EFFECT OF PARTICLES SIZE ON EPINEPHRINE SUBLINGUAL DIFFUSION FOR THE POTENTIAL FIRST-AID TREATMENT OF ANAPHYLAXIS: IN VITRO AND EX VIVO STUDY

Objective. To evaluate the in vitro and ex vivo diffusion of epinephrine microcrystals (Epi-MC) from our rapidly disintegrating sublingual tablets (RDSTs). Background. Epi 0.3 mg IM injection in the thigh is the drug of choice and the only available dosage form for the treatment of anaphylaxis in community settings. Previously, we showed that Epi 40 mg from RDST is bioequivalent to 0.3 mg IM Injection in our validated rabbit model. We hypothesized that substantial reduction in Epi particles size would significantly enhances its sublingual diffusion. Methods. Epi-MC were prepared by top-down technique using LV-1 Microfluidizer. RDSTs were manufactured by direct compression using our previously developed and published formulation. The in vitro and ex vivo diffusion of Epi 10, 20, and 40 mg RDSTs, and Epi-MC 10, 20 mg RDSTs (n=4) through dialysis and excised sublingual porcine mucosal membranes respectively, were evaluated using Franz cells. Epi 10 mg solution was used as a control. Results. Mean (SD) JAUC0- 90 of diffused Epi, Jmax, and Epi influx (J) from Epi 40 mg RDSTs (484,185±29,656μg/cm2/min, 7,508±569μg/cm2, 234±100μg/cm2/min, respectively) and Epi-MC 20 mg RDSTs (402,852±55,299μg/cm2/min, 6,727±736μg/cm2, 172±50μg/cm2/min, respectively) were not significantly different in vitro (p \u3e 0.05). Mean (SD) JAUC0-90 of diffused Epi, Jmax, and Epi influx (J) from Epi 40 mg RDSTs (264,556±182,820μg/cm2/min, 4,796±2,988μg/cm2, 106±82μg/cm2/min, respectively) and Epi-MC 20 mg RDSTs (211,369±116,025μg/cm2/min, 3,527±1,755μg/cm2, 91±55μg/cm2/min, respectively) were not significantly different ex vivo (p \u3e 0.05). Conclusion. The Epi-MC RDSTs improved Epi diffusion two-fold and have the potential to reduce the bioequivalent dose of sublingually administered Epi by 50%. Grants. This study was funded by the Health Professions Division Grant and the President\u27s Faculty Research & Development Grant, Nova Southeastern University

FABRICATION AND CHARACTERIZATION OF EPINEPHRINE NANOCRYSTALSUSING TOP-DOWN TECHNIQUE

Objective. To fabricate and characterize epinephrine bitartrate nanocrystals (EpiBit-NCs) using Microfluidizer. Background. Epinephrine(Epi) 0.3mg IM injection is the drug of choice for the treatment of anaphylaxis in community sittings. Previously, we showed that Epi 40mg rapidly disintegrating sublingual tablets (RDSTs) is bioequivalent to Epi 0.3mg IM injection in a rabbit model. We hypothesized that significant reduction in the Epi particle size will significantly increase Epi dissolution and absorption and permit for the reduction of Epi sublingual dose. Methods. EpiBit NCs were prepared using LV-1/Microfluidizer. EpiBit 0.7mg/ml, 1.4mg/ml, 2.8mg/ml, 3.5mg/ml, and 4.5mg/ml were suspended in isopropyl alcohol (n=3) and processed at 15,000, 25,000, or 30,000Psi for 4 cycles. Mean particles size distribution (PSD) and zeta potential (ZP) were measured after each cycle using Zetasizer(n=3). Reproducibility and fabrication yield were calculated(n=5). Results. Mean(SD) PSD of EpiBit before processing was 131.8±10.5μm. Processing EpiBit 0.7mg/ml, 1.4mg/ml, 2.8mg/ml, 3.5mg/ml, and 4.5mg/ml for 1 cycle at 30,000Psi resulted in PSD and ZP of 709±288nm and -14±6mV, 665±47nm, 249±38nm and -28±2mV (fabrication yield 36±6%), 1211±389nm and -16±2mV, and 1091±43nm and -28±1mV, respectively. Processing EpiBit 2.8mg/ml for 2, 3, 4 cycles resulted in PSD of 827±114nm, 971±124nm, and 976±163nm, respectively. Processing EpiBit 2.8 mg/ml for 1 cycle at 25,000 or 15,000Psi resulted in PSD and ZP of 603±169nm and -9±4mV, and 649±473nm and -12±7mV, respectively. Conclusion. The fabrication of the EpiBit NC using LV-1 Microfluidizer was feasible. Particles size was reduced 135 fold. EpiBit NC as RDSTs have the potential to enhance the sublingual absorption of Epi. Grants. This study was funded by the Health Professions Division Grant and the President\u27s Faculty Research & Development Grant, Nova Southeastern Universit

Los modos de acción exterior de la unión Europea: el caso del Cáucaso del Sur

Este artículo propone un marco de análisis del sistema europeo de acción exterior de la Unión Europea para contribuir en la comprensión de su funcionamiento. Elaborado a partir del concepto de modos de acción exterior, este artículo estudia el caso del Cáucaso del sur. Esta aproximación propone representar, comprender y explicar la acción exterior europea en una región sobre la cual la literatura disponible acerca de las políticas de la UE y sus Estados miembros es casi inexistente, y en donde sus políticas y acciones reflejan sólo parcialmente sus lógicas de poder y sus factores determinantes.This article proposes a framework for the analysis of the European Union’s foreign action system, to contribute to an understanding of its functioning. Based on the concept of modes of foreign action, this article studies the case of the South Caucasus. It attempts to describe, understand, and explain European foreign actions in a region about which there is practically no literature available concerning the policies of the EU and its member states, and in which their policies and actions only partially reflect their power logic and determining factors

Adrenaline (epinephrine) microcrystal sublingual tablet formulation: enhanced absorption in a preclinical model

OBJECTIVES: For anaphylaxis treatment in community settings, adrenaline (epinephrine) administration using an auto-injector in the thigh is universally recommended. Despite this, many people at risk of anaphylaxis in community settings do not carry their prescribed auto-injectors consistently and hesitate to use them when anaphylaxis occurs.The objective of this research was to study the effect of a substantial reduction in adrenaline (Epi) particle size to a few micrometres (Epi microcrystals (Epi-MC)) on enhancing adrenaline dissolution and increasing the rate and extent of sublingual absorption from a previously developed rapidly disintegrating sublingual tablet (RDST) formulation in a validated preclinical model. METHODS: The in-vivo absorption of Epi-MC 20 mg RDSTs and Epi 40 mg RDSTs was evaluated in rabbits. Epi 0.3 mg intramuscular (IM) injection in the thigh and placebo RDSTs were used as positive and negative controls, respectively. KEY FINDINGS: Epimean (standard deviation) area under the plasma concentration vs time curves up to 60 min and Cmax from Epi-MC 20 mg and Epi 40 mg RDSTs did not differ significantly (P \u3e 0.05) from Epi 0.3 mg IM injection. After adrenaline, regardless of route of administration, pharmacokinetic parameters were significantly higher (P \u3c 0.05) than after placebo RDSTs administration (reflecting endogenous adrenaline levels). CONCLUSION: Epi-MC RDSTs facilitated a twofold increase in Epi absorption and a 50% reduction in the sublingual dose. This novel sublingual tablet formulation is potentially useful for the first-aid treatment of anaphylaxis in community settings

Mitosis-specific MPM-2 phosphorylation of DNA topoisomerase IIα is regulated directly by protein phosphatase 2A

Recent results suggest a role for topoIIα (topoisomerase IIα) in the fine-tuning of mitotic entry. Mitotic entry is accompanied by the formation of specific phosphoepitopes such as MPM-2 (mitotic protein monoclonal 2) that are believed to control mitotic processes. Surprisingly, the MPM-2 kinase of topoIIα was identified as protein kinase CK2, otherwise known as a constitutive interphase kinase. This suggested the existence of alternative pathways for the creation of mitotic phosphoepitopes, different from the classical pathway where the substrate is phosphorylated by a mitotic kinase. In the present paper, we report that topoIIα is co-localized with both CK2 and PP2A (protein phosphatase 2A) during interphase. Simultaneous incubation of purified topoIIα with CK2 and PP2A had minimal influence on the total phosphorylation levels of topoIIα, but resulted in complete disappearance of the MPM-2 phosphoepitope owing to opposite sequence preferences of CK2 and PP2A. Accordingly, short-term exposure of interphase cells to okadaic acid, a selective PP2A inhibitor, was accompanied by the specific appearance of the MPM-2 phosphoepitope on topoIIα. During early mitosis, PP2A was translocated from the nucleus, while CK2 remained in the nucleus until pro-metaphase thus permitting the formation of the MPM-2 phosphoepitope. These results underline the importance of protein phosphatases as an alternative way of creating cell-cycle-specific phosphoepitopes

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort.

Objective:To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).Background:AL after RC resection often results in a permanent stoma.Methods:This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.Results:This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).Conclusions:The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies