PHASE BEHAVIOR OF AMORPHOUS SOLID DISPERSIONS: MISCIBILITY AND MOLECULAR INTERACTIONS

Over the past few decades, amorphous solid dispersions (ASDs) have been of great interest to pharmaceutical scientists to address bioavailability issues associated with poorly water-soluble drugs. ASDs consist of an active pharmaceutical ingredient (API) that is typically dispersed in an inert polymeric matrix. Despite promising advantages, a major concern that has resulted in limited marketed formulations is the physical instability of these complex formulations. Physical instability is often manifested as phase heterogeneity, where the drug and carrier migrate and generate distinct phases, which can be a prelude to recrystallization. One important factor that dictates the physical stability of ASDs is the spatial distribution of API in the polymeric matrix. It is generally agreed that intimate mixing of the drug and polymer is necessary to achieve maximum stabilization, and thus understanding the factors controlling phase mixing and nano-domain structure of ASDs is crucial to rational formulation design. The focus of this thesis work is to better understand the factors involved in phase mixing on the nanometric level and get insights on the role of excipients on overall stabilization of these systems. The central hypothesis of this research is that an intimately mixed ASD will have better physical stability as compared to a partially homogeneous or a non-homogeneous system. Our approach is to probe and correlate phase homogeneity and intermolecular drug-excipient interactions to better understand the physical stability of ASDs primarily using solid-state nuclear magnetic resonance (SSNMR) spectroscopy and other solid-state characterization tools. A detailed investigation was carried out to understand the role of hydrogen bonding on compositional homogeneity on different model systems. A comprehensive characterization of ternary ASDs in terms of molecular interactions and physical stability was studied. Finally, long-term physical stability studies were conducted in order to understand the impact of different grades of a cellulosic polymer on phase homogeneity for two sets of samples prepared via different methods. Overall, through this research an attempt has been made to address some relevant questions pertaining to nano-phase heterogeneity in ASDs and provide a molecular level understanding of these complex systems to enable rational formulation design

Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children\u27s Health Service.

Methadone has the potential to assist in the management of pain in children with life-limiting illness, but its use is limited by its complex pharmacokinetic profile and limited research on its use in children. This is a retrospective review of the use of methadone as an analgesic in 16 children with life-limiting illness. Efficacy, dosing and side effect profile were analysed. Fifteen (94%) patients had improvements in their analgesia with minimal observed adverse effects. Patients were either rapidly converted from a prior opioid in one change or received methadone as an adjunct medication. Conversions were calculated using ratios frequently in the range of 10:1 to 20:1 from the oral morphine equivalent total daily dose (MEDD). Adjunct initial dosing was a low dose trial, often beginning with 1 mg at night. Only two patients required a dose adjustment due to side effects attributed to methadone. This was despite the cohort having significant underlying illnesses, extensive concurrent medications, and high methadone dosing where needed. Analysis of dosing and ratios indicates that an individualised approach is required. Based on this and on the infrequency of methadone use in this population, specialist assistance with dosing is recommended. Further research, including prospective and pharmacokinetic studies, is recommended

Isolated hydatid cyst of adrenal gland with hypertension mimicking Conn’s syndrome: a very rare case

Hydatid cyst of the adrenal gland is one of the rare conditions caused by the larval stage of Echinococcus granulosus. The incidence of adrenal gland involvement is less than 1% of all hydatid disease in humans and isolated adrenal involvement is extremely rare. Hydatid disease is frequent in endemic regions and sheep farming areas with equal sex distribution. Here, a case of 23 year old female with isolated adrenal gland hydatid cyst is presented, that was evaluated clinically, investigated radiographicaly and by blood investigations and finally histopathology confirmed the diagnosis. No complications occurred at peri and postoperative period. The patient was given 6 cycles of albendazole (10 mg/kg in two divided doses), each for a period of four weeks followed by a week’s rest. The patient is on regular follow-up without recurrence in last 1 year

Percutaneous nephrolithotripsy for renal pelvis stone in a crossed fused ectopic kidney: a case report

Crossed renal ectopia is the second most common fusion anomaly of the kidney after horseshoe kidney. The incidence of both fused and unfused cases is 1 in 7000 in autopsies. Percutaneous nephrolithotripsy (PCNL) is a well-established technique in the surgical management of nephrolithiasis. The conventional fluoroscopic guidance of PCNL will be of limited value in ectopic anomalous kidneys due to the abnormal anatomical landmarks with consequent compromise of the procedure’s safety.  A 30-year old male patient, previously healthy, presented to our urology outpatient clinic complaining of dull flank pain of six month duration with tenderness in the right renal area and an enlarged right kidney and 1 episode of gross haematuria. Radiological investigations showed left side crossed ectopia with nephrolithiasis. Patient was managed successfully by fluoroscopic guided percutaneous nephrolithotripsy. The position of the stone-containing ectopic kidney can make it easy to reach the pelvis of the target kidney without injuring any adjoining structure. The superimposition of the different soft tissue densities in the radiologic view may limit the ability of the operator to distinguish between different tissue identities. Laparoscopic guidance can represent as a practical solution to this technical problem

Whether retrograde pyelography mandatory for percutaneous nephrolithotomy: a randomized clinical trial

Background: Percutaneous nephrolithotomy (PCNL) technique was introduced a new era in the management of renal calculi, and day by day many changes occurred regarding the puncture points to an opaque stone as a guided landmark. We aim at comparing the outcome of many renal calculi with or without retrograde pyelography (RGP).Methods: In a randomized clinical trial 110 cases with opaque renal calculi for PCNL with stone in the calyces, in the pelvis, both in the calyx and pelvis, simultaneously, included in 2 year study. They were randomized in 2 groups, non RGP (56) and RGP (54), called interventional and control group respectively.Results: 2 groups are analyzed according to gender, age, duration of operation and hospital stay, past history of any surgical intervention on kidney and stone size. Outcome was evaluated with plain x-ray and USG abdomen. No differences in outcome were observed in between the two groups.Conclusions: Present findings conclude that there is no difference in major clinical outcome between the 2 groups. So we can say RGP is not mandatory for selected patients while doing PCN

Methadone for analgesia in children with life-limiting illness: experience from a tertiary children’s health service

Methadone has the potential to assist in the management of pain in children with life-limiting illness, but its use is limited by its complex pharmacokinetic profile and limited research on its use in children. This is a retrospective review of the use of methadone as an analgesic in 16 children with life-limiting illness. Efficacy, dosing and side effect profile were analysed. Fifteen (94%) patients had improvements in their analgesia with minimal observed adverse effects. Patients were either rapidly converted from a prior opioid in one change or received methadone as an adjunct medication. Conversions were calculated using ratios frequently in the range of 10:1 to 20:1 from the oral morphine equivalent total daily dose (MEDD). Adjunct initial dosing was a low dose trial, often beginning with 1 mg at night. Only two patients required a dose adjustment due to side effects attributed to methadone. This was despite the cohort having significant underlying illnesses, extensive concurrent medications, and high methadone dosing where needed. Analysis of dosing and ratios indicates that an individualised approach is required. Based on this and on the infrequency of methadone use in this population, specialist assistance with dosing is recommended. Further research, including prospective and pharmacokinetic studies, is recommended

Abnormal Resting State fMRI Activity Predicts Processing Speed Deficits in First-Episode Psychosis

Little is known regarding the neuropsychological significance of resting state functional magnetic resonance imaging (rs-fMRI) activity early in the course of psychosis. Moreover, no studies have used different approaches for analysis of rs-fMRI activity and examined gray matter thickness in the same cohort. In this study, 41 patients experiencing a first-episode of psychosis (including N = 17 who were antipsychotic drug-naive at the time of scanning) and 41 individually age-and sex-matched healthy volunteers completed rs-fMRI and structural MRI exams and neuropsychological assessments. We computed correlation matrices for 266 regions-of-interest across the brain to assess global connectivity. In addition, independent component analysis (ICA) was used to assess group differences in the expression of rs-fMRI activity within 20 predefined publicly available templates. Patients demonstrated lower overall rs-fMRI global connectivity compared with healthy volunteers without associated group differences in gray matter thickness assessed within the same regions-of-interest used in this analysis. Similarly, ICA revealed worse rs-fMRI expression scores across all 20 networks in patients compared with healthy volunteers, with posthoc analyses revealing significant (

Interaction of Cannabis Use Disorder and Striatal Connectivity in Antipsychotic Treatment Response

Antipsychotic (AP) medications are the mainstay for the treatment of schizophrenia spectrum disorders (SSD), but their efficacy is unpredictable and widely variable. Substantial efforts have been made to identify prognostic biomarkers that can be used to guide optimal prescription strategies for individual patients. Striatal regions involved in salience and reward processing are disrupted as a result of both SSD and cannabis use, and research demonstrates that striatal circuitry may be integral to response to AP drugs. In the present study, we used functional magnetic resonance imaging (fMRI) to investigate the relationship between a history of cannabis use disorder (CUD) and a striatal connectivity index (SCI), a previously developed neural biomarker for AP treatment response in SSD. Patients were part of a 12-week randomized, double-blind controlled treatment study of AP drugs. A sample of 48 first-episode SSD patients with no more than 2 weeks of lifetime exposure to AP medications, underwent a resting-state fMRI scan pretreatment. Treatment response was defined a priori as a binary (response/nonresponse) variable, and a SCI was calculated in each patient. We examined whether there was an interaction between lifetime CUD history and the SCI in relation to treatment response. We found that CUD history moderated the relationship between SCI and treatment response, such that it had little predictive value in SSD patients with a CUD history. In sum, our findings highlight that biomarker development can be critically impacted by patient behaviors that influence neurobiology, such as a history of CUD

Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers

BackgroundPotentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited.ObjectivesDetermine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate.MethodsProspective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0–17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale.ResultsOf 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty.ConclusionsWhile treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions

Antipsychotic Treatment and Functional Connectivity of the Striatum in First-Episode Schizophrenia

IMPORTANCE Previous evidence has implicated corticostriatal abnormalities in the pathophysiology of psychosis. Although the striatum is the primary target of all efficacious antipsychotics, the relationship between its functional connectivity and symptomatic reduction remains unknown. OBJECTIVE To explore the longitudinal effect of treatment with second-generation antipsychotics on functional connectivity of the striatum during the resting state in patients experiencing a first episode of psychosis. DESIGN, SETTING, AND PARTICIPANTS This prospective controlled study took place at a clinical research center and included 24 patients with first-episode psychosis and 24 healthy participants matched for age, sex, education, and handedness. Medications were administered in a double-blind randomized manner. INTERVENTIONS Patients were scanned at baseline and after 12 weeks of treatment with either risperidone or aripiprazole. Their symptoms were evaluated with the Brief Psychiatric Rating Scale at baseline and follow-up. Healthy participants were scanned twice within a 12-week interval. MAIN OUTCOMES AND MEASURES Functional connectivity of striatal regions was examined via functional magnetic resonance imaging using a seed-based approach. Changes in functional connectivity of these seeds were compared with reductions in ratings of psychotic symptoms. RESULTS Patients had a median exposure of 1 day to antipsychotic medication prior to being scanned (mean [SD] = 4.5 [6.1]). Eleven patients were treated with aripiprazole and 13 patients were treated with risperidone. As psychosis improved, we observed an increase in functional connectivity between striatal seed regions and the anterior cingulate, dorsolateral prefrontal cortex, and limbic regions such as the hippocampus and anterior insula (P \u3c .05, corrected for multiple comparisons). Conversely, a negative relationship was observed between reduction in psychosis and functional connectivity of striatal regions with structures within the parietal lobe (P \u3c .05, corrected for multiple comparisons). CONCLUSIONS AND RELEVANCE Our results indicated that corticostriatal functional dysconnectivity in psychosis is a state-dependent phenomenon. Increased functional connectivity of the striatum with prefrontal and limbic regions may be a biomarker for improvement in symptoms associated with antipsychotic treatment