Practical notes on the current ESMO consensus guidelines for the management of patients with metastatic colorectal cancer in resource-constrained environments of low- to middle-income countries.

Letter (no abstract).

Nanotechnology-Assisted Metered-Dose Inhalers (MDIs) for High-Performance Pulmonary Drug Delivery Applications.

PURPOSE: Respiratory disorders pose a major threat to the morbidity and mortality to public health. Here we reviewed the nanotechnology based pulmonary drug delivery using metered dose inhalers. METHODS: Major respiratory diseases such as chronic obstructive pulmonary diseases (COPD), asthma, acute lower respiratory tract infections, tuberculosis (TB) and lung cancer. At present, common treatments for respiratory disorders include surgery, radiation, immunotherapy, and chemotherapy or a combination. The major challenge is development of systemic delivery of the chemotherapeutic agents to the respiratory system. Conventional delivery of chemotherapy has various limitation and adverse side effected. Hence, targeted, and systemic delivery need to be developed. Towards this direction nanotechnology, based controlled, targeted, and systemic drug delivery systems are potential candidate to enhance therapeutic efficacy with minimum side effect. Among different route of administration, pulmonary delivery has unique benefits such as circumvents first pass hepatic metabolism and reduces dose and side effects. RESULTS: Respiratory disorders pose a major threat to the morbidity and mortality to public health globally. Pulmonary delivery can be achieved through various drug delivery devices such as nebulizers, dry powder inhalers, and metered dose inhalers. Among them, metered dose inhalers are the most interesting and first choice of clinician over others. This review focused on nanotechnology based pulmonary drug delivery using metered dose inhalers. This report focused on delivery of various types of therapeutics using nanocarriers such as polymeric nanoparticles and micelles, dendrimers, lipid nanocarriers such as liposomes, solid lipid nanostructures and nanostructured lipid carriers, and other using metered dose inhalers discussed comprehensively. This report provides insight about the effect of parameters of MDI such as co-solvent, propellants, actuators shape, nozzle diameters, and jet lengths, and respiratory flow rate, and particle size of co-suspension of drug on aerodynamics and lung deposition of formulation. This review also provided the insight about various metered dose inhalers market scenario and digital metered dose inhalers. CONCLUSION: This report concluded the clinical potential of metered dose inhalers, summary of current progress and future perspectives towards the smart digital metered dose inhalers development.

Effect of USP Induction Ports, Glass Sampling Apparatus, and Inhaler Device Resistance on Aerodynamic Patterns of Fluticasone Propionate-Loaded Engineered Mannitol Microparticles.

The present investigation is to study the effect of two different induction ports (IP), i.e., USP IP and USP-modified IP equipped with andersen cascade impactor on in vitro aerodynamic performance along with the impact of USP-modified glass sampling apparatus on delivered dose uniformity of fluticasone propionate (FP) dry powder inhaler (DPI). FP DPI was fabricated by spray drying technique using engineered mannitol microparticles (EMP) with different force controlling agents, i.e., leucine and magnesium stearate. Additionally, commercially available two DPI inhaler devices namely Handihaler® and Breezhaler® were used to aerosolize the FP blends. Spherical smooth surface of EMP showed good powder flow properties and acceptable percentage content uniformity (> 95%). Amounts of FP deposited in cascade assembly using USP-modified IP with the Breezhaler® device was significantly higher (1.32-fold) as compared with the Handihaler® device. Moreover, USP-modified IP showed better deposition as compared with USP IP. Additionally, both inhaler devices showed a satisfactory delivered dose (> 105%) for FP using modified glass sampling apparatus at a flow rate of 60 L/min for 2 s. It was interesting to note that not only formulation properties but also IP geometry and device resistance have significant impact on DPI deposition pattern. This study is a first detailed account of aerodynamic performance of FP using USP-modified IP and USP-modified glass sampling apparatus. Thus, it can be of potential importance for both the academic and industry perspective.

Efavirenz Self-Nano-Emulsifying Drug Delivery System: In Vitro and In Vivo Evaluation.

Self-emulsifying drug delivery system (SEDDS) is the isotropic and thermodynamically stable mixture of oil, surfactant, co-solvent/surfactant, and drug. It emulsifies spontaneously when introduced into an aqueous phase under a mild agitation. The current study was aimed to prepare SNEDDS to augment solubility, release rate, and oral bioavailability of BCS class II drug, efavirenz (EFV). A series of oil, surfactant, and co-surfactant was screened out by a ternary phase diagram to locate a better homogenous mixture. The prepared SNEDDS was evaluated regarding its appearance, mean droplet size, phase separation, in vitro drug release, and oral bioavailability. Among the screened oil, surfactant, and co-surfactant, Labrafil M 2125 CS, Tween 80, and Transcutol®P mixture exhibited superior solubilizing capacity, respectively. Optimized SNEDDS exhibits 98.39% drug release. SNEDDS dissolution behavior was attributed to oil/surfactant ratios and properties of the surfactant phase. It also demonstrates threefold increments in the area under curve (AUC) in comparison to neat EFV. Furthermore, the optimized SNEDDS does not show any vitrification during its 3-month storage. In the present study, better performance of SNEDDS is explained by various factors like (i) improved surface area of droplets, (ii) superior solubilization potential for hydrophobic drugs due to Labrafil M 2125 CS, and (iii) result of surfactant on mucosal permeability. This study demonstrated that SNEDDS may be an alternative approach for the poorly soluble drugs to improve their solubility and oral bioavailability.

Uncertainty quantification techniques for data-driven space weather modeling: thermospheric density application.

Machine learning (ML) has been applied to space weather problems with increasing frequency in recent years, driven by an influx of in-situ measurements and a desire to improve modeling and forecasting capabilities throughout the field. Space weather originates from solar perturbations and is comprised of the resulting complex variations they cause within the numerous systems between the Sun and Earth. These systems are often tightly coupled and not well understood. This creates a need for skillful models with knowledge about the confidence of their predictions. One example of such a dynamical system highly impacted by space weather is the thermosphere, the neutral region of Earth's upper atmosphere. Our inability to forecast it has severe repercussions in the context of satellite drag and computation of probability of collision between two space objects in low Earth orbit (LEO) for decision making in space operations. Even with (assumed) perfect forecast of model drivers, our incomplete knowledge of the system results in often inaccurate thermospheric neutral mass density predictions. Continuing efforts are being made to improve model accuracy, but density models rarely provide estimates of confidence in predictions. In this work, we propose two techniques to develop nonlinear ML regression models to predict thermospheric density while providing robust and reliable uncertainty estimates: Monte Carlo (MC) dropout and direct prediction of the probability distribution, both using the negative logarithm of predictive density (NLPD) loss function. We show the performance capabilities for models trained on both local and global datasets. We show that the NLPD loss provides similar results for both techniques but the direct probability distribution prediction method has a much lower computational cost. For the global model regressed on the Space Environment Technologies High Accuracy Satellite Drag Model (HASDM) density database, we achieve errors of approximately 11% on independent test data with well-calibrated uncertainty estimates. Using an in-situ CHAllenging Minisatellite Payload (CHAMP) density dataset, models developed using both techniques provide test error on the order of 13%. The CHAMP models-on validation and test data-are within 2% of perfect calibration for the twenty prediction intervals tested. We show that this model can also be used to obtain global density predictions with uncertainties at a given epoch.

The minimum land area requiring conservation attention to safeguard biodiversity.

Ambitious conservation efforts are needed to stop the global biodiversity crisis. In this study, we estimate the minimum land area to secure important biodiversity areas, ecologically intact areas, and optimal locations for representation of species ranges and ecoregions. We discover that at least 64 million square kilometers (44% of terrestrial area) would require conservation attention (ranging from protected areas to land-use policies) to meet this goal. More than 1.8 billion people live on these lands, so responses that promote autonomy, self-determination, equity, and sustainable management for safeguarding biodiversity are essential. Spatially explicit land-use scenarios suggest that 1.3 million square kilometers of this land is at risk of being converted for intensive human land uses by 2030, which requires immediate attention. However, a sevenfold difference exists between the amount of habitat converted in optimistic and pessimistic land-use scenarios, highlighting an opportunity to avert this crisis. Appropriate targets in the Post-2020 Global Biodiversity Framework to encourage conservation of the identified land would contribute substantially to safeguarding biodiversity.

Novel and Evolving Therapies for COVID-19 Related Pulmonary Complications.

Coronaviruses disease 2019 (COVID-19) is the most crucial threat, the world has ever witnessed. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of this disease pandemic. The World Health Organization has confirmed the continuing epidemic as a worldwide public health crisis. Presently, the research on COVID-19 is even in the primitive stage. Studies on unveiling the natural route of COVID-19 infection and related pathophysiology, the biology of pulmonary airways pose a more rational restorative approach in the management of COVID-19. Thus, based on the existing facts, we methodically reviewed the efforts put forth by various research institutes, pharmaceutical companies and biotechnology firms in pulmonary delivery to prevent and control the COVID-19. This article would be valuable for the healthcare community, which is efficiently dealing with the SARS-CoV-2 crisis.

Repurposing drug molecules for new pulmonary therapeutic interventions.

Drug repurposing with novel strategies has substantially contributed to the identification and analysis of new molecules for better pulmonary intervention. This review would offer insights into the drug repurposing for effective pulmonary therapy. The review begins by explaining the relevant background knowledge of drug repurposing, the need for drug repurposing, and their potential advantages in treating pulmonary diseases. This article takes into account clinical trial problems, drug delivery challenges, regulatory issues, and human ergonomics along with chemistry manufacturing and control strategies for effective pulmonary drug repurposing. This article elaborates on pulmonary drug repurposing with help of strengths, weaknesses, opportunities, and threat analysis. In brief, this article is the first inclusive account of drug repurposing for better pulmonary therapy. Graphical abstract.

Imagine the Superiority of Dry Powder Inhalers from Carrier Engineering.

Inhalation therapy has strong history of more than 4000 years and it is well recognized around the globe within every culture. In early days, inhalation therapy was designed for treatment of local disorders such as asthma and other pulmonary diseases. Almost all inhalation products composed a simple formulation of a carrier, usually α-lactose monohydrate orderly mixed with micronized therapeutic agent. Most of these formulations lacked satisfactory pulmonary deposition and dispersion. Thus, various alternative carrier's molecules and powder processing techniques are increasingly investigated to achieve suitable aerodynamic performance. In view of this fact, more suitable and economic alternative carrier's molecules with advanced formulation strategies are discussed in the present review. Furthermore, major advances, challenges, and the future perspective are discussed.

Emerging novel drug delivery strategies for bioactive flavonol fisetin in biomedicine.

Fisetin (FIS), a bioactive flavonol found in the smoke tree (Cotinus coggygria), vegetables, fruits and nuts. It exhibits various therapeutic activities such as anti-oxidant, anti-inflammatory, anti-invasive, anti-tumorigenic, anti-angiogenic, anti-diabetic, cardioprotective and neuroprotective activities. In spite of the ever rising support for therapeutic activities, its clinical application is mainly limited because of poor water solubility, high lipophilicity and low oral bioavailability. Till date, numerous efforts have been made to surpass these limitations with the development of new improved delivery platforms. This article aims to review and analyze the various delivery strategies used to improve the biopharmaceutical properties of FIS. Furthermore, an attempt has been made to touch upon various features related to the progress of drug delivery including their influence on FIS chemistry, pharmacokinetics and other physicochemical attributes are discussed thoroughly.

Potential of dry powder inhalers for tuberculosis therapy: facts, fidelity and future.

Tuberculosis (TB) is a contagious and airborne infectious disease caused by the pathogen Mycobacterium tuberculosis (Mtb). In spite of substantial research efforts, continuous multiple high-dose drug therapy regularly for 4-7 months can impede patient quality of life. The pathology of TB and biology of pulmonary airways permits for a variety of drug delivery strategies and natural route of infection denotes a more logical remedial approach for treatment of TB. Pulmonary delivery is non-invasive, allow easy transcytosis in alveolar region, avoids first-pass metabolism and extensive vascularization facilitates delivery of therapeutic agents to infection site. It also potentially reduces the frequency with dose requirement and linked side effects. Dry powder is a most preferred inhalation option due to their greater physiochemical stability over liquid or suspension based formulations. Dry powder inhalers (DPIs) are easy to handle and appropriate for high-dose formulations. Moreover, the progress of disciplines such as nanotechnology, particle engineering, material science and molecular biology permits further expansion of treatment capability and efficiency. Thus, this article will focus on the role of novel DPIs systems for treatment of TB. This article also contains a dedicated section discussing about technical limitations and clinical challenges with help of strengths, weaknesses, opportunities and threats (SWOT) analysis. Additionally, it will also offer some basic background information for drug repurposing, formulation development and drug delivery systems.

Phytoconstituent based dry powder inhalers as biomedicine for the management of pulmonary diseases.

Pulmonary disease represents a major global health issue. They are commonly treated by various synthetic molecules. But, frequent high-dose of oral and injectable drugs may lead to severe side effects and this juncture demands inhaled formulations that facilitate effective drug delivery to the lower airways with negligible side effects. Natural phytoconstituents or phytoalexin (i.e. plant antibiotics) have showed an unique treatment array with minimum side effects and great capability to treat intrapulmonary and extrapulmonary diseases compared to synthetic drugs. Moreover, the progress of disciplines such as nanotechnology, material science and particle engineering allows further improvement of the treatment capability and efficiency. This article review and analyze literatures on inhaled phytoconstituents which were published in the last 10 years. Additionally, it will also offer the researcher with some basic background information for phytoconstituents profile, formulation requirements and drug delivery systems.

Contemporary acupressure therapy: Adroit cure for painless recovery of therapeutic ailments.

Since time immemorial, complementary and alternative medicines (CAM) have played a significant role in human health care. CAM is known to have a strong reputation and reliability within every culture to provide basic health care treatment for patients. CAM acts as a better therapeutic option in human being for treating various diseases and improving quality of life with apt consideration to the economic aspects. Acupressure, one of the known CAM, originated in ancient China is based on the principal of acupoints activation across the meridians which correct the imbalance between Qi. Activation of specific points on the meridians is known to facilitate reduction of pain at the local sites. It also reduces the pain from other body parts. This review outlines various types, devices and mechanisms involved in the acupressure treatment.

Dry Powder Inhalers: A Focus on Advancements in Novel Drug Delivery Systems.

Administration of drug molecules by inhalation route for treatment of respiratory diseases has the ability to deliver drugs, hormones, nucleic acids, steroids, proteins, and peptides, particularly to the site of action, improving the efficacy of the treatment and consequently lessening adverse effects of the treatment. Numerous inhalation delivery systems have been developed and studied to treat respiratory diseases such as asthma, COPD, and other pulmonary infections. The progress of disciplines such as biomaterials science, nanotechnology, particle engineering, molecular biology, and cell biology permits further improvement of the treatment capability. The present review analyzes modern therapeutic approaches of inhaled drugs with special emphasis on novel drug delivery system for treatment of various respiratory diseases.

Expression of Tip60, an androgen receptor coactivator, and its role in prostate cancer development.

Prostate cancer (CaP) is initially androgen sensitive and responsive to hormone ablation therapy. However, cancer growth recurs despite androgen deprivation in the majority of cases of advanced disease. The molecular basis of this progression still remains unknown. The significance of androgen receptor (AR) coactivator proteins in this androgen-dependent malignancy is only beginning to emerge. In the present study, we examined the role of Tat interactive protein, 60 kDa (Tip60), an AR coactivator, in CaP progression. In hormone refractory CaP biopsies, we observed a nuclear accumulation of Tip60 expression in contrast to a more diffuse distribution pattern observed in benign prostate hyperplasia and primary CaP. Furthermore, in both the prostate xenograft model CWR22 and the LNCaP CaP cell line, we observed that androgen withdrawal promoted upregulation of Tip60 as well as nuclear accumulation. In contrast, androgen exposure resulted in decreased Tip60 expression that was more closely linked to a cytoplasmic presence. Chromatin immunoprecipitation analysis revealed Tip60's recruitment to the PSA gene promoter in both androgen-dependent and -independent cell lines. Thus, in vitro and in vivo data support a possible role for Tip60 in the molecular pathway leading to the development of androgen-independent CaP following long-term androgen deprivation therapy.

Cupping therapy: A prudent remedy for a plethora of medical ailments.

Since ancient times, complementary and alternative medicine (CAM; bǔ chong yǔ tì dài yi xué) have played an important role in human health and welfare. Many therapeutic approaches in healthcare outside the realm of conventional medicine persist in various parts of the world. There is considerable scientific and commercial potential in CAM, which needs to be explored precisely. Cupping therapy ( bá guàn liáo fǎ), one of the CAM, is practiced across the world. This therapy is believed to act by correcting imbalances in the internal bio field, such as by restoring the flow of "Qi (qì)". Cupping involves applying a heated cup to generate a partial vacuum that mobilizes the blood flow and promotes effective healing. This review outlines various tools and techniques of cupping therapy.