Bangladeshi children with acute diarrhoea show faecal microbiomes with increased Streptococcus abundance, irrespective of diarrhoea aetiology.

We report streptococcal dysbiosis in acute diarrhoea irrespective of aetiology. Compared with 20 healthy local controls, 71 Bangladeshi children hospitalized with acute diarrhoea (AD) of viral, mixed viral/bacterial, bacterial and unknown aetiology showed a significantly decreased bacterial diversity with loss of pathways characteristic for the healthy distal colon microbiome (mannan degradation, methylerythritol phosphate and thiamin biosynthesis), an increased proportion of faecal streptococci belonging to the Streptococcus bovis and Streptococcus salivarius species complexes, and an increased level of E. coli-associated virulence genes. No enteropathogens could be attributed to a subgroup of patients. Elevated lytic coliphage DNA was detected in 2 out of 5 investigated enteroaggregative E. coli (EAEC)-infected patients. Streptococcal outgrowth in AD is discussed as a potential nutrient-driven consequence of glucose provided with oral rehydration solution.

Long-Term Gastrointestinal Consequences are Frequent Following Sporadic Acute Infectious Diarrhea in a Tropical Country: A Prospective Cohort Study.

BACKGROUND: Postinfection irritable bowel syndrome (PI-IBS) and functional dyspepsia (PI-FD), though reported from the temperate countries, have not been studied in the tropics; PI-malabsorption syndrome (MAS), which mimics PI-IBS, is reported from the tropics. No report till date on PI-IBS excluded PI-MAS. We studied: (i) the frequency of continuing bowel dysfunction after acute gastroenteritis (AG), (ii) its predictors, and (iii) PI-MAS among patients with PI-IBS. METHODS: 345 consecutive subjects each, with AG and age- and gender-matched healthy controls were followed up 3-monthly for 12 months using a translated-validated questionnaire and functional gastrointestinal disorders (FGIDs) were diagnosed by Rome III criteria. Symptom duration >3 months but <6 months was diagnosed as chronic bowel dysfunction (CBD) and dyspeptic symptoms, respectively. MAS was diagnosed if 2/3 tests (D-xylose H2 breath test, Sudan III-stained stool microscopy, and duodenal histology) were abnormal. Fecal microbiological studies were performed in 245/345 (71%) patients. RESULTS: AG patients more often developed PI-IBS and PI-FD than controls (16.5 vs. 2.6% and 7.4 vs. 0.6%, respectively; p<0.001). Presence of FD was a risk factor for PI-IBS and IBS for PI-FD. On multivariate analysis, dyspeptic symptoms, CBD, and weight loss were the risk factors for PI-FGIDs. The frequency of PI-IBS following Vibrio cholera and other bacterial infection was comparable. Malabsorption was present among 2/23 (9%) patients with PI-IBS. CONCLUSION: FGIDs are common after AG; dyspeptic symptoms, CBD, and weight loss were risk factors for PI-FGIDs. Vibrio cholerae infection caused PI-FGID, which was never reported. About 9 % patients fulfilling the criteria for PI-IBS had PI-MAS.

Establishing Palliative Care across the AKDN Health Services: Opportunities and Challenges.

AKDN has one of the most comprehensive private not-for-profit health care systems in the developing world. It has state-of-the-art urban academic tertiary care centers, service hospitals and community based primary care centers spread across the most remote areas of Central and South Asia and East Africa. In response to a global initiative to make palliative care widely available, the AKDN is spearheading the integration of palliative care across its international health network. The scope includes specialist palliative care services in urban tertiary care centers across secondary and outreach programs to home based palliative care services. The ultimate goal is to develop a comprehensive structure of palliative care services which, in addition tofulfilling the vision of quality, also fulfills the needs of the communities that it serves. This article describes the international undertaking; its challenges and the key contextual design principles of the implementation.

Development and evaluation of nanosized niosomal dispersion for oral delivery of Ganciclovir.

Encapsulation of Ganciclovir in lipophilic vesicular structure may be expected to enhance the oral absorption and prolong the existence of the drug in the systemic circulation. So the purpose of the present study was to improve the oral bioavailability of Ganciclovir by preparing nanosized niosomal dispersion. Niosomes were prepared from Span40, Span60, and Cholesterol in the molar ratio of 1:1, 2:1, 3:1, and 3:2 using reverse evaporation method. The developed niosomal dispersions were characterized for entrapment efficiency, size, shape, in vitro drug release, release kinetic study, and in vivo performance. Optimized formulation (NG8; Span60:Cholesterol 3:2 molar ratio) has shown a significantly high encapsulation of Ganciclovir (89±2.13%) with vesicle size of 144±3.47 nm (polydispersity index [PDI]=0.08). The in vitro release study signifies sustained release profile of niosomal dispersions. Release profile of prepared formulations have shown that more than 85.2±0.015% drug was released in 24 h with zero-order release kinetics. The results obtained also revealed that the types of surfactant and Cholesterol content ratio altered the entrapment efficiency, size, and drug release rate from niosomes. In vivo study on rats reveals five-time increment in bioavailability of Ganciclovir after oral administration of optimized formulation (NG8) as compared with tablet. The effective drug concentration (>0.69 µg/mL in plasma) was also maintained for at least 8 h on administration of the niosomal formulation. In conclusion, niosomes can be proposed as a potential oral delivery system for the effective delivery of Ganciclovir.

Blended Oncology Nursing Training: A Quality Initiative in East Africa.

PURPOSE: Lack of education and awareness about cancer treatment may result in suboptimal care of patients with cancer. Unlike high-income countries, resource-limited countries lack the standardized training and scope of practice in oncology nursing. This quality improvement project was conducted to assess nurses' knowledge gain, retention of knowledge and clinical skill set, and feasibility of a blended learning approach in the care of adult oncology patients across four hospitals in Kenya and Tanzania. METHOD: We used a combination of computer-led eLearning sessions and face-to-face interactions over 12 months for cancer education to oncology nurses. Pre- and posttests with each training session were combined with face-to-face clinical skills training at beginning and completion of the course. A comprehensive postassessment was conducted immediately after the training, and at 6, 9, and 12 months to evaluate knowledge gain and retention. CONCLUSION: Of 21 participants across four sites, there was a statistically significant improvement in knowledge scores for 12 participants (P value < .05). The mean pre- and posttest results found significant differences across 10 sessions individually and cumulatively (P value < .01). Results from a one-way repeated measures analysis of variance (ANOVA) test on comprehensive test results suggested that there was no significant difference in knowledge retention across 9 months (F(2, 30) = 1.648412, P > .05). IMPLICATIONS FOR NURSING PRACTICE: Blended learning is an effective tool in improving knowledge, skills, and self-efficacy for clinicians practicing in resource-limited countries. Developing a structured oncology training program has implications for bridging knowledge gaps among clinicians in resource-limited countries and promoting international knowledge exchange.

Microemulsions as a surrogate carrier for dermal drug delivery.

Microemulsions are isotropic, thermodynamically stable transparent (or translucent) systems of oil, water, and surfactant, frequently in combination with a cosurfactant with a droplet size usually in the range of 20-200 nm. Since their discovery, they have attained increasing significance both in basic research and in industry. Due to their distinct advantages such as enhanced drug solubility, thermodynamic stability, facile preparation, and low cost, uses and applications of microemulsions have been numerous. Recently, there is a surge in the exploration of microemulsion for transdermal drug delivery for their ability to incorporate both hydrophilic (5-fluorouracil, apomorphine hydrochloride, diphenhydramine hydrochloride, tetracaine hydrochloride, and methotrexate) and lipophilic drugs (estradiol, finasteride, ketoprofen, meloxicam, felodipine, and triptolide) and enhance their permeation. Very low surface tension in conjunction with enormous increase in the interfacial area due to nanosized droplets of the microemulsion influences the drug permeation across the skin. A large number of oils and surfactants are available, which can be used as components of microemulsion systems for transdermal delivery but their toxicity, irritation potential, and unclear mechanism of action limit their use. Besides surfactants, oils can also act as penetration enhancers (oleic acid, linoleic acid, isopropyl myristate, isopropyl palmitate, etc.). The transdermal drug delivery potential of microemulsions is dependent not only on the applied constituents of the vehicle but also drastically on the composition/internal structure of the phases which may promote or hamper the drug distribution in the vehicles. This article explores microemulsion as transdermal drug delivery vehicles with emphasis on components selection for enhanced drug permeation and skin tolerability of these systems and further future directions.

Solid self-nanoemulsifying delivery systems as a platform technology for formulation of poorly soluble drugs.

New drug discovery programs produce molecules with poor physico-chemical properties, making delivery of these molecules at the right proportion into the body a big challenge to the formulation scientist. The various options available to overcome the hurdle include solvent precipitation, micronisation/nanonization using high-pressure homogenization or jet milling, salt formation, use of microspheres, solid dispersions, cogrinding, complexation, and many others. Self-nanoemulsifying systems (SNES) form one of the most popular and commercially viable approaches for delivery of poorly soluble drugs exhibiting dissolution rate limited absorption, especially those belonging to the Biopharmaceutics Classification System II/IV. SNES are essentially an isotropic blend of oils, surfactants, and/or cosolvents that emulsify spontaneously to produce oil in water nanoemulsion when introduced into aqueous phase under gentle agitation. Conventional SNES consist of liquid forms filled in hard or soft gelatin capsules, which are least preferred due to leaching and leakage phenomenon, interaction with capsule shell components, handling difficulties, machinability, and stability problems. Solidification of these liquid systems to yield solid self-nanoemulsifying systems (SSNES) offer a possible solution to the mentioned complications, and that is why these systems have attracted wide attention. Other than the advantages and wide application of SSNEDS, the present paper focuses on formulation considerations, selection, and function of solidifying excipients; techniques of preparation; and case studies of drugs selected from different therapeutic categories. Developments in the techniques for in vitro evaluation of SSNEDS have also been discussed.

Development and in vitro evaluation of an acid buffering bioadhesive vaginal gel for mixed vaginal infections.

An acid buffering bioadhesive vaginal (ABBV) gel was developed for the treatment of mixed vaginal infections. Different bioadhesive polymers were evaluated on the basis of their bioadhesive strength, stability and drug release properties. Bioadhesion and release studies showed that guar gum, xanthan gum and hydroxypropyl methylcelullose K4M formed a good combination of bioadhesive polymers to develop the ABBV gel. Monosodium citrate was used as an acid buffering agent to provide acidic pH (4.4). The drugs clotrimazole (antifungal) and metronidazole (antiprotozoal as well as antibacterial) were used in the formulation along with Lactobacillus spores to treat mixed vaginal infections. The ex vivo retention study showed that the bioadhesive polymers hold the gel for 12-13 hours inside the vaginal tube. Results of the in vitro antimicrobial study indicated that the ABBV gel had better antimicrobial action than the commercial intravaginal drug delivery systems and retention was prolonged in an ex vivo retention experiment.

Comparative efficacy of liposome-entrapped amiloride and free amiloride in animal models of seizures and serum potassium in mice.

The present study was aimed to evaluate a liposomal formulation of amiloride on experimental seizure models including the increasing current electroshock seizure threshold test (ICES), pentylenetetrazole (PTZ)-induced seizures and PTZ-induced status epilepticus in mice. Further, the effect of liposomal amiloride on serum K(+) levels was also investigated using flame photometry. We found an improved anticonvulsant action with liposome-entrapped amiloride as compared to free amiloride. Further, free amiloride showed an increase in serum K(+) levels, however the latter was unaffected with liposomal formulation treatment. These results, together with previously published data, suggest that as drug delivery vehicles, liposomes can enhance the effectiveness of drugs in the CNS without producing peripheral toxicity (hyperkalemia).

Development and evaluation of acid-buffering bioadhesive vaginal tablet for mixed vaginal infections.

An acid-buffering bioadhesive vaginal tablet was developed for the treatment of genitourinary tract infections. From the bioadhesion experiment and release studies it was found that polycarbophil and sodium carboxymethylcellulose is a good combination for an acid-buffering bioadhesive vaginal tablet. Sodium monocitrate was used as a buffering agent to provide acidic pH (4.4), which is an attribute of a healthy vagina. The effervescent mixture (citric acid and sodium bicarbonate) along with a superdisintegrant (Ac-Di-sol) was used to enhance the swellability of the bioadhesive tablet. The drugs clotrimazole (antifungal) and metronidazole (antiprotozoal as well as an antibacterial) were used in the formulation along with Lactobacillus acidophilus spores to treat mixed vaginal infections. From the ex vivo retention study it was found that the bioadhesive polymers hold the tablet for more than 24 hours inside the vaginal tube. The hardness of the acid-buffering bioadhesive vaginal tablet was optimized, at 4 to 5 kg hardness the swelling was found to be good and the cumulative release profile of the developed tablet was matched with a marketed conventional tablet (Infa-V). The in vitro spreadability of the swelled tablet was comparable to the marketed gel. In the in vitro antimicrobial study it was found that the acid-buffering bioadhesive tablet produces better antimicrobial action than marketed intravaginal drug delivery systems (Infa-V, Candid-V and Canesten 1).

Development and evaluation of thymoquinone-encapsulated chitosan nanoparticles for nose-to-brain targeting: a pharmacoscintigraphic study.

Chitosan (CS) nanoparticles of thymoquinone (TQ) were prepared by the ionic gelation method and are characterized on the basis of surface morphology, in vitro or ex vivo release, dynamic light scattering, and X-ray diffractometry (XRD) studies. Dynamic laser light scattering and transmission electron microscopy confirmed the particle diameter was between 150 to 200 nm. The results showed that the particle size of the formulation was significantly affected by the drug:CS ratio, whereas it was least significantly affected by the tripolyphosphate:CS ratio. The entrapment efficiency and loading capacity of TQ was found to be 63.3% ± 3.5% and 31.23% ± 3.14%, respectively. The drug-entrapment efficiency and drug-loading capacity of the nanoparticles appears to be inversely proportional to the drug:CS ratio. An XRD study proves that TQ dispersed in the nanoparticles changes its form from crystalline to amorphous. This was further confirmed by differential scanning calorimetry thermography. The flat thermogram of the nanoparticle data indicated that TQ formed a molecular dispersion within the nanoparticles. Optimized nanoparticles were evaluated further with the help of scintigraphy imaging, which ascertains the uptake of drug into the brain. Based on maximum concentration, time-to-maximum concentration, area-under-curve over 24 hours, and elimination rate constant, intranasal TQ-loaded nanoparticles (TQ-NP1) proved more effective in brain targeting compared to intravenous and intranasal TQ solution. The high drug-targeting potential and efficiency demonstrates the significant role of the mucoadhesive properties of TQ-NP1.

Antiepileptic intranasal Amiloride loaded mucoadhesive nanoemulsion: development and safety assessment.

Current investigation aimed to develop a novel Amiloride loaded mucoadhesive nanoemulsion formulation for nose-to-brain delivery. Furthermore, nasal irritation study and histopathological examination of the nasal mucosa were also carried out to assess nonirritant nature of the nanoemulsion. The optimized formulation, surface epithelium lining and the granular cellular structure of the nasal mucosa were totally intact, whereas KCl caused major changes in the ultrastructure of mucosa. Amiloride loaded mucoadhesive nanoemulsion formulations are non toxic on nasal mucosa and can be administered by intranasal route for effective treatment of epilepsy.

Assessment of ocular pharmacokinetics and safety of Ganciclovir loaded nanoformulations.

Ganciclovir (GCV) plays an important role in the treatment of ocular viral infections. A high dose results in dose-related toxicity including bone marrow suppression and neutropenia. The aim of the present study was to investigate the comparative potential of different mucoadhesive nano formulations for the topical ocular delivery of Ganciclovir. GCV mucoadhesive Nanoemulsions (GCV-NEs), chitosan nanoparticles (GCV-NPs), GCV mucoadhesive niosomal dispersion (GCV-NDs) were prepared by the reverse-phase evaporation technique. All of the three formulations were evenly round in shape with mean particle size in the range of 23-200 nm. These results indicated the nonirritant and nontoxic nature of the developed formulations. The achieved results may be useful for formulation development of GCV, which could be effective in the treatment of ocular infections by topical instillation.

Microemulsions: a novel approach to enhanced drug delivery.

Microemulsions are isotropic, thermodynamically stable transparent (or translucent) systems of oil, water and surfactant, frequently in combination with a cosurfactant with a droplet size usually in the range of 20-200 nm. They can be classified as oil-in-water (o/w), water-in-oil (w/o) or bicontinuous systems depending on their structure and are characterized by ultra low interfacial tension between oil and water phases. These versatile systems are currently of great technological and scientific interest to the researchers because of their potential to incorporate a wide range of drug molecules (hydrophilic and hydrophobic) due to the presence of both lipophilic and hydrophilic domains. These adaptable delivery systems provide protection against oxidation, enzymatic hydrolysis and improve the solubilization of lipophilic drugs and hence enhance their bioavailability. In addition to oral and intravenous delivery, they are amenable for sustained and targeted delivery through ophthalmic, dental, pulmonary, vaginal and topical routes. Microemulsions are experiencing a very active development as reflected by the numerous publications and patents being granted on these systems. They have been used to improve the oral bioavailability of various poorly soluble drugs including cyclosporine and paclitaxel as professed by Hauer et al., US patent 7235248, and Gao et al., US patent 7115565, respectively. Furthermore, they can be employed for challenging tasks such as carrying chemotherapeutic agents to neoplastic cells and oral delivery of insulin as diligently described by Maranhao, US patent 5578583 and Burnside et al., US patent 5824638 respectively. The recent commercial success of Sandimmune Neoral (Cyclosporine A), Fortovase (Saquinavir), Norvir (Ritonavir), etc. also reflects the tremendous potential of these newer drug therapeutic systems. A critical evaluation of recent patents claiming different approaches to improve the drug delivery is the focus of the current review.

Emerging role of microemulsions in cosmetics.

Microemulsions represent a promising carrier system for cosmetic active ingredients due to their numerous advantages over the existing conventional formulations. They are capable of solubilizing both hydrophilic and lipophilic ingredients with relatively higher encapsulation. There is growing recognition of their potential benefits in the field of cosmetic science in addition to the drug delivery. They are now being widely investigated for preparing personal care products with superior features such as having improved product efficiency, stability or appearance. They are well suited for the preparation of various cosmetic products for use as moisturizing and soothing agents, as sunscreens, as antiperspirants and as body cleansing agents. They are also valuable for use in hair care compositions which ensure a good conditioning of the hair as well as good hair feel and hair gloss. They have also found application in after shave formulations which upon application to the skin provide reduced stinging and irritation and a comforting effect without tackiness. These newer formulations elicit very good cosmetic attributes and high hydration properties with rapid cutaneous penetration which may accentuate their role in topical products. These smart systems are also suitable for perfuming purposes where minimum amount of organic solvents is required, such as for perfuming skin or hair. This article highlights the recent innovations in the field of microemulsion technology as claimed by different patents which can bring unique products with great commercial prospects in a very competitive and lucrative global cosmetic market.

Urinary tract injuries during obstetrics and gynaecological surgical procedures at the Aga Khan University Hospital Karachi, Pakistan: a 20-year review.

OBJECTIVE: To determine the prevalence of urinary tract injuries, identification of risk factors and methods employed for repair and their outcomes. STUDY DESIGN: Cross-sectional study of patients who had urinary tract injuries during major obstetric and gynaecological surgeries at the Aga Khan University Hospital (AKUH) from 1985 to 2004. MATERIAL AND METHODS: Computer-generated discharge summaries of patients who underwent major obstetric and gynaecological procedures during the 20 years of study period were retrieved. Information was collected on data collection form, and entered in SPSS version 13 and analysed. RESULTS: During the study period 12,567 obstetrics and 5,966 gynaecological procedures were performed. There were 3,910 abdominal hysterectomies, 984 myomectomies, 591 ovarian/adenexal surgeries and 481 vaginal hysterectomies. Out of these 110 urinary tract injuries were identified, 71 (64.5%) were of the urinary bladder and 39 (35.5%) were ureteric in origin, 31 (43.6%) bladder injuries were sustained during caesarean sections while 40 (56.3%) were during gynaecological procedures. In obstetric cases there were two ureteric injuries, the other ureteric injuries were sustained during surgeries for benign gynaecological conditions. The prevalence of bladder and ureteric injuries in obstetric surgeries was 0.25 and 0.02%, respectively, whereas in gynaecological surgeries the prevalence was 0.7 and 0.6% for urinary bladder and ureteric injuries. These figures compare well with other published series. CONCLUSION: Urinary tract injuries are an uncommon occurrence but when they occur they have serious implications in terms of morbidity and litigation. The prevalence of urinary bladder and ureteric injuries observed in our review is comparable to previous reported international series. Of concern is the fact that most of the ureteric injuries were diagnosed post operatively which means that further vigilance and preventive strategies need to be designed.