Chronic DVT in the Setting of a Long-Term IVC Filter, Protein C Deficiency, and Non-Compliance

Introduction: Inferior vena cava filters are often placed with the intention of removal and IVC filters are a temporary intervention, so leaving them in long term can present with significant risk of complications. When combined with protein C deficiency, the patient is at even greater risk. Case: This case presents a 35-year-old Hispanic woman who presented to the emergency department for a one-week history of pain and swelling of the right leg. Past medical history includes protein C deficiency, chronic DVT, IVC filter (twelve-years ago), and venous insufficiency. Due to non-compliance, and financial difficulties, the patient didn’t continue her treatment and her IVC filter was never removed. The patient’s laboratory findings were PT 13.7 and INR 1.16. CT of the abdomen and pelvis showed that the IVC filter infiltrated past the walls of the IVC, which represented significant risk for removal. Ultimately, a second IVC filter was placed superior to the prior one after attempting thrombolysis. Conclusion: The timeframe of removal for a retrievable filter is 2-3 weeks after anticoagulation, complications risk increases over time. One of the most common reasons that patients do not have their filter removed is that they are lost to follow up, as in this case. The patient noted that her current economic status, along with being incarcerated, kept her from following up and taking her anticoagulation medication appropriately. This case highlights the importance of removal of retrievable IVC filters, especially in patients with hypercoagulable conditions such as protein C deficiency

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<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

QUALITY CONTROL TESTING OF CONVENTIONAL CLOPIDOGREL BISULFATE TABLETS MARKETED IN IRAQ

Objective: This study was employed to evaluate the quality of marketed oral tablets containing clopidogrel bisulfate. Tablets produced by various companies and commercialized in the Iraq market were used in the study. Methods: Batches of clopidogrel bisulfate conventional tablets (containing 75 mg of drug) were exposed to the quality control tests. These tests involved friability, weight variation, hardness, drug content, disintegration time, and in vitro release study; these tests were conducted depending on USP pharmacopeia. Results: The data indicate that all batches of clopidogrel bisulfate complied with the limitations of USP pharmacopeia for variation of weight, results of the hardness of tablets were 7.2-9.6 Kg/cm2. Friability value (% loss) was less than one, which was within the required limits. The time of disintegration was less than 25 min in both artificial gastric fluid (AGF) and artificial intestinal fluid (AIF). Drug content was observed between 97.1 % and 99.8 %, indicating compliance with the limits of pharmacopeia (85-115 %). An in vitro release study of batches was greater than 80 % within 25 min. Conclusion: All batches of clopidogrel bisulfate were manufactured within the criteria of tablet manufacturing. The quality control tests of tablets showed acceptable pharmaceutical properties (effectiveness and safety) that lie within the limits of USP pharmacopeia

IVIG for refractory dysphagia in Antisynthetase syndrome: A truth hard to swallow

Refractory dysphasia could be the main symptom of Antisynthetase syndrome (ASS). IVIG may have a major impact in the successful treatment of dysphasia in patients with ASS. In our patient with ASS, IVIG treatment was an unreplaceable treatment option, and the patient regains her ability to swallow within 2 days

A COMPARATIVE STUDY OF QUALITY CONTROL TESTING OF MEFENAMIC ACID TABLETS IN IRAQ

Objective: This research was performed to assess the quality of different marketed tablets having mefenamic acid (500 mg). The selected tablets are produced by numerous companies and presented in the Iraqi pharmaceutical marketplace. Methods: Different batches of mefenamic acid conventional tablets were exposed for several tests of quality control. These evaluation tests include hardness, weight variation, friability, disintegration time, drug content, and drug dissolution profile. The properties of these quality tests were made conferring to the specification of USP-pharmacopeia. Results: The data of this study indicate that each tablet of mefenamic acid batches conformed to the requirement of USP pharmacopeia, the hardness was (6.87-8.06 Kg/cm2), and the drug content results were (90.666-99.214%) within USP limitation. The data of disintegration time and weight uniformity were agreeable with pharmacopeia and the in vitro release assay showed that the release of each mefenamic acid marketed tablet was highest than (80 %) in 45 min, which reproducing compliance with the USP pharmacopeia's limitation. Conclusion: From this study, it was proved that all of the marketed brands of mefenamic acid tablets meet the standard character in the USP pharmacopeia for in vitro quality control tests

Quality Improvement Project to Increase Hepatitis C Virus Screening for Ambulatory GME Internal Medicine Clinic Patients

Background: In 2020, CDC established new guideline expanding Hepatitis C virus (HCV) screening to all adults aged 18 to 79 years. Our QI project objective is to enhance HCV screening amongst the UTRGV-DHR IM department by establishing suitable reminders and educational sessions. Methods: We reviewed HCV screening status of all adult patients 18 to 79 years old from June 1st 2020 to December 1st 2020. We then provided one lecture on the new screening recommendation from CDC 2020 guideline. We also encouraged residents to educate patients on the importance of HCV screening, and to identify and overcome barriers against screening. We then measured HCV screening performed from March 1st 2021 to May 1st 2021. The primary objective is to increase HCV screening in the ambulatory setting by 50%. Results: Among 843 patients from June 1st 2020 to December 1st 2020, 219 patients were screened for HCV (26%). The results from March 1st 2021 to May 1st 2021 was 190 out 548 patients (35%). The difference was significant with p-value of 0.0005 using Chi-square statistical analysis. Conclusions: Even though we did not achieve our primary objective, HCV screening performance in our clinic had increased significantly from 26% to 35%. With this positive result, we will continue to enhance awareness among the residents by implementing didactic lectures to support evidence –based medicine practice about HCV screening. It is also important to identify the drawbacks of HCV screening including stress on patients and their family, future costs and side-effects of further testing and treatments

PREPARATION AND OPTIMIZATION OF CILOSTAZOL NANOEMULSION ORAL LIQUID DOSAGE FORM

Objective: Cilostazol has poor water solubility and low oral bioavailability. Therefore, the formulation of cilostazol as a nanoemulsion may enhance its solubility and improve oral bioavailability. Hence, the aim of this study was to formulate and characterize an oil-in-water (o/w) nanoemulsion of cilostazol as an oral liquid dosage form. Methods: Pseudo-ternary phase diagrams were constructed using the aqueous titration method. Formulations of pseudo-ternary phase plots consisting of oil, various weight ratios of S mix (mixture of surfactant and co-surfactant), and deionized water were made. Different characterization studies, droplet size measurement, polydispersity index, drug content, zeta potential measurement, and in vitro release, have been conducted to choose the optimized formula. Results: The characterization studies have demonstrated that the optimized formula is (F-6), consisting of 20 % S mix (3:1), 10% ginger oil, and 70% deionized water. This formula had the following characteristics; droplet size (72.9-110 nm), polydispersity index (0.22), percentage of drug content (99.8%), and in vitro release of cilostazol nanoemulsion was significantly higher (P<0.05) in comparison with other formulations. A Scanning probe microscopy (SPM) study has revealed that the droplet size of F-6 was at the nano-scale. Conclusion: In conclusion, the optimized cilostazol formula (F-6) is a promising formula, which may have the capability of improving the oral bioavailability of cilostazol

A A COMPARATIVE STUDY OF QUALITY CONTROL TESTING ON CANDESARTAN CILEXETIL CONVENTIONAL TABLETS IN IRAQ

Objective: The present study was performed to compare the quality of conventional tablets loaded with candesartan cilexetil. The selected candesartan cilexetil tablets were commercialized in the Iraq market and produced by different companies.  Methods: Different batches of candesartan cilexetil oral tablets (the concentration of candesartan was 8 mg) were subjected to quality control tests. Tests included weight variation, friability, hardness, drug content, disintegration time and in vitro release study. The protocols of these tests were performed according to USP pharmacopeia. Results: The results, in this study, revealed that all the used batches of candesartan cilexetil oral tablets complied with the specification of USP pharmacopeia for weight uniformity, friability value (% loss) was<1. Hardness results of the tablets were 4.9-6.6 Kg/cm2, which was within the required limits (i.e. 4-8 Kg/cm2). Disintegration time was<15 min in both Simulated Gastric Fluid (SGF) and Simulated Intestinal Fluid (SIF). The percentage of drug content in all marketed tablets was found between 96.2 % and 99.8 %, reflecting compliance with the pharmacopeia limits (i.e. 85-115 %). An in vitro release study indicated that the release of all marketed tablets exceeds 80 % within 15 min. Conclusion: All the studied tablets, loaded with candesartan cilexetil, were produced within the standard criteria of tablet production. The quality control analysis of the selected tablets, in this study, revealed satisfactory pharmaceutical properties (including safety and effectiveness) that comply within the limits of USP pharmacopeia

QUALITY EVALUATION OF BRANDS OF PROPRANOLOL HCL TABLETS AVAILABLE ON IRAQI MARKET

Objective: The purpose of this study is to evaluate the quality control of marketed tablets containing propranolol hydrochloride available on the Iraqi market and manufactured by different companies. Methods: Different batches of propranolol hydrochloride 40 mg tablets were assessed using quality control tests. Weight variation, diameter, thickness, friability, disintegration time and dissolution study were carried out in this study. Results: Based on the data obtained in this study, all brands of PPL available on the Iraqi market showed weight variation within the acceptable limit of USP. Marketed products of Becardin and Propranolol lie within the acceptable limit of hardness and Inderal was observed to be slightly higher than the normal upper range of USP. Diameter and thickness for all brands were almost the same, except the diameter of Becardin was slightly higher and friability was zero for all brands. All brands demonstrated a time of disintegration of fewer than 30 min. The tested marketed propranolol products; Inderal, Procard, Becardin and Propranolol showed cumulative drug release of 90.08%, 94.46%, 92.4% and 79.51%, respectively at the end of the first 20 min. This variation in the release profile of marketed tablets of Propranolol HCl might be attributed to the excipients present in the marketed tablets where some of these excipients may behave as a disintegrant and enhance dissolution rate while others may act as dissolution retardants. Conclusion: All marketed tablets of Propranolol HCl employed in this study were produced within the standard criteria of tablet manufacturing. Evaluation of quality control of these selected tablets showed acceptable pharmaceutical properties that lie within the limits of USP