Appraisal of selected ethnomedicinal plants as alternative therapies against onychomycosis: Evaluation of synergy and time-kill kinetics.

Introduction: This study aims at the biological profiling of Allium sativum, Zingiber officinale, Nigella sativa, Curcuma longa, Mentha piperita, Withania somnifera, Azadirachta indica, and Lawsonia inermis as alternatives against onychomycosis to combat the treatment challenges. Methods: An extract library of aqueous (DW), ethyl acetate (EA), and methanol (M) extracts was subjected to phytochemical and antioxidant colorimetric assays to gauge the ameliorating role of extracts against oxidative stress. RP-HPLC quantified therapeutically significant polyphenols. Antifungal potential (disc diffusion and broth dilution) against filamentous (dermatophytes and non-dermatophytes) and non-filamentous fungi (yeasts; Candida albicans), synergistic interactions (checkerboard method) with terbinafine and amphotericin-B against resistant clinical isolates of dermatophytes (Trichophyton rubrum and Trichophyton tonsurans) and non-dermatophytes (Aspergillus spp., Fusarium dimerum, and Rhizopus arrhizus), time-kill kinetics, and protein estimation (Bradford method) were performed to evaluate the potential of extracts against onychomycosis. Results: The highest total phenolic and flavonoid content along with noteworthy antioxidant capacity, reducing power, and a substantial radical scavenging activity was recorded for the extracts of Z. officinale. Significant polyphenolics quantified by RP-HPLC included rutin (35.71 ± 0.23 µg/mgE), gallic acid (50.17 ± 0.22 µg/mgE), catechin (93.04 ± 0.43 µg/mgE), syringic acid (55.63 ± 0.35 µg/mgE), emodin (246.32 ± 0.44 µg/mgE), luteolin (78.43 ± 0.18 µg/mgE), myricetin (29.44 ± 0.13 µg/mgE), and quercetin (97.45 ± 0.22 µg/mgE). Extracts presented prominent antifungal activity against dermatophytes and non-dermatophytes (MIC-31.25 µg/ml). The checkerboard method showed synergism with 4- and 8-fold reductions in the MICs of A. sativum, Z. officinale, M. piperita, L. inermis, and C. longa extracts and doses of amphotericin-B (Amp-B) and terbinafine (against non-dermatophytes and dermatophytes, respectively). Furthermore, the synergistic therapy showed a time-dependent decrease in fungal growth even after 9 and 12 h of treatment. The inhibition of fungal proteins was also observed to be higher with the treatment of synergistic combinations than with the extracts alone, along with the cell membrane damage caused by terbinafine and amp-B, thus making the resistant fungi incapable of subsisting. Conclusion: The extracts of A. sativum, Z. officinale, M. piperita, L. inermis, and C. longa have proven to be promising alternatives to combat oxidative stress, resistance, and other treatment challenges of onychomycosis.

Chitosan Nanoparticles Loaded Poloxamer 407 Gel for Transungual Delivery of Terbinafine HCl.

The current study aimed to develop chitosan nanoparticles (CSNP) loaded poloxamer 407 (P407) gel formulation for transungual delivery of terbinafine HCl (TBN). TBN-CSNP were prepared by nanoprecipitation method and optimized by face-centered central composite design (FCCCD). Optimized TBN-CSNP formulation exhibited a spherical shape with hydrodynamic diameter; zeta potential and entrapment efficiency (EE) of 229 ± 5 nm; 37 ± 1.5 mV; and 75 ± 2% respectively. The solid state of TBN and its compatibility with formulation ingredients were confirmed through XRD and FTIR analysis respectively. TBN-CSNP loaded P407 gel exhibited pseudoplastic rheological behavior having a spreadability of 11 ± 2 g·cm/s. The washability study showed that 40 ± 2% of the gel was eroded after washing 12 times. Drug release from TBN-CSNP- and TBN-CSNP-loaded gel was 84 ± 5% and 57 ± 3%, respectively. The cumulative quantity of TBN permeated from TBN-CSNP-loaded P407 gel and TBN-loaded P407 gel was 25 ± 8 and 27 ± 4 µg/cm2, respectively. The nail uptake study showed that 3.6 ± 0.7 and 2.1 ± 0.3 µg of rhodamine was uptaken by the nail following 2 h topical application of TBN-CSNP loaded P407 gel and TBN loaded P407 gel, respectively. Hence, the developed CSNP-based P407 gel formulation can be a potential carrier for transungual delivery of TBN to topically treat onychomycosis.

Development and Evaluation of PLGA Nanoparticle-Loaded Organogel for the Transdermal Delivery of Risperidone.

A transdermal delivery approach may circumvent the limitations associated with the oral use of risperidone (RIS), an atypical antipsychotic drug. The current study focuses on the utilization of poloxamer (pluronic) lecithin organogel (PLO), a suitable transdermal vehicle, and a biodegradable nanoparticulate system of PLGA with the potential to deliver RIS in an efficient way. PLGA nanoparticles were fabricated using different ratios of the polymer and surfactant. The optimization was performed principally on the basis of particle size and entrapment efficiency (EE). The developed PLGA nanoparticles were spherical, sized around 109 nm with negative charge (−9.3 mv) and enhanced drug entrapment efficiency (58%). The in vitro drug release study of lyophilized nanoparticles showed a sustained pattern. Statistical analysis confirmed that there was a significant difference (p < 0.05) between the nanoparticle-loaded PLO gel and conventional drug formulations in terms of drug release and ex vivo permeation across rat skin (three-fold). The results confirm enhanced drug release and permeation through the skin at 72 h. Hence, the investigated formulation could be a better alternative to the conventional route for improving patient compliance.

A cutback in Imiquimod cutaneous toxicity; comparative cutaneous toxicity analysis of Imiquimod nanotransethosomal gel with 5% marketed cream on the BALB/c mice.

Herein, Imiquimod (IMQ) was incorporated in nanotransethosomes (nTES) to develop the IMQ-nTES nano-drug delivery system. IMQ-nTES was optimized using 23 factorial design. The optimized formulation was expressed with a particle size of 192.4 ± 1.60 nm, Poly-dispersibility of 0.115 ± 0.008, and IMQ percent entrapment efficiency of 91.05 ± 3.22%. Smooth and round morphology of IMQ-nTES vesicles was confirmed by TEM micrographs. Moreover, FTIR results have shown drug-excipient compatibility. The IMQ-nTES was laden inside the low molecular weight chitosan gel, which exhibited easy application, spreadability and no irritation to the applied skin. The release pattern has clearly exhibited improved dissolution properties of IMQ with the provision of the sustain release pattern. Higher IMQ content was deposited in deeper epidermis and dermis with IMQ-nTES gel, in contrast to ALDARA. In vivo, comparative toxicity study on BALB/c mice has shown significantly reduced (p < 0.001) psoriatic area severity index (PASI) score and less increment in ear thickness. Epidermal hyperplasia was an obvious finding with ALDARA which was, providentially, minimal in IMQ-nTES gel-treated skin. FTIR analysis of skin tissue has shown an enhancement of lipid and protein content in the ALDARA group, however, in the IMQ-nTES group no such change was observed. With ALDARA application, CD4+ T-cells and constitutive NF-κß expression were significantly elevated, in comparison to the IMQ-nTES gel treated group. Moreover, the adequate expression of IFN-γ and cytotoxic CD8+ T-cells were suggesting the preserved IMQ efficacy with IMQ-nTES gel. Quantification of cutaneous as well as systemic inflammatory markers has also suggested the reduced psoriatic potential of IMQ-nTES gel. In essence, IMQ-nTES gel can be a suitable alternative to ALDARA owing to its better safety profile.

Comparative Evaluation of Biomedical Applications of Zinc Nanoparticles Synthesized by Using Withania somnifera Plant Extracts.

Green synthesis of metal nanoparticles is of great importance in the modern health care system. In this study, zinc nanoparticles (ZnONPs) were synthesized using leaf and root extracts of Withania somnifera using four different solvents. ZnONPs were characterized by UV-vis spectrophotometer with a range between 350-400 nm. Scanning electron microscope revealed spherical morphology with an overall size of 70-90 nm and XRD pattern confirmed the crystalline structure. The total flavonoids, phenolic, and alkaloid contents were significantly greater in the crude extracts as compared to ZnONPs. The highest scavenging activity was observed in ZnONPs from n-hexane and ethyl-acetate extracts of roots with IC50 values of 27.36 µg/mL and 39.44 µg/mL, respectively. ZnONPs from methanol and aqueous extracts showed significant antibacterial activity against Escherichia coli, Staphylococcus aureus, and Bacillus subtilis while none of the extracts were found to have significant antifungal activity. Maximum cytotoxic activity was observed in ZnONPs synthesized from aqueous and n-hexane root extracts with LC50 values of 9.36 µg/mL and 18.84 µg/mL, respectively. The highest antidiabetic potential was exhibited by ZnONPs from n-hexane leaf extracts, i.e., 47.67 ± 0.25%. Maximum protein kinase inhibitory potential was observed in ZnONPs of ethyl-acetate extract of roots with a bald zone of 12 mm. These results indicated that Withania somnifera-based ZnONPs showed significant biological activities compared to crude extracts. These findings can further be utilized for in-vivo analysis of nano-directed drug delivery systems.

Comparative evaluation of biomedical and phytochemical applications of zinc nanoparticles by using Fagonia cretica extracts.

The use of the green approach for nanoparticle synthesis yielded noticeable concern due to its eco-friendliness, cost-effectiveness, and reduced production of toxic chemicals. The current study was designed to formulate Zinc oxide nanoparticles (ZnO NPs) by using Fagonia cretica extracts, evaluating its phytochemical content, and different biological activities. Four different solvents; methanol (MeOH), n-Hexane (n-H), aqueous (Aq), and ethyl acetate (EA), had been utilized in the extracting method. ZnO NPs were successfully synthesized and characterized by UV-vis spectroscopy and scanning electron microscopy (SEM). The UV-vis spectra showed absorbance peaks between 350-400 nm range and SEM analysis revealed spherical morphology with particle sizes ranging from 65-80 nm. In phytochemical analysis, crude extracts exhibited the highest phytochemical content as they contain enriched secondary metabolites. n-hexane extract showed the highest phenolic contents while aqueous extracts showed the highest flavonoid content. Maximum free radicle scavenging activity was observed in NPs synthesized from ethyl-acetate extract with an IC50 value of 35.10 µg/ml. Significant antibacterial activity was exhibited by NPs polar solvents against K. pneumonae, E. coli, and B. subtilis. Polar solvents showed considerable antifungal potential against A. flavus and F. solani. NPs synthesized from nH extract showed potential cytotoxic activity with an LC50 value of 42.41 µg/ml against brine shrimps. A noteworthy antidiabetic activity was exhibited by nanoparticles synthesized from methanol extract i.e., 52.61 ± 0.36%. Significant bald zones were observed in nanoparticles synthesized from methanol extract rendering protein kinase inhibition. The present study highlights the significance of F. indica as a natural source for synthesizing functional nanoparticles with substantial antioxidant, antimicrobial, cytotoxic, protein kinase inhibitory, and antidiabetic properties.

Exploration of microplastic pollution with particular focus on source identification and spatial patterns in riverine water, sediment and fish of the Swat River, Pakistan.

Microplastics (MPs) have been reported as an emerging xenobiotic organic pollutant in freshwater ecosystems and a universal hazard for ecosystems because of the rapid increase in global demand. The present study was conducted to explore MPs' occurrence, abundance and spatial distribution in sediment, water and Schizothorax plagiostomus samples, collected from the Swat River. ATR-FTIR spectroscopy was used for chemical characterization of visually identified MPs by using standard protocols such as digestion using H2O2, density separation using ZnCl2, vacuum filtration with borosilicate glass micro filter papers and digital microscopy using a stereomicroscope connected with a camera. Range of mass abundance of identified MPs in river sediments, river water, tributaries sediment and tributary water was found to be 0.6-2.5 mg kg-1, 0.7-3.8 mg L-1, 0.9-4.5 mg kg-1 and 0.6-1.1 mg L-1 respectively. Meanwhile, in Schizothorax plagiostomus digestive tracts samples, it was 0.6-1.9 mg per fish. Numeric abundance of MPs in all matrices was found to be tributary sediment (202 items per kg) > river water (192 items per L) > river sediment (182 items per kg) > fish (153 items per fish) > tributary water (92 items per L). MPs identified on the basis of morphology in all matrices were found to be fragments > fibers > pellets > films > foams. MPs were dominant in all urban stations while their spatial distribution along with the study site was heterogeneous due to the surroundings such as tourist spots, hydrodynamic conditions, and proximity to urban areas, plastic industries and due to recharge by the highly contaminated tributaries. The MPs identified on the basis of size dimensions show that S1 (0.5-1 mm) in all matrices was highest while S2 (1-5 mm) was the lowest. Primary source MPs identified were fibers, films, fragments and foams particles while secondary sources were pellets. Results of ATR-FTIR showed that PE was the most common plastic type identified in all samples followed by PVC, PET, PP and PS. This is the first study exploring the MPs' occurrence, numeric and mass abundance and spatial distribution in the SR ecosystem. The present study may be a valuable reference for better understanding the MPs' pollution in Pakistan. The findings of the present study can help to identify the potential sources (i.e., primary and secondary) of MPs to improve waste management in the Swat District and model the transport fluxes of these microplastics in other rivers using water quality parameters and basin characteristics.

Illness perception about hepatitis C virus infection: a cross-sectional study from Khyber Pakhtunkhwa Pakistan.

BACKGROUND: Hepatitis C virus (HCV) infection is a debilitating chronic health problem and can be fatal if left untreated. Illness perceptions are self-manifested beliefs that influence the ability of individuals to cope with their disease and perceive it as manageable or threatening condition. Limited evidence is available from low resource settings regarding patient perception about HCV. In this study, we aimed to assess the perception of individuals with HCV, the impact of their sociodemographic and clinical characteristics on their HCV perception, and its link to patient-oriented treatment outcomes. METHODS: A cross-sectional survey was undertaken enrolling individuals with HCV who attended Hepatitis C clinics at two hospitals of Khyber Pakhtunkhwa, Pakistan. Illness perception was measured using Brief Illness Perception Questionnaire (BIPQ). Descriptive statistics, Kruskal Wallis tests and Mann Whitney U tests were performed to study patient sociodemographic and clinical characteristics and to analyze the questionnaire results. Multivariable linear regression was used to assess determinants associated with perception scores. RESULTS: Participants represented poor HCV perception and their overall mean BIPQ score was 43.35, SD = 13.15. Participants had a low degree of understanding about their illness (mean coherence score = 2.92, SD = 1.85). Individuals with more than four years, compared to less than one year, of estimated HCV infection were more likely to view that their illness would continue (mean timeline score = 6.27, SD = 2.50 versus 5.36, SD = 2.53; respectively, p < 0.01). Similarly, individuals with hepatic cirrhosis, compared to without, were more likely to attribute symptoms to their disease (mean identity score = 5.48, SD = 2.14 versus 4.89, SD = 2.38; respectively, p = 0.04). Female participants reported higher degrees at which the illness affected them emotionally (i.e., emotional representation) and lower coherence about HCV than males (p = 0.04 and 0.006, respectively). Individuals who did not achieve sustained virological response 24 weeks after treatment with interferon-based therapy, compared to treatment naïve individuals, reported lower trust in being successfully treated with newer anti-HCV agents (i.e., direct acting antivirals) (p = 0.029). However, multivariable linear regression revealed that no sociodemographic or clinical determinants were associated with a higher BIPQ score (i.e., more threatening, or negative perceptions). CONCLUSION: Individuals with HCV in Pakistan generally report threatening or negative views about HCV infection. Lack of trust in treatment efficacy was also apparent, especially in those who experienced failed anti-HCV treatments in the past. Healthcare professionals should consider these perceptions when treating individuals with HCV to optimize their compliance by aligning their perception with the high effectiveness of current anti-HCV therapies.

Poloxamer 407 Based Gel Formulations for Transungual Delivery of Hydrophobic Drugs: Selection and Optimization of Potential Additives.

The current study aimed to develop poloxamer 407 (P407) gel for transungual delivery of antifungal hydrophobic drugs with sufficient gel strength and drug loading. Gel strength and drug loading of P407 gel was improved by use of functional additives. Hydration enhancement effect was used to select optimum nail penetration enhancer. Face-centered central composite design (FCCCD) was used to observe the effect of the selected penetration enhancer (thioglycolic acid (TGA)) and cosolvent (ethanol) on gelation behavior to develop formulation with enough loading of hydrophobic drug, i.e., terbinafine HCl (TBN), and its permeation across the nail plate without compromising on gel strength. It was observed that increasing concentration of P407 and TGA significantly reduced gelation temperature and enhanced the gel strength of P407 gel and can be used to improve P407 gel strength. Under the scanning electron microscope, the significant effect of TGA as an ungual penetration enhancer was observed on the morphology of the nail plate. Optimized P407 gel prepared with modified cold method showed a gelation temperature of 8.7 ± 0.16 °C, gel strength of 122 ± 7.5 s and drug loading of 1.2% w/w, which was four times more than the drug loading in the gels prepared with conventional cold method. Rheological behavior was pseudoplastic with 47.75 ± 3.48% of gel erosion after 12 washings and 67.21 ± 2.16% of drug release after 12 h. A cumulative amount of TBN permeated from P407 gel with and without PE after 24 h was 27.30 ± 4.18 and 16.69 ± 2.31 µg/cm2, respectively. Thioglycolic acid can be used as a nail penetration enhancer without the chemical modification or addition of extra additives while retaining the gel strength. Water miscible cosolvents with moderate evaporability such as ethanol, can be incorporated to P407 gel by minor modification in method of preparation to load the required dose of hydrophobic drugs. Developed P407 gel formulation with sufficient gel strength and drug loading will be a promising carrier for transungual delivery of hydrophobic antifungal agents.

Effect of Displacement on Adherence to TB Treatment: An Observational Study in TB Patients from Internally Displaced Persons of Pakistan.

OBJECTIVE: This study was aimed to investigate TB patients adherence and treatment outcomes among internally displaced patients in comparison with adjacent settled areas. METHODS: The study was designed as an observational cross-sectional study among the TB patients of internally displaced populations (IDPs) of North Waziristan Agency (NWA) and adjacent settled areas of Bannu and Lakki Marwat (NIDPs). Based on the study inclusion and exclusion criteria 330 patients fullfilled the inclusion criteria and were assigned equally to both IDPs and NIDPs study groups. Odds ratio (OR) with 95% confidence interval was calculated and p-values, 0.05 were considered statistically significant. RESULTS: The treatment outcomes with the status of "cured" and "completed treatment" were better among NIDPs as compared to IDPs. Patients with treatment outcome status of "defaulted treatment", "without documentary evidence, and "failure" were high in IDPs as compared to NIDPs. Adherence to TB treatment was better among NIDPs (50.9%) as compared to IDPs (39.4%). The patients showing non-adherence to TB treatment were more among IDPS (27.3%) than NIDPs (10.9%). CONCLUSION: Overall results of this study revealed a poor adherence to the TB treatment medications with an odds ratio of 0.286, (p<0.05) among IDPs as compared with NIDPs.

Assessment of the Current State of Pharmacovigilance System in Pakistan Using Indicator-Based Assessment Tool.

Objectives: Pakistan felt the need for an effective and robust pharmacovigilance (PV) system after one of the deadliest drug-related tragedies causing more than 300 deaths in 2012. The country set up its national PV center in 2015 and joined WHO's Program for International Drug Monitoring (PIDM) in 2018 as a full member. The current study was aimed to evaluate the PV system's functionality, identify the gaps, areas of improvement, and a strategy to lead a functional PV system in Pakistan. Methods: The descriptive cross-sectional study was conducted by providing an interviewer-administered questionnaire of the PV system across Pakistan by utilizing the Indicator based Pharmacovigilance assessment tool (IPAT). By a convenience sampling method 36 study participants were selected from the Drug Regulatory Authority of Pakistan (DRAP), drug administration of provincial health departments of 4 provinces and federally affiliated areas, 5 national public health programs, and 23 public and private hospitals. The assessment includes document review, interviews of the key informants by structured open-ended questions, and a review of websites of relevant organizations. Results: Drug Regulatory Authority of Pakistan (DRAP) with a national PV center received a 75% overall performance score on IPAT. To be regarded as "minimally functioning," a country's PV and drug safety system must meet all core indicators. DRAP scored 80.76% on the core indicators so cannot be deemed functional at this time. The only province with a regional PV center, Punjab, had scored 72.13% on relevant parameters. Despite receiving funding from the Global Fund, none of the National Public Health Programs (PHPs) have PV centers or associated activities. All hospitals except two private hospitals could not qualify the minimum requirements for functional PV. The absence of a legal framework for mandatory ADR reporting, lack of drug information center, budgetary constraints, no active surveillance activities, the nonexistence of pharmacovigilance risk assessment expert committee, and insufficient coordination among stakeholders were identified as major gaps. Conclusion: The results of the study reveal that Pakistan's PV system is not fully functional at all levels. A two-phased strategy encompassing the non-financial and financial interventions is proposed to improve the PV systems at the national, provincial, PHPs, and hospitals levels.

Improving access to the treatment of hepatitis C in low- and middle-income countries: evaluation of a patient assistance programme.

Background Modern antiviral treatments have high cure rates against the hepatitis C virus however, the high cost associated with branded medicines and diagnostic tests, have resulted in poor access for many low-income patients residing in low-and-middle-income countries. Objective This study aimed to evaluate the role of a patient assistance programme and generic medicines in improving access to treatment of low-income hepatitis C patients in a low-and-middle-income country. Setting A major teaching public hospital in Islamabad, Pakistan. Methods Hepatitis C patients who presented and enrolled for the patient assistance programme during 12 months (1st July 2015 and 30th June 2016) were included. Demography, prescription characteristics, the total costs of Hepatitis C treatment, medicine cost supported by the programme, out-of-pocket cost borne by the patient and average cost effectiveness ratio per sustained virologic response were calculated and compared for different generic and branded regimens. Main outcome measure cost contribution of patient assistance programme. Results A total of 349 patients initiated the treatment through the programme and of those 334 (95.7%) completed the prescribed treatment. There were 294 (88.02%) patients who achieved sustained virologic response. Patient assistance programme contributed medicines cost averaging 60.28-86.26% of the total cost of treatment ($1634.6) per patient. The mean (SE) cost per patient for generic option (Sofosbuvir/Ribavirin) was the lowest [$658.36 (22.3) per patient, average cost effectiveness ratio = $720.1/SVR] than branded option (Sovaldi/Ribavirin) [$2218.66 (37.6) per patient, average cost effectiveness ratio = $2361.8/SVR] of the three available treatment regimens. From patients' perspectives, the mean (SE) out-of-pocket cost was $296.9 (6.7) which primarily included diagnostic cost (69.9%) of the total cost. Conclusions Patient assistance programme, combined with generic brands of newer hepatitis C treatment offered a significant reduction in cost and widens access to hepatitis C treatment in low-and middle-income countries. However, substantial out-of-pocket costs of the treatment presents an important barrier for service access. There is a scope to widen such financial assistance programme to offer other costs attributed to patients, specifically for diagnosis, to widen service use in low-and-middle-income countries.

Health risk assessment of radioactive footprints of the urban soils in the residents of Dera Ghazi Khan, Pakistan.

The aim of the study was to evaluate the radiation levels, radiological doses and excess lifetime cancer risk possessed by the urban soils that were collected from the vicinity of the exclusive mining and excavation centers of Dera Ghazi Khan. The high purity germanium detector was utilized for assessment of naturally occurring radionuclides (NORMs) in soil and results showed that the average activity concentrations of 226Ra, 232Th, and 40K (37 Bq/kg, 43.07 Bq/kg, 737 Bq/kg respectively) surpassed the world's average documented values (35 Bq/kg, 30 Bq/kg, and 400 Bq/kg respectively). Moreover, the average values of radiological hazards assessment like radium equivalent, internal and external hazard indices, absorbed dose rate, annual gonadal dose equivalent and excess lifetime cancer risk were 155.70 (Bq/kg), 0.4, 0.5, 73.96 (nGy/h) 90.73 (µSv/y), 476.24 (µSv/y) and 0.31(10-3) respectively. The data acquired was analyzed using descriptive statistics, cluster analysis and principal component analysis. ArcGIS (10.5) software was utilized for developing maps of radionuclide's concentration for the study area. Results of the study may serve as an important baseline radiometric data for future epidemiological studies and monitoring initiatives in the study area.

Complementary and Alternative Medicines for the Treatment of Hepatitis C: Perspectives of Users and CAM Practitioners.

BACKGROUND: Despite substantial progress in the treatment of hepatitis C through the use of direct-acting antivirals which have been shown to cure the disease, complementary and alternative medicines (CAM) are popular among patients as a substitute or complement of allopathic medicines. This study aimed to explore the perspectives of patients and CAM practitioners on the use of CAM for the treatment of hepatitis C in Pakistan. METHODS: A cross-sectional design was adopted. Participants (CAM practitioners and patients) were recruited from the capital and two provinces: Khyber Pakhtunkhwa and Punjab of Pakistan. A survey using paper-based questionnaires, each specific for patients and CAM practitioners, was conducted to gather information pertaining to demography, disease status, treatment history, and participants' perspectives (about the disease, reasons to switch to CAM, and referring source). RESULTS: A total of 417 respondents (n = 284 patients, n = 133 practitioners) were recruited. Of the total patients, 170 (59.9%) had started CAM during the previous three months. There were 168 (59.2%) of the total patients who had used allopathic treatments for hepatitis C prior to their use of CAM. The confidence in CAM (24.6%), high cost (19%), and unbearable side effects (52.1%) of allopathic medicines were the main reasons to switch to CAM treatment. Majority (49.3%) of the patients were referred to CAM on the recommendations of relatives or care givers (17.3%) whereas only 9.5% were referred by health care professionals. Out of 133 practitioners, 48 (36.1%) were practicing herbal medicines. From practitioners' perspectives, club-moss (Lycopodium clavatum) was the best treatment option for hepatitis C. The majority, 73 (54.9%), of the patients had chosen to use CAM because of the side effects of allopathic medicines. Patients who had previous "good experience" with CAM were the most common referral source (56.4%) for CAM use in hepatitis C. CONCLUSIONS: Patients' beliefs in CAM, side effects of allopathic therapy, high cost of allopathic medicines, and referrals from previous CAM users are key factors in the switching of hepatitis C patients to CAM.

Tumor aggression among hepatitis-C related hepatocellular carcinoma patients: an observational study regarding the impact of anti-HCV therapy.

BACKGROUND: Hepatitis C virus (HCV) represents a major risk factor for hepatocellular carcinoma (HCC) development and anti-HCV therapy is a significant measure to reduce the incidence of HCC, however development of HCC in HCV treated patients is an emerging clinical problem which needs to be investigated. In this study we aim to analyze association between anti-HCV therapy and tumor pattern of HCV related HCC patients. METHODS: Hepatocellular Carcinoma (HCC) patients with seropositivity for hepatitis C virus (HCV) antibodies, registered at three tertiary care hospitals of Rawalpindi and Islamabad, Pakistan during August 2017 to July 2018 were enrolled. Selected patients were then segregated in two groups on the basis of their HCV treatment history i.e., "TN" (HCV Treatment Naïve i.e. having no history/medical record for treatment prior to HCC diagnosis) and "TH" (Treated for HCV infection). Aggressiveness index (AgI) scoring system was applied to determine the tumor pattern. Univariate and multivariate analysis was carried out to analyze the independent effect of anti-HCV therapy on tumor pattern. RESULTS: Out of 234 consecutive HCC patients, 171 HCV-related HCC patients were enrolled in final analysis and labeled as "TN" (n = 120) and "TH" (n = 51). Tumor pattern was found to be significantly aggressive (P = 0.02) in the treated cohort with an adjusted odds of 2.47 for aggressive and 6.92 for highly aggressive tumor. Neutrophil to lymphocyte ratio (NLR) was strongly associated with highly aggressive tumor pattern (P = 0.012). Patients in TN group were found to be marginally older than those in the TH group (59.5 vs. 55 years) where mean age of the patients treated with direct acting anti-viral agents was found to be visibly lower than mean age of patients who received interferon based treatment (53.5 vs. 57 years) with significant masculine predominance (62.1 vs. 37.9%, P = 0.049). CONCLUSION: We observed raised neutrophil to lymphocyte ratio and prominence of younger age with aggressive tumor biology in HCV treated HCC patients. These observations highlight the need for a longitudinal prospective study on HCV positive subjects treated with antivirals, irrespective of treatment response.

Environmental risk assessment of diclofenac residues in surface waters and wastewater: a hidden global threat to aquatic ecosystem.

Pharmaceuticals are chemical compounds employed as medicinal drugs. They have severe physic-chemical properties which make them destructive for non-target species. Consequently, their continuous addition in the environment may pose hazardous effects. Among these, diclofenac (DCF), a non-steroidal anti-inflammatory drug (NSAID), is extensively used in Pakistan which may lead to its accumulation in both terrestrial and aquatic environment. Present study aims to assess the presence and concentration of pharmaceutically active drug (DCF) in surface water and wastewater of twin cities of Pakistan (Rawalpindi and Islamabad). For this purpose, a validated high-performance liquid chromatography (HPLC) method was adopted involving solid-phase extraction procedure. Wastewater samples were collected from various sites of Rawalpindi and Islamabad. Results of HPLC analysis revealed that DCF was extant with considerably high concentration, not only in wastewater but also in surface water samples. Concentrations as high as 216 µg L-1 was detected in Rawat industrial area and low as 8 µg L-1 was detected in dairy farm wastewater samples collected from Taramri. However, maximum DCF levels in residential wastewater and hospital wastewater were detected to be 105 µg L-1 and 34 µg L-1, respectively. Moreover, the highest detected level (116 µg L-1) was found in surface water of Sawan River. Further, results of ecological risk assessment revealed its possible toxic effects of DCF on various aquatic organisms.

Impact of HIV and chronic kidney disease comorbidities on hepatitis C treatment choices, drug-drug interactions and hepatitis C cure.

Background Human immunodeficiency virus (HIV) co-infection and chronic kidney disease add challenges to hepatitis C virus treatment. Objective To conduct a comparative study of treatment choices, drug-drug interactions and clinical outcomes in hepatitis C mono-infected patients, or those with HIV or chronic kidney disease comorbidities. Setting Hepatitis C treatment centers of West Midlands England, United Kingdom. Method An observational study was conducted analyzing datasets of all hepatitis C patients that were referred to a large tertiary liver unit in the West Midlands, UK between July 2015 and January 2018. Patients aged ≥ 18 years with diagnosis of hepatitis C alone or co-infected with HIV or comorbid with chronic kidney disease were eligible. Main outcome measures The treatment choices, relevant potential drug-drug interactions and sustained virologic response 12 weeks post end of treatment were assessed. Results Out of 313 patients, 154 (49.2%) were hepatitis C mono-infected, 124 (39.6%) hepatitis C/HIV co-infected and 35 (11.2%) were hepatitis C/chronic kidney disease comorbid. There were 151 (98.1%) of hepatitis C mono-infected, 110 (88.7%) of hepatitis C/HIV and 20 (57.1%) of hepatitis C/chronic kidney disease patients treated with 1st line regimens. Significantly more patients who had co-morbidity with either HIV or chronic kidney disease were prescribed 2nd line regimens (8.1% and 37.1% respectively), compared to patients with hepatitis C mono-infection (1.9%) (P value < 0.05). Comorbid patients (12.1% of HIV and 25.8% of chronic kidney disease) were more likely to required drug-drug interactions advice (grade 5) than hepatitis C mono-infected (1.8%). Higher cure rates were observed in hepatitis C mono-infected (95.33%), hepatitis C/HIV (96.1%) compared to hepatitis C/chronic kidney disease patients (90.3%). Conclusion This study shows that treatment pathways permitting access to individual treatment adjustments in accordance with comorbidities and with consideration of drug-drug interaction in a multi-disciplinary team, provides successful outcomes in hepatitis C patients co-morbid with HIV or chronic kidney disease.

A Randomized Controlled Trial to Assess the Impact of Clinical Pharmacy Interventions on Treatment Outcomes, Health Related Quality of Life and Medication Adherence Among Hepatitis C Patients.

PURPOSE: The role of specialized pharmacy services remains unexplored in clinical practice for hepatitis C patients in Pakistan. This study aimed to evaluate the impact of clinical pharmacy interventions on treatment outcomes, health-related quality of life (HRQoL), and medication adherence among hepatitis C patients. METHODS: A randomized control trial was conducted at two tertiary-care teaching hospitals in Pakistan. Hepatitis C patients who attended the outpatient clinics between October 2015 and September 2018 were randomized to two groups [usual care (UC) and pharmaceutical care (PC)] in a 1:1 ratio, applying simple envelope method. The PC group received pharmaceutical care led by a clinical pharmacist. The care that patients received included education and counseling on medication compliance, labeling of medication packs, and monitoring of adverse drug events, led by a qualified clinical pharmacist during the 15- to 20-minute monthly sessions, while the UC group received standard care at hospital, which did not involve clinical pharmacist input. Outcome measures, such as sustained virological response, HRQoL, and adherence rate (pharmacy data) were assessed at enrolment and distinct time intervals: 4 weeks, 8 weeks, and end of treatment. RESULTS: A total of 931 patients were included in the study (UC 466 and PC 465), with mean age 42.35±1.9 years. Sustained virological response at 12 weeks was achieved in 86.0% patients in the PC group, significantly (p<0.001) higher than the UC (69.3%) group. Fewer patients (9.9%) in the PC group reported mobility problems, significantly fewer (p<0.001) than the UC group (11.8%). Self-care, usual activity, pain, and depression were relieved significantly in the PC group compared to the UC group. The EuroQol visual analogue scale (baseline 56.1 of UC group versus 55.2 for PC group) was raised to 71.8 and 71.9 in the UC and PC groups, respectively. Medication adherence was significantly improved (p<0.001) in the PC group (88.6%) when compared to the UC group (77.9%, 95% CI 88.9%-91.9%). CONCLUSION: Pharmacist-led clinical pharmacy interventions as part of multidisciplinary care had a significant impact on improving cure rates, HRQoL, and medication adherence for hepatitis C patients. This study suggests that clinical pharmacists should be incorporated into the multidisciplinary health-care team for care of hepatitis C patients.

Extraction optimization of medicinally important metabolites from Datura innoxia Mill.: an in vitro biological and phytochemical investigation.

BACKGROUND: The present study aims to probe the impact of polarity dependent extraction efficiency variation on pharmacological spectrum of Datura innoxia Mill. in order to reconnoiter its underexplored therapeutic potential. METHODS: A range of solvent extracts was subjected to phytochemical and biological assays to find the most proficient solvent system and plant part for each type of bioactivity. Total phenolic and flavonoid contents were determined colorimetrically and specific polyphenols were quantified by HPLC-DAD analysis. The samples were biologically evaluated by employing multimode antioxidant, cytotoxic, protein kinase inhibition and antimicrobial assays. RESULTS: Among all the solvents used, maximum percent extract recovery (33.28 %) was obtained in aqueous leaf extract. The highest amount of gallic acid equivalent phenolic and quercetin equivalent flavonoid content was obtained in the distilled water and ethyl acetate-ethanol extracts of leaf i.e., 29.91 ± 0.12 and 15.68 ± 0.18 mg/g dry weight (DW) respectively. Reverse phase HPLC-DAD based quantification revealed the presence of significant amounts of catechin, caffiec acid, apigenin and rutin ranging from 0.16 to 5.41 mg/g DW. Highest DPPH radical scavenging activity (IC50 = 16.14 µg/ml) was displayed by the ethyl acetate-acetone stem extract. Maximum total antioxidant capacity and reducing power potential were recorded in the aqueous leaf and ethyl acetate stem extracts i.e., 46.98 ± 0.24 and 15.35 ± 0.61 mg ascorbic acid equivalent/g DW respectively. Cytotoxicity against brine shrimps categorized 25 % of the leaf, 16 % of the stem and 8.3 % of the fruit extracts as highly potent (LC50 ≤ 100 µg/ml). Significant cytotoxicity against human leukemia (THP-1) cell line was exhibited by the chloroform and n-hexane fruit extracts with IC50 4.52 and 3.49 µg/ml respectively. Ethyl acetate and methanol-chloroform extracts of leaf and stem exhibited conspicuous protein kinase inhibitory activity against Streptomyces 85E strain with 22 mm bald phenotype. A noteworthy antimicrobial activity was exhibited by leaf extracts against Micrococcus luteus and n-hexane fruit extract against Aspergillus niger (MIC 3.70 and 12.5 µg/ml respectively). CONCLUSION: Multiple solvent system is a crucial variable to retrieve pharmacological potential of medicinal plants and D. innoxia can be envisaged as a novel source of natural antioxidants, antimicrobials and anticancer compounds.

Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems.

BACKGROUND: Medication errors in chemotherapy are frequent and lead to patient morbidity and mortality, as well as increased rates of re-admission and length of stay, and considerable extra costs. Objective: This study investigated the proposition that computerised chemotherapy ordering reduces the incidence and severity of chemotherapy protocol errors. METHOD: A computerised physician order entry of chemotherapy order (C-CO) with clinical decision support system was developed in-house, including standardised chemotherapy protocol definitions, automation of pharmacy distribution, clinical checks, labeling and invoicing. A prospective study was then conducted in a C-CO versus paper based chemotherapy order (P-CO) in a 30-bed chemotherapy bay of a tertiary hospital. Both C-CO and P-CO orders, including pharmacoeconomic analysis and the severity of medication errors, were checked and validated by a clinical pharmacist. A group analysis and field trial were also conducted to assess clarity, feasibility and decision making. RESULTS AND CONCLUSION: The C-CO was very usable in terms of its clarity and feasibility. The incidence of medication errors was significantly lower in the C-CO compared with the P-CO (10/3765 [0.26%] versus 134/5514 [2.4%]). There was also a reduction in dispensing time of chemotherapy protocols in the C-CO. The chemotherapy computerisation with clinical decision support system resulted in a significant decrease in the occurrence and severity of medication errors, improvements in chemotherapy dispensing and administration times, and reduction of chemotherapy cost.