Development and In Vitro Evaluation of Long Circulating Liposomes for Targeted Delivery of Gemcitabine and Irinotecan in Pancreatic Ductal Adenocarcinoma.

The classically used nontargeted chemotherapeutic approach to pancreatic cancer has a dual drawback of suboptimal drug delivery at the target site and the systemic side effects produced by the unfettered exposure of the drug to healthy tissue. This study has the objective of developing novel poly(2-ethyl-2-oxazoline) (PETOX)-based long circulating liposomes loaded with gemcitabine and irinotecan for the treatment of pancreatic ductal adenocarcinoma, with a juxtaposition to PEGylated and uncoated liposomes. A PETOX-cholesteryl chloroformate lipopolymer conjugate (PETOX-ChC) with a carbonate linkage was prepared and characterized by 1H NMR, FTIR, and DSC. Liposomes were prepared using the thin film hydration technique followed by freeze-thaw and membrane extrusion methods. Liposome characterization includes particle size determination, zeta potential determination using a zetameter, and structural elucidation using 31P NMR and cryo-TEM. The PETOXylated liposomes showed a particle size of 180.1 ± 2.2 nm and a zeta potential of - 33.63 ± 1.23 mV. The liposomal combination therapy of gemcitabine and irinotecan was found to have an IC50 value 39 times lower in comparison to the drug combination in solution, while the PEGylated and PETOXylated liposomes showed IC50 values 1.6 times lower and 2 times lower than that of uncoated liposomes, respectively, against Mia PaCa II pancreatic cancer cell line. The PEGylated and PETOXylated liposomes showed 4.1 and 5.4 times slower macrophagial uptake in vitro in comparison to the uncoated liposomes respectively. The PEGylated liposomes showed 11% higher in vitro macrophagial uptake in comparison to PETOXylated liposomes.

The in vitro sub-cellular localization and in vivo efficacy of novel chitosan/GMO nanostructures containing paclitaxel.

PURPOSE: To determine the in vitro sub-cellular localization and in vivo efficacy of chitosan/GMO nanostructures containing paclitaxel (PTX) compared to a conventional PTX treatment (Taxol). METHODS: The sub-cellular localization of coumarin-6 labeled chitosan/GMO nanostructures was determined by confocal microscopy in MDA-MB-231 cells. The antitumor efficacy was evaluated in two separate studies using FOX-Chase (CB17) SCID Female-Mice MDA-MB-231 xenograph model. Treatments consisted of intravenous Taxol or chitosan/GMO nanostructures with or without PTX, local intra-tumor bolus of Taxol or chitosan/GMO nanostructures with or without PTX. The tumor diameter and animal weight was monitored at various intervals. Histopathological changes were evaluated in end-point tumors. RESULTS: The tumor diameter increased at a constant rate for all the groups between days 7-14. After a single intratumoral bolus dose of chitosan/GMO containing PTX showed significant reduction in tumor diameter on day 15 when compared to control, placebo and intravenous PTX administration. The tumor diameter reached a maximal decrease (4-fold) by day 18, and the difference was reduced to approximately 2-fold by day 21. Qualitatively similar results were observed in a separate study containing PTX when administered intravenously. CONCLUSION: Chitosan/GMO nanostructures containing PTX are safe and effective administered locally or intravenously. Partially supported by DOD Award BC045664.

Clinical Applications of PET and PET-CT.

Positron emission tomography (PET) and PET/ computed tomography (CT) are emerging as important imaging techniques and their popularity is growing within the medical fraternity. Though PET has been a useful research tool for many decades its real growth into clinical applications has occurred in the last one decade or so. Currently its major use is in oncologic imaging. However it has a multitude of clinical applications in cardiology, neurology and psychiatry as well. In oncologic imaging, a major advantage of PET is that a single whole-body examination can provide accurate assessment of disease activity and spread. PET/CT amalgamates the functional information of PET with the structural details of the CT scan, thus greatly aiding in accurate staging, therapy response assessment and early detection of recurrent disease.

A novel nanoparticle formulation for sustained paclitaxel delivery.

PURPOSE: To develop a novel nanoparticle drug delivery system consisting of chitosan and glyceryl monooleate (GMO) for the delivery of a wide variety of therapeutics including paclitaxel. METHODS: Chitosan/GMO nanoparticles were prepared by multiple emulsion (o/w/o) solvent evaporation methods. Particle size and surface charge were determined. The morphological characteristics and cellular adhesion were evaluated with surface or transmission electron microscopy methods. The drug loading, encapsulation efficiency, in vitro release and cellular uptake were determined using HPLC methods. The safety and efficacy were evaluated by MTT cytotoxicity assay in human breast cancer cells (MDA-MB-231). RESULTS: These studies provide conceptual proof that chitosan/GMO can form polycationic nano-sized particles (400 to 700 nm). The formulation demonstrates high yields (98 to 100%) and similar entrapment efficiencies. The lyophilized powder can be stored and easily be resuspended in an aqueous matrix. The nanoparticles have a hydrophobic inner-core with a hydrophilic coating that exhibits a significant positive charge and sustained release characteristics. This novel nanoparticle formulation shows evidence of mucoadhesive properties; a fourfold increased cellular uptake and a 1000-fold reduction in the IC(50) of PTX. CONCLUSION: These advantages allow lower doses of PTX to achieve a therapeutic effect, thus presumably minimizing the adverse side effects.

Therapeutic applications of implantable drug delivery systems.

In the past, drugs were frequently administered orally, as liquids or in powder forms. To avoid problems incurred through the utilization of the oral route of drug administration, new dosage forms containing the drug(s) were introduced. As time progressed, there was a need for delivery systems that could maintain a steady release of drug to the specific site of action. Therefore, drug delivery systems were developed to optimize the therapeutic properties of drug products and render them more safe, effective, and reliable. Implantable drug delivery systems (IDDS) are an example of such systems available for therapeutic use. The application of currently available implantable drug delivery systems is the main focus of this review. IDDS can be classified into three major categories: biodegradable or nonbiodegradable implants, implantable pump systems, and the newest atypical class of implants. Biodegradable and nonbiodegradable implants are available as monolithic systems or reservoir systems. The release kinetics of drugs from such systems depend on both the solubility and diffusion coefficient of the drug in the polymer, the drug load, as well as the in vivo degradation rate of the polymer, especially, in the case of the biodegradable systems. Controlled release of drug from the implantable pump is generally achieved utilizing the microtechnology of electronic systems and remote-controlled flow rate manipulation through the maintenance of a constant pressure difference. The third atypical class includes those which have been recently developed such as ceramic hydroxyapatite antibiotic systems used in the treatment of bone infections, intraocular implants for the treatment of glaucoma, and transurethral implants utilized in the treatment of impotence. The major advantages of these systems include targeted local delivery of drugs at a constant rate, less drug required to treat the disease state, minimization of possible side effects, and enhanced efficacy of treatment. Also, these forms of delivery systems are capable of protecting drugs which are unstable in vivo and that would normally require a frequent dosing intervals. Due to the development of such sustained release formulations, it is now possible to administer unstable drugs once a week to once a year that in the past required frequent daily dosing. Preliminary studies using these systems have shown superior effectiveness over conventional methods of treatment. However, one limitation of these newly developed drug delivery systems is the fact that their cost-to-benefit ratio (cost/benefit) is too high which restricts their use over conventional dosage forms. Hopefully, in the future, new implantable systems can be developed at a lower cost, thereby minimizing the cost-to-benefit ratio and therefore, be used extensively in standard therapeutic practice. Some of the most recently discovered implants are in the early developmental stages and more rigorous clinical testing is required prior to their use in standard practice.

Nitric oxide concentrations and cerebrospinal fluid parameters in an experimental animal model of Streptococcus pneumoniae meningitis.

Streptococcus pneumoniae is a common cause of meningitis. Nitric oxide (NO) has been implicated in causing cerebral edema. Modulating NO production in cerebrospinal fluid (CSF) may have a role in the treatment of bacterial meningitis. Experimental S. pneumoniae meningitis was induced in a rabbit model to determine CSF parameters and NO concentrations. An electrochemical probe in the CSF throughout the 7-hour experiment monitored NO concentrations. The animals had S. pneumoniae (10(5)) injected intracisternally and incubated for 1 hour. Cerebrospinal fluid 200-300 microl was obtained by intracisternal puncture at zero, 2, 4, and 7 hours after drug administration to measure glucose, protein, and lactic acid by standard chemical methods. White blood cell count was measured by hemocytometry. Three groups of five animals were used-control (C), ceftriaxone (CTX), and ceftriaxone plus dexamethasone (CTX+D). Ceftriaxone concentrations in CSF were obtained by microdialysis and analyzed by high-performance liquid chromatography. Mean (+/- SEM) CSF white blood cell count was significantly higher at 2 hours in the C group than in the other two groups (C 7307 +/- 1302, CTX 605 +/- 345, CTX+D 730 +/- 43/mm3, p<0.002). Ceftriaxone induced a significant rise in protein at 4 hours compared with the other groups (C 364 +/- 107, CTX 1158 +/- 797, CTX+D 365 +/- 100 mg/dl, p<0.02). Cerebrospinal fluid lactic acid was significantly different at 4 and 7 hours between C and CTX+D groups (4-hr C 8.0 +/- 2.2, CTX+D 2.0 +/- 0.4 mmol/L, p<0.05; 7-hr C 10.2 +/- 2.4, CTX+D 2.8 +/- 0.8 mmol/L, p<0.01). Median NO concentrations were significantly elevated in the control group compared with the other two groups (C 11.7, CTX 6.8, CTX+D 6.5 micro, p<0.02 C vs CTX, p<0.01 C vs CTX+D). Average (+/- SEM) NO concentrations were significantly higher in the C group at 4 hours (18.1 +/- 0.4, CTX 5.8 +/- 1.8 microM, p<0.05; CTX+D 11.5 +/- 4.0 microM, p>0.05), whereas they did not rise significantly until 7 hours in the CTX group (CTX 18.7 +/- 0.7, C 8.9 +/- 0.4 microM, p=0.055; CTX+D 8.1 +/- 2.2 microM, p<0.05). These results indicate that ceftriaxone with or without dexamethasone significantly decreases lactic acid concentrations and white cell penetration into the CSF in an experimental model of S. pneumoniae meningitis. In addition, ceftriaxone induced a significant elevation in CSF protein. Median NO production in the CSF was significantly attenuated by ceftriaxone.

Solid-state characterization of AG337 (Thymitaq), a novel antitumor drug.

AG337 (Thymitaq) is an antitumor compound synthesized by Agouron Pharmaceuticals, Inc., using protein structure-based drug design. AG337 is a hydrochloride salt with a molecular formula of C14H12N4OS.2HCl. This compound was subjected to thermal analyses, Karl Fischer titrimetry, powder X-ray diffractometry, scanning electron microscopy, and FTIR. On the basis of the Karl Fischer and thermogravimetric analysis, it was conclude to be a dihydrate. The differential scanning calorimetric studies revealed, that on heating, AG337 dehydrates and form a metastable form with a melting point of 213 degrees C followed by crystallization into a stable form at 261 degrees C. This stable form was finally melted at 312 degrees C with decomposition. On the basis of the FTIR and HPLC studies, it was concluded that the final exothermic peak at 320 degrees C was due to sample decomposition. The powder X-ray diffraction studies confirmed the existence of these two polymorphs of AG337. Scanning electron microscopic studies revealed that the crystal habits of both the polymorphs were quite different. FTIR spectra of both the polymorphs showed pronounced difference in the range of 600-1800 cm-1.

Use of gelatin-acacia coacervate containing benzocaine in topical formulations.

The in vitro release of a drug from topical formulations depends on the concentration of the drug in the formulation, the solubility of the drug in the base, the diffusion coefficient of the drug in the vehicle, and the partition coefficient of the drug between the vehicle, and the release medium. Incorporation of both complexing agents and cosolvents into such formulations has been used to enhance the in vitro release of a drug from topical formulations. In this investigation, a novel approach to enhance the in vitro release of benzocaine from different ointment formulations has been introduced. In this study, benzocaine was microencapsulated using gelatin-acacia complex coacervation technique. Various weight fractions of the coacervate, 5, 10, and 20% (w/w), were incorporated into both oleaginous and absorption bases. The in vitro release characteristics of benzocaine from the resulting ointments were studied using a modified USP Dissolution Apparatus 2. A plot of the cumulative amount of drug released (7-8%) per unit surface area versus (time)(1/2) was linear. Microscopic studies of the formulations revealed that the coacervates maintained their integrity in the formulation during the preparation and storage of the dosage form. Differential scanning calorimetric (DSC) studies indicated that the drug existed in the crystalline state in all formulations including those at a low drug load (0.5% w/w). DSC was also used to determine the solubility of the drug in the formulation. The rate and extent of drug release was higher in the absorption base as compared to the oleaginous base.

X-ray powder diffractometric method for quantitation of crystalline drug in microparticulate systems. I. Microspheres.

Ethylcellulose microspheres containing tolnaftate (I) were prepared by the emulsion-solvent evaporation technique. An X-ray powder diffractometric method was developed to quantify the content of crystalline I in these microspheres. X-ray lines of I with d-spacings of 5.5 and 4.2 A were chosen for the quantitative analyses. Physical mixtures containing various weight fractions of I and blank (empty) microspheres were prepared and lithium fluoride (20% w/w) was added as the internal standard. The 5.5 and 4.3 A lines of I and the 2.3 A line of lithium fluoride were used for the quantitative analysis. A plot of the intensity ratio (intensity of the 5.5 A line of I/intensity of 2.3 A line of lithium fluoride) as a function of the weight percent of I in the mixture, resulted in a straight line. The crystalline content of I in the tolnaftate-loaded microspheres was determined using this standard curve. A second independent determination of the content of I was possible from the intensities of the 4.3 A line. The enthalpy of fusion of I, determined by differential scanning calorimetry (DSC), was also used as a measure of the crystalline content of I in the microspheres. The X-ray and DSC methods measure the content of crystalline I in the microspheres at room temperature ( approximately 25 degrees C) and at the melting point of I (111 degrees C), respectively. The total content of I in the microspheres was determined by HPLC. The DSC and X-ray results indicated that a substantial fraction of the incorporated I was dissolved in the ethylcellulose matrix.

Development of an in vitro dissolution method using microdialysis sampling technique for implantable drug delivery systems.

The major challenge faced during the development of implantable dosage forms for site-specific delivery is monitoring the local concentration of the drug at or around the site of action. The tissue concentration at the site is generally measured by either sacrificing the animal at different points in time or by determining the amount of drug left in the implants at various time intervals. Unfortunately, there are no official in vitro dissolution methods available to study the release characteristics of drugs from this drug delivery system. The objective of this investigation was to develop a simple method using microdialysis sampling technique to serve as an in vitro dissolution method for implantable drug delivery systems. Ciprofloxacin implants were prepared by compressing ciprofloxacin microcapsules in poly(lactic acid) (PLA) and poly(lactic-glycolic acid) (PLGA). A sensitive HPLC method was developed and validated for the assay of Ciprofloxacin. An in vitro dissolution method was developed to study the release characteristics of drug from these implants. The method used a microdialysis sampling technique and a small sample volume of release medium. The various advantages and disadvantages of this method over other USP methods are discussed.

Evaluation of creatine transport using Caco-2 monolayers as an in vitro model for intestinal absorption.

Creatine is a nutraceutical that has gained popularity in both well-trained and casual athletes for its performance-enhancing or ergogenic properties. The major disadvantages of creatine monohydrate formulations are poor solubility and oral bioavailability. In the present study, creatine transport was examined using Caco-2 monolayers as an in vitro model for intestinal absorption. Confluent monolayers of Caco-2 cells (passage 25-35) were used for the permeability studies. Monolayers were placed in side-by-side diffusion chambers. (14)C-Creatine (0.1-0.5 microCi/mL) was added to either the apical or basolateral side, and the transport of the creatine across the Caco-2 monolayer was measured over a 90-min period. The apical to basolateral transport of (14)C-creatine was small, ranging from 0.2-3% of the original amount appearing on the receiver side in a 90-min period. Interestingly, the basolateral to apical permeability of radiolabeled creatine was substantially greater than that observed in the apical to basolateral direction. Studies with drug efflux transport inhibitors indicate that neither the P-glycoprotein nor multidrug resistance-associated protein is involved in the enhanced basolateral to apical transport of creatine.

Effect of cross-linking on the in vitro release kinetics of doxorubicin from gelatin implants.

Doxorubicin is one of the most potent anti-tumor agents used generally in the treatment of bone cancer. Like other cancer chemotharepeutics, it produces undesirable side effects such as cardiotoxicity, which is especially severe when administrated via the conventional intravenous route. In order to minimize the systemic toxicities and to make this drug more suitable for the treatment of bone cancer, an implantable delivery system with cross-linked gelatin as the biodegradable matrix material was developed. This delivery system could possibly improve targeting of the drug as well as sustain the rate of release of the drug to the tumor. Glutaraldehyde was used as a cross-linking agent. Incorporation of glutaraldehyde in the matrix was needed to maintain the mechanical strength of the implant and to sustain the rate of release of the drug from the implant. Besides cross-linking the gelatin matrix, glutaraldehyde was found to cross-link the free amino group of doxorubicin. The effect of cross-linker concentration on the stability of the drug in the implant and on the rate and extent of release were also evaluated. In conclusion, cross-linked gelatin implants were developed for the local delivery of doxorubicin.

Development of a rectal nicotine delivery system for the treatment of ulcerative colitis.

The aims of this investigation were: i. to develop a rectal nicotine delivery system with bioadhesives for the treatment of ulcerative colitis and ii. to evaluate nicotine transport and cytotoxicity of the delivery system using Caco-2 cell culture systems. Rectal nicotine suppository formulations were prepared in semi-synthetic glyceride bases (Suppocire AM and AI, Gattefosse Inc.) by fusion method. The in vitro release of nicotine was carried out in modified USP dissolution apparatus 1. Differential scanning calorimetry (DSC) and powder X-ray diffraction were used to study the polymorphic changes if any in the formulations. An LC method was used for the assay of nicotine. The effect of bioadhesives (glyceryl monooleate (GMO), and Carbopol) on the nicotine flux was evaluated using Caco-2 cell permeability studies and Caco-2 cell viability was determined using the MTT toxicity assay. In vitro release studies indicated that the low melting AI base was superior to that of the AM base. Presence of GMO in the formulation enhanced the release of nicotine whereas Carbopol showed an opposite effect. The enhanced release of nicotine in the presence of GMO was found to be partly due to the melting point lowering effect of this compound. Caco-2 cell absorption studies showed that there was a decrease in the flux of nicotine in the presence of both the bioadhesives. The flux of the fluorescein marker which is used to study the integrity of the cell monolayers was found to be slightly higher only in the presence of 10% (w/w) Carbopol. Nicotine, Carbopol, and GMO do not have any cytotoxic effect on these cell monolayers within the concentration range used in the formulations. Rectal nicotine formulations containing bioadhesives were developed and characterized. Both in vitro release and cell culture studies have indicated that one can manipulate the nicotine release from these rectal delivery systems by incorporation of various bioadhesives or the use of different bases in the formulation. Nicotine concentration below 2% (w/v) and bioadhesive concentration below 10% (w/w) do not have any cytotoxic effect on Caco-2 cells.

A liquid chromatographic method for the determination of tolnaftate in pharmaceutical formulations.

A simple LC method was developed and validated for the analysis of tolnaftate in various pharmaceutical formulations. This method did not require any complex sample extraction procedure. The chromatographic separation was achieved on a reversed-phase, C18 column with UV detection at 258 nm. This isocratic system was operated at ambient temperature and required 9 min of chromatographic time. The mobile phase consisted of methanol-aqueous potassium dihydrogen phosphate solution (80:20, v/v) at a flow rate of 1.5 ml min-1. Standard curves were linear over the concentration range of 1.0-51.0 micrograms ml-1. Within-day and between-day relative standard deviation values ranged from 0.7 to 2.9% and from 1.3 to 3.4%, respectively. This method was used to quantify tolnaftate in microcapsule, microsphere, cream, powder, liquid, liquid aerosol and powder aerosol formulations. This method was also used to study the stability of tolnaftate in solution during its extraction from microcapsule formulations.

A liquid-chromatographic method for the determination of tobramycin.

A rapid and sensitive liquid-chromatographic method was developed to quantify the release of tobramycin from polymeric drug delivery systems in vitro. Pre-column derivatization of tobramycin and kanamycin B sulphate (internal standard) was carried out with 2,4,6-trinitrobenzenesulphonic acid. The sample volume required was only 50 microliters. The chromatographic separation was achieved on an octyl reversed-phase column with UV detection at 340 nm. This isocratic method was performed at ambient temperature and required only 8 min of chromatography time. The standard curves were linear over the concentration range 0.50-50.0 mg l-1. Inter-day and intra-day relative standard deviations ranged from 3.6 to 9.3% and from 1.6 to 6.8%, respectively. The assay method was used to determine the tobramycin content in different pharmaceutical formulations and to study the stability of the drug both in the solid-state and in solution.

A simple HPLC method using a microbore column for the analysis of doxorubicin.

Doxorubicin is one of the most potent anti-tumor agents generally used in the treatment of bone cancer. A simple and sensitive HPLC method was developed and validated for the assay of doxorubicin. The method used a C18 Luna microbore column (50 x 1 mm) with a fluorescent detector (505 nm Ex. and 550 nm Em.). The mobile phase consisted of water-acetonitrile-acetic acid (80:19:1, v/v/v, pH 3.0) and the flow rate was 0.1 ml min(-1). Daunomycin was used as the internal standard. This isocratic system required a 10-min run-time, giving a detection limit of 0.02 ng (0.035 pmol per injection). Standard curves were linear over the concentration range of 0.01-0.1 microg ml(-1). Relative standard deviations (R.S.D.) for the within-day, day-to-day precision, and the accuracy measurement for the assay were less than 4.0, 3.2, and 4.1%, respectively. This HPLC method was used to study the in vitro release characteristics of doxorubicin from implantable drug delivery system.

Evaluation of an acetic acid ester of monoglyceride as a suppository base with unique properties.

The objective of this investigation was to evaluate an acetic acid ester of monoglycerides made from edible, fully hydrogenated palm oil (AC-70) as a suppository base and compare it with a commercially available semisynthetic base (Suppocire AI). Benzocaine and miconazole were used as model drugs. Suppositories were prepared by the fusion method. The drug loads in the suppositories were kept at 2% to 5% (wt/wt). In vitro release of drug from the suppositories into Sorensen's phosphate buffer (pH 7.4) was studied using a US Pharmacopeia dissolution apparatus 1 and a spectrophotometer. The melting behavior of the bases and the physical state of the drug in the suppositories were studied using a differential scanning calorimeter (DSC). Powder x-ray diffractometry was used to study any possible polymorphic changes in the AC-70 base during formulation and storage. In vitro release studies revealed that the release of benzocaine from the AC-70 suppository was substantially slower than that of the commercial AI base. At a 2.5% (wt/wt) benzocaine load, the release of drug from the AC-70 suppositories was found to be linear. This slow and linear release was attributed to the physical property of the base, which forms liquid crystalline phases in the aqueous dissolution medium. The lyotropic liquid crystalline phase has the ability to incorporate drug into its structure and can control the release kinetics of the drug from such a system. The apparent pH of the release medium (water) was decreased by 1 to 1.5 pH units when the AC-70 base was used. The DSC studies revealed that the melting range of the AC-70 base is 36 degrees C to 38 degrees C, which is ideal for suppository formulations. The results of these studies support the possibility of using this new base for slow-release suppository formulations. This base may be of particular interest for a drug that requires an acidic environment to maintain its activity.

Evaluation of quick disintegrating calcium carbonate tablets.

The purpose of this investigation was to develop a rapidly disintegrating calcium carbonate (CC) tablet by direct compression and compare it with commercially available calcium tablets. CC tablets were formulated on a Carver press using 3 different forms of CC direct compressed granules (Cal-Carb 4450, Cal-Carb 4457, and Cal-Carb 4462). The breaking strength was measured using a Stokes-Monsanto hardness tester. The disintegration and dissolution properties of the tablets were studied using USP methodology. The calcium concentration was determined by an atomic absorption spectrophotometer. Scanning electron microscopy was used to evaluate the surface topography of the granules and tablets. Breaking strength of Cal-Carb 4450, Cal-Carb 4457, and Cal-Carb 4462 tablets was in the range of 7.2 to 7.7 kg, as compared with a hardness of 6.2 kg and 10 kg for the commercially available calcium tablets Citracal and Tums, respectively. The disintegration time for the tablets presented in the order earlier was 4.1, 2.1, 1.9, 2.9, and 9.7 minutes, respectively. The dissolution studies showed that all formulations released 100% of the elemental calcium in simulated gastric fluid in less than 20 minutes. In summary, this study clearly demonstrated that quick disintegrating CC tablets can be formulated without expensive effervescence technology.

Subclinical atherosclerosis and silent myocardial ischaemia in patients with type 2 diabetes: a protocol of a clinico-observational study.

INTRODUCTION: Atherosclerotic cardiovascular disease is a significant modifiable complication in patients with diabetes and subclinical atherosclerosis is considered a surrogate marker of future vascular events. The clustering of cardiometabolic-risk factors in patients with diabetes and cardiovascular disease is increasingly being recognised. Recent evidence indicates that 20-50% of asymptomatic patients with diabetes may have silent coronary heart disease. However, the identification of subclinical atherosclerosis and silent myocardial ischaemia in patients with diabetes has been less well-explored, especially in low-resource population settings where cost-effective non-invasive clinical tools are available. The objective of this study is to identify patients with physician-diagnosed diabetes who are at risk of developing future cardiovascular events measured as subclinical atherosclerosis and silent myocardial ischaemia in an urban population of Eastern India. METHODS AND ANALYSIS: This is a cross-sectional clinico-observational study. A convenience sampling of approximately 350 consecutive patients with type 2 diabetes based on predefined inclusion and exclusion criteria will be identified at an urban diabetes center. This estimated sample size is based on an expected prevalence of silent myocardial ischaemia of 25% (± 5%), we computed the required sample size using OpenEpi online software assuming an α level of 0.05 (95% CI) to be 289. On factoring 20% non-response the estimated sample size is 350. Previously validated questionnaire tools and well-defined clinical, anthropometric and biochemical measurements will be utilised for data collection. The two primary outcomes-subclinical atherosclerosis and silent myocardial ischaemia will be measured using carotid intima-media thickness and exercise tolerance testing, respectively. Descriptive and multivariate logistic regression statistical techniques will be employed to identify 'at risk' patients with diabetes, and adjusted for potential confounders. ETHICS AND DISSEMINATION: Ethical approval was granted by the institutional review board of Kalinga Institute of Medical Sciences, Bhubaneshwar, India. Data will be presented at academic fora and published in peer-reviewed journals.

Effect of obesity on cardiometabolic risk factors in Asian Indians.

OBJECTIVES: To determine the prevalence of overweight and obesity and their effects on cardiometabolic risk factors in a representative sample of urban population in Eastern India. MATERIALS AND METHODS: A population-based survey was conducted among a randomly selected study population aged 20-80 years in an urban population of Berhampur city of Eastern India. Both anthropometric and biochemical information were collected, in addition to detailed information on classical cardiometabolic risk factors. Both descriptive and inferential statistical analyses were performed. Obesity and overweight were defined based on the revised Asian-Pacific population criteria (Body mass index [BMI] ≥25 kg/m(2) and ≥23 kg/m(2), respectively). RESULTS: The age-standardized rates of obesity and overweight are 36.8% (Males: 33.2%; Females: 40.8%) and 17.6%, (Males: 20.4%; Females: 15.1%) respectively, i.e., over half are either obese or overweight in this study population. Compared to the World Health Organization (WHO) standard cutoff criteria of overweight [BMI ≥25 kg/m(2)] and obesity [BMI >30 kg/m(2)], the cardiometabolic risk factors studied showed a significant incremental rise even with the lower cutoffs of the revised Asia-Pacific criteria. Older age, female gender, family history of diabetes, being hypertensive, hypertriglyceridemia, hypercholesterolemia, physical inactivity and middle to higher socioeconomic status significantly contributed to increased obesity risk among this urban population. CONCLUSION: One-third of the urban populations are obese in Eastern India - an underestimate compared to the standard BMI cutoff criteria. Nevertheless, significant associations of the classical cardiometabolic risk factors with obesity were observed using the revised Asia-Pacific criteria clearly indicating a more aggressive cardiovascular prevention strategy for Asian Indians.