the process map allows for targeted development of resources to facilitate each core stage. The feasibility of developing a generic process map suggests adaptability of the CB to varying clinical contexts, strengthening the CBs potential to facilitate national implementation of health informatics research. Safety concerns highlighted by pharmacoepidemiology studies could be addressed by adapting the CBs' content, allowing seamless translation of evidence into practice

Application of process mapping to understand integration of high risk medicine care bundles within community pharmacy practice

Objective: The Scottish Patient Safety Programme – Pharmacy in Primary Care collaborative is a quality improvement initiative adopting the Institute of Healthcare Improvement Breakthrough Series collaborative approach. The programme developed and piloted High Risk Medicine (HRM) Care Bundles (CB), focused on warfarin and non-steroidal anti-inflammatories (NSAIDs), within 27 community pharmacies over 4 NHS Regions. Each CB involves clinical assessment and patient education, although the CB content varies between regions. To support national implementation, this study aims to understand how the pilot pharmacies integrated the HRM CBs into routine practice to inform the development of a generic HRM CB process map. Methods: Regional process maps were developed in 4 pharmacies through simulation of the CB process, staff interviews and documentation of resources. Commonalities were collated to develop a process map for each HRM, which were used to explore variation at a national event. A single, generic process map was developed which underwent validation by case study testing. Results: The findings allowed development of a generic process map applicable to warfarin and NSAID CB implementation. Five steps were identified as required for successful CB delivery: patient identification; clinical assessment; pharmacy CB prompt; CB delivery; and documentation. The generic HRM CB process map encompasses the staff and patients' journey and the CB's integration into routine community pharmacy practice. Pharmacist involvement was required only for clinical assessment, indicating suitability for whole-team involvement. Conclusions: Understanding CB integration into routine practice has positive implications for successful implementation. The generic process map can be used to develop targeted resources, and/or be disseminated to facilitate CB delivery and foster whole team involvement. Similar methods could be utilised within other settings, to allow those developing novel services to distil the key processes and consider their integration within routine workflows to effect maximal, efficient implementation and benefit to patient care