Collaborative Medication Reviews to Identify Inappropriate Prescribing in Pre-Admission Medications at Emergency Department Short-Term Ward.

PURPOSE: Collaborative medication reviews (CMR) have been shown to reduce inappropriate prescribing (IP) in various settings. This study aimed at describing a CMR practice in an emergency department (ED) short-term ward in Finland to investigate IP in pre-admission medications. PATIENTS AND METHODS: Pre-admission medications were collaboratively reviewed for all the adult ED admissions within a 5-month study period in 2016. Types of IP were inductively categorized, and descriptive statistics were used to show the incidence and type of IP events. RESULTS: The pre-admission medications of 855 adult ED patients were reviewed by the pharmacist, with 113 IP events identified in 83 (9.7%) of the patients. The majority (81%, n=67) of these patients were older adults (≥65 years). Of these 94 IP events identified in 67 older patients, 58 (62%) were confirmed by the ED physicians. The following 3 main categories were inductively developed for the types of identified and confirmed IP events: 1) Misprescribing (prescription of medications that significantly increase the risk of adverse drug events); 2) Overprescribing (prescription of medications for which no clear clinical indications exist); and 3) Underprescribing (omission of potentially beneficial medications that are clinically indicated for treatment or prevention of a disease). Misprescribing was the most common type of IP identified (79% of the identified and 72% confirmed IP events). Benzodiazepines (29%) and antidepressants (28%) were involved in 33 out of 58 (57%) confirmed IP events. Medications with strong anticholinergic effects were involved in 19% of the confirmed IP events. CONCLUSION: The CMR practice was able to identify IP in pre-admission medications of about one-tenth of ED patients. Older patients using benzodiazepines and drugs with strong anticholinergic effects should be paid special attention to ED admissions.

Auditing Safety of Compounding and Reconstituting of Intravenous Medicines on Hospital Wards in Finland.

On the hospital wards in Finland, nurses generally reconstitute intravenous medicines, such as antibiotics, analgesics, and antiemetics prescribed by doctors. Medicine reconstitution is prone to many errors. Therefore, it is important to identify incorrect practices in the reconstitution of medicine to improve patient safety in hospitals. The aim of this study was to audit the compounding and reconstituting of intravenous medicines on hospital wards in a secondary-care hospital in Finland by using an assessment tool and microbiological testing for identifying issues posing patient safety risks. A hospital pharmacist conducted an external audit by using a validated 65-item assessment tool for safe-medicine compounding practices on 20 wards of the selected hospital. Also, three different microbiological samples were collected to assure the aseptics. Practices were evaluated using a four-point rating scale of "never performed," "rarely performed," "often performed," and "always performed," and were based on observation and interviews with nurses or ward pharmacists. In addition, glove-, settle plate-, and media fill-tests were collected. Associations between microbial sample results and audit-tool results were discussed. Altogether, only six out of the 65 items were fully implemented in all wards; these were related to logistic practices and quality assurance. More than half of the wards used incorrect practices ("rarely performed" or "never performed") for five items. Most of these obviated practices related to aseptic practices. All media-fill tests were clean but the number of colony forming units in glove samples and settle- plate samples varied from 0 to >100. More contamination was found in wards where environmental conditions were inadequate or the use of gloves was incorrect. Compounding practices were [mostly] quite well adapted, but the aseptic practices needed improvement. Attention should have been directed particularly to good aseptic techniques and compounding environment on the wards. These results can be used for updating the guidelines and for training nurses involved in compounding.

Development and content validation of an assessment tool for medicine compounding on hospital wards.

Background Medicines should be compounded by using an aseptic technique to assure patient safety. The parenteral administration of microbiologically contaminated doses can result in bacteriaemia, other morbidity and even death. Objective The purpose was to develop and content validate an assessment tool for medicine compounding on hospital wards suitable for self-assessment and external audit to ensure the safety of medicine compounding on wards. Setting Finland as setting. Method The first draft of the tool was based on ISMP "Guidelines for safe preparation of sterile compounds" and a systematic literature search. The tool was validated by using a two-rounded Delphi-method with a panel of 19 experts. Suitability and feasibility of each item was evaluated. Main outcome measure An agreement of ≥70% on each item was required. Results The final tool comprises of 64 items under the following topics: (1) general principles of good compounding practices (23 items), (2) recording and confirming medicine orders on the wards (5 items), (3) storage of medicines on the wards (7), (4) aseptic compounding of intravenous medicines (25 items) and (5) quality assurance (4 items). Most items related to General principles of good compounding practices and Compounding of IV medicines (36 and 38% of the items, respectively). Conclusion It was possible to develop and content validate, by the Delphi method, an assessment tool for safe aseptic compounding on hospital wards. A two-round Delphi process yielded consensus on 64 items for this purpose.

Paracellular porosity and pore size of the human intestinal epithelium in tissue and cell culture models.

The paracellular space defines the passive permeation of hydrophilic compounds in epithelia. The goal of this study was to characterise the paracellular permeation pathway in the human intestinal wall and differentiated epithelial cell models (MDCKII, Caco-2 and 2/4/A1). The permeabilities of hydrophilic polyethylene glycols (PEG) were investigated in diffusion chambers, and mass spectrometry was used to obtain accurate concentrations for each PEG molecule. The paracellular porosity and the size of the pores in the membranes were estimated from the PEG permeability data using an effusion-based approach. The porosities were found to be low (fraction 10(-7)-10(-5) of the epithelial surface) in all investigated membranes. Two different pore sizes (radii 5-6 and >10 A) were detected in the human intestinal epithelium and the Caco-2 and MDCKII cells, while only one (about 15 A) in the 2/4/A1 monolayer. The paracellular porosities of the human small intestine and 2/4/A1 monolayers were larger (>10(-7)) than that of the MDCKII and Caco-2 cells (<10(-7)). We report for the first time the quantitative values describing both porosity and pore size of the paracellular space in the human intestine. The cell models deviate from the small intestine either with respect to porosity (Caco-2, MDCKII) or pore size distribution (2/4/A1).

High-performance liquid chromatography/electrospray ionization tandem mass spectrometry for characterization of enzymatic degradation of 2,2'-bis(2-oxazoline)-linked poly-epsilon-caprolactone.

This paper describes a straightforward and rapid on-line characterization using high-performance liquid chromatography/electrospray ionization tandem mass spectrometry (HPLC/ESI-MS(n)) of the enzymatic degradation products of 2,2'-bis(2-oxazoline)-linked poly-epsilon-caprolactone (PCL-O). These new PCL-O polymers are expected to be used in a variety of pharmaceutical and biomedical applications since they are degraded enzymatically by surface erosion. PCL-O was polymerized in a three-step reaction and characterized by (1)H-NMR and size-exclusion chromatography (SEC). Solvent cast polymer films were exposed to enzymatic degradation in phosphate buffer (pH 7.5, 1% pancreatin). The enzymatic degradation of the polymer produced a wide variety of water-soluble oligomers which were separated and identified by HPLC/ESI-MS(n). Optimization of the gradient HPLC method resulted in effective separation of the oligomers. Furthermore, specific structures of the oligomers were clearly identified by tandem mass spectrometry. According to these results, ester bonds seem to be most sensitive to enzymatic degradation and, correspondingly, pancreatic lipase seems to be mainly responsible for the enzymatic erosion of the PCL-O films. This novel mass spectrometric method provides important knowledge about the enzymatic degradation process and structure of the polymer which is difficult to ascertain by other conventional methods.

Drug adsorption to plastic containers and retention of drugs in cultured cells under in vitro conditions.

Loss of drug content during cell culture transport experiment can lead to misinterpretations in permeability analysis. This study analyses drug adsorption to various plastic containers and drug retention in cultured cells under in vitro conditions. The loss of various drugs to polystyrene tubes and well plates was compared to polypropylene and glass tubes both in deionised water and buffer solution. In cellular uptake experiments, administered drugs were obtained from cultured cells by liquid extraction. Samples were collected at various time points and drug concentrations were measured by a new HPLC-MS/MS method. Acidic drugs (hydrochlorothiazide, naproxen, probenicid, and indomethacin) showed little if any sorption to all tested materials in either water or buffer. In the case of basic drugs, substantial loss to polystyrene tubes and well plates was observed. After 4.5 h, the relative amount remaining in aqueous test solution stored in polystyrene tubes was 64.7 +/- 6.8%, 38.4 +/- 9.1%, 31.9 +/- 6.7%, and 23.5 +/- 6.1% for metoprolol, medetomidine, propranolol, and midazolam, respectively. Interestingly, there was no significant loss of drugs dissolved in buffer to any of the tested materials indicating that buffer reduced surficial interaction. The effect of drug concentration to sorption was also tested. Results indicated that the higher the concentration in the test solution the lower the proportional drug loss, suggesting that the polystyrene contained a limited amount of binding sites. Cellular uptake studies showed considerable retention of drugs in cultured cells. The amounts of absorbed drugs in cellular structures were 0.45%, 4.88%, 13.15%, 43.80%, 23.57% and 11.22% for atenolol, metoprolol, medetomidine, propranolol, midazolam, and diazepam, respectively. Overall, these findings will benefit development and validation of further in vitro drug permeation experiments.

Absorption properties and P-glycoprotein activity of modified Caco-2 cell lines.

Caco-2 cell line is extensively used as an in vitro model in studying small intestinal absorption but it lacks proper expression of efflux pumps and cytochrome P450 enzymes that are involved in absorption and first pass metabolism of drugs. We created two novel Caco-2 cell lines expressing orphan nuclear receptors pregnane X receptor and constitutive androstane receptor that regulate many genes involved in xenobiotic metabolism. We conducted a systematic study on expression of some metabolic genes, P-glycoprotein activity and absorption properties of several drugs with these new cell lines and previously described modified Caco-2 cell lines (MDR1 transfection, vincristine treatment and 1alpha,25-dihydroxyvitamin D3 treatment). A short culture time medium was also included in the study. Most modified cell lines formed tight differentiated monolayers. MDR1, CYP2C9 and CYP3A4 genes were upregulated in some cell lines. Elevated P-glycoprotein activities were observed by calcein-AM uptake experiments but this did not affect significantly the permeability of selected P-glycoprotein substrates. Some cell lines had similar passive and active permeability properties to Caco/WT cells while in few cell lines these were altered. Passive transcellular permeability was modestly elevated in all modified cell lines. In addition, several compounds showed pH-dependent permeability properties.

Quantitative determination of cholesterol, sitosterol, and sitostanol in cultured Caco-2 cells by liquid chromatography-atmospheric pressure chemical ionization mass spectrometry.

In this study, we describe a simple liquid extraction (methanol/choloroform, 1:1, v/v) method for endogenous free cholesterol and administered sterols extracted from cultured Caco-2 cells. To quantify sterol contents in Caco-2 cells, a new HPLC-APCI-MS method was developed. All the sterols were baseline separated using reversed-phase column (C8, 2.1 mm x 150 mm, 3.5 microm) and isocratic conditions (90%, v/v, methanol-water mixture containing 0.2 mM ammonium acetate). The full scan mass spectra of sterols were measured by an ion trap mass spectrometer equipped with an APCI ion source. The intense fragment ions resulting from the loss of water [M+H-H2O]+ (m/z 369, 395, 397 and 399 for cholesterol, stigmasterol, sitosterol, and sitostanol, respectively) were used for determinations. The absolute extraction recovery of sterols from the spiked cell samples were 109.7+/-26.2, 105.7+/-5.1, 109.8+/-5.0 and 99.0+/-7.0% for cholesterol, stigmasterol, sitosterol, and sitostanol, respectively. Furthermore, no significant matrix effect was observed for the sterols in the cell samples. The sample assay was based on the internal standard method using stigmasterol as an internal standard. The method was linear over the concentration ranges of 0.45-9.0 microM (cholesterol) and 0.225-7.2 microM (sitosterol and sitostanol). The within- and between-day precision was less than 7% and accuracy ranged from 93.51 to 101.77%. The lowest limit of quantitation (LLOQ) was 0.225 microM for sitosterol and sitostanol, and 0.45 microM for cholesterol. The accuracy range was 95-106% and precision was lower than 9% for all LLOQ values.

Characterization of Caco-2 cell monolayer drug transport properties by cassette dosing using UV/fluorescence HPLC.

Cassette dosing is commonly used in pharmacokinetic studies to decrease time, labor and expenditures. Cassette dosing (having several compounds in a mixture) has been used to screen in vitro permeabilities in Caco-2 cell monolayers. The cassette dosing method has accelerated both transport experiments and sample analyses, which are both part of Caco-2 permeability screening. In this study, a cassette dosing method was used for a mixture of heterogeneous test drugs, which are transported by various mechanisms across the Caco-2 cell monolayer. To characterize the Caco-2 cell monolayer absorption properties, we developed a new UV/fluorescence HPLC method for nine heterogeneous drugs. This new analytical method is fast and specific for high throughput analysis. Fluorescence detection was used to analyze the low concentration of drugs while UV detection was suitable for higher concentrations. The permeability results of single drugs and the mixture of drugs showed a high degree of similarity for each individual compound. All drugs can be applied to the Caco-2 cell culture as a mixture, and the cassette dosing method is suitable for permeability studies.

Paracellular and passive transcellular permeability in immortalized human corneal epithelial cell culture model.

A cell culture model of human corneal epithelium (HCE-model) was recently introduced [Invest. Ophthalmol. Vis. Sci. 42 (2001) 2942] as a tool for ocular drug permeation studies. In this study, passive permeability and esterase activity of the HCE-model were characterised. Immortalised human corneal epithelial cells were grown on collagen coated filters under air-lift. The sensitivity of transcellular permeability to lipophilicity was tested in studies using nine beta-blockers. The size selectivity of the paracellular route was investigated using 16 polyethylene glycol oligomers (PEG). An effusion-like approach was used to estimate porosity and pore sizes of the paracellular space in HCE membrane. Permeability and degradation of fluorescein diacetate to fluorescein in HCE-cells was used to probe the esterase activity of the HCE-model. Drug concentrations were analyzed using HPLC (beta-blockers), LC-MS (PEGs), and fluorometry (fluorescein). Permeabilities were compared to those in the excised rabbit cornea. Penetration of beta-blockers increased with lipophilicity according to a sigmoidal relationship. This was almost similar to the profile in excised cornea. No apical to basolateral directionality was seen in the permeation of beta-blockers. Paracellular permeability of the HCE-model was generally slightly higher than that of the excised rabbit cornea. The HCE-model has larger paracellular pores, but lower pore density than the excised cornea, but the overall paracellular space was fairly similar in both models. The HCE-model shows significant esterase activity (i.e. fluorescein diacetate was converted to free fluorescein). These data on permeability of 27 compounds demonstrate that the barrier of the HCE-model closely resembles that of the excised rabbit cornea. Therefore, the HCE-model is a promising alternative corneal substitute for ocular drug delivery studies.

Liquid chromatographic-electrospray ionization mass spectrometric analysis of neutral and charged polyethylene glycols.

Poly(ethylene glycols) (PEGs) are widely used water soluble and biocompatible polymers. PEGs are suitable as paracellular probes in biomembrane permeability studies because they are hydrophilic and various oligomers have defined molecular sizes. In previous studies corneal and conjunctival permeability for neutral PEGs has been measured, and the results were used to calculate the number and size of the cellular pores. In this study we have developed a high-performance liquid chromatographic-electrospray ionization-mass spectrometric method for analysis of neutral PEGs and positively changed amino PEGs simultaneously. The new method is fast, accurate, sensitive and specific for high throughput analysis. The method was used to evaluate the paracellular permeability of PEGs through a corneal epithelial cell culture. Paracellular pores are negatively charged and it was in our interest to characterize the interactions of positive charge and size of the molecules with the paracellular pores.