A Distributed Cancer Care Model with a Technology-Driven Hub-and-Spoke and further Spoke Hierarchy: Findings from a Pilot Implementation Programme in Kerala, India.

BACKGROUND: The technology enabled distributed model in Kerala is based on an innovative partnership model between Karkinos Healthcare and private health centers. The model is designed to address the barriers to cancer screening by generating demand and by bringing together the private health centers and service providers at various levels to create a network for continued care. This paper describes the implementation process and presents some preliminary findings.  Methods: The model follows the hub-and-spoke and further spoke framework. In the pilot phases, from July 2021 to December 2021, five private health centers (partners) collaborated with Karkinos Healthcare across two districts in Kerala. Screening camps were organized across the districts at the community level where the target groups were administered a risk assessment questionnaire followed by screening tests at the spoke hospitals based on a defined clinical protocol. The screened positive patients were examined further for confirmatory diagnosis at the spoke centers. Patients requiring chemotherapy or minor surgeries were treated at the spokes. For radiation therapy and complex surgeries the patients were referred to the hubs. RESULTS: A total of 2,459 individuals were screened for cancer at the spokes and 299 were screened positive. Capacity was built at the spokes for cancer surgery and chemotherapy. A total of 189 chemotherapy sessions and 17 surgeries were performed at the spokes for cancer patients. 70 patients were referred to the hub. CONCLUSION: Initial results demonstrate the ability of the technology Distributed Cancer Care Network (DCCN) system to successfully screen and detect cancer and to converge the actions of various private health facilities towards providing a continuum of cancer care. The lessons learnt from this study will be useful for replicating the process in other States.

Self-nanoemulsifying drug delivery systems (SNEDDS) for oral delivery of protein drugs: II. In vitro transport study.

To develop a self-nanoemulsifying drug delivery system (SNEDDS) for protein drugs, and particularly, to test the in vitro transport of beta-lactamase (BLM) by SNEDDS across the cell monolayer. Fluorescently labeled BLM (FITC-BLM), a model protein, formulated into 16 SNEDDS preparations through a solid dispersion technique were studied for transport across MDCK monolayer. All the SNEDDS nanoemulsions resulted in higher transport rate than the free solution. The transport rate by SNEDDS depends on the SNEDDS composition. SNEDDS NE-12-7 (oil: Lauroglycol FCC, surfactant: Cremophor EL and a cosurfactant: Transcutol HP) at the ratio of 5:4:3, rendered the highest transportation rate, 33% as compared to negligible transport by the free solution. FITC-BLM solution mixed with the surfactant and the cosurfactant of SNEDDS NE-12-7 or with blank SNEDDS NE-12-7 increased the transport only by 3.3 and 1.5 folds, respectively, compared to free solution alone. It was found that the monolayer integrity was not compromised in the presence of SNEDDS NE-12-7 or its surfactant/cosurfactant. The SNEDDS significantly increased the transport of FITC-BLM across MDCK monolayer in vitro. SNEDDS may be a potential effective delivery system for non-invasive protein drug delivery.

Self-nanoemulsifying drug delivery systems (SNEDDS) for oral delivery of protein drugs: I. Formulation development.

The global aim of this research project was to develop a self-nanoemulsifying drug delivery system (SNEDDS) for non-invasive delivery of protein drugs. The specific aim of this study was to develop SNEDDS formulations. An experimental design was adopted to develop SNEDDS. Fluorescent labeled beta-lactamase (FITC-BLM), a model protein, was loaded into SNEDDS through solid dispersion technique. The experimental design provided 720 compositions of different oil, surfactant, and co-surfactant at various ratios, of which 33 SNEDDS prototypes were obtained. Solid dispersion of FITC-BLM in SoyPC prepared was able to dissolve in 16 SNEDDS prototypes (approximately 2200 mU BLM in 1g SNEDDS). SNEDDS NE-12-7 (composition: Lauroglycol FCC, Cremophor EL and Transcutol; ratio: 5:4:3) formed O/W nanoemulsion with mean droplet size in the range of 22-50 nm when diluted with various pH media and different dilution factor with PBS (pH 7.4). The phase diagram of NE-12-7 indicated a broad region of nanoemulsion. BLM-loaded SNEDDS (NE-12-7) stored at 4 degrees C for 12 weeks indicated 10% loss of BLM activity. A SNEDDS was developed to load FITC-BLM into the oil phase which can spontaneously form O/W nanoemulsion upon the addition of water.

Self-nanoemulsifying drug delivery system (SNEDDS) for oral delivery of protein drugs: III. In vivo oral absorption study.

To use self-nanoemulsifying drug delivery system (SNEDDS) to deliver hydrophilic proteins orally. beta-Lactamase (BLM), a 29 kDa protein was used as a model protein, and formulated into the oil phase of a SNEDDS through solid dispersion technique. The oral absorption of BLM in rats when delivered by such a SNEDDS was investigated. Oral delivery of 4500 mU/kg of BLM in SNEDDS nanoemulsion resulted in the relative bioavailability of 6.34%, C(max) of 1.9 mU/ml and mean residence time of 12.12h which was 1.5-, 2.7- and 1.3-fold higher than that by free solution, respectively. Delivery of BLM in the aqueous phase of the nanoemulsion resulted in a PK profile similar to that by the free solution. BLM when loaded in oil phase of SNEDDS, can significantly enhance the oral bioavailability of BLM. SNEDDS has a great potential for oral protein delivery.