A comparative analysis of the patient characteristics and cost of managing intravenous drug users (IVDU) with soft tissue abscesses with non-IVDU.

BACKGROUND: Intravenous drug users (IVDU) often present to hospitals with complex co-morbidities, associated with prolonged in-patient admissions. The aim of this study was to compare a cohort of IVDU patients with soft tissue abscesses with non-IVDUs. We analysed the demographics, comorbidities, location of abscesses, multidisciplinary input and financial costs of managing both groups. METHODS: A retrospective cohort study was conducted between January 2010 and September 2013. Two age and sex matched cohorts were compared: IVDU and non-IVDU. RESULTS: We identified 44 IVDU patients and 54 non-IVDU patients. The IVDU had higher rates of smoking (89% p < 0.001) and unemployment (73% p < 0.05). The most common comorbidities in the IVDU cohort were hepatitis C (17%) and HIV (14%), whereas diabetes mellitus (15%) and hypertension (11%) were the most common in the non-IVDUs (p < 0.01). The most common location for an abscess in non-IVDU patients was the hand, whereas IVDU patients had abscesses in their groin. Groin injecting led to a referral to multiple specialties. The median length of stay for the IVDU patients was 4 days and for non-IVDU patients 1 day (p < 0.01). The average cost of managing IVDU patients in our unit was £1280: for non- IVDU the cost was £530 (p < 0.001). CONCLUSIONS: IVDU patients with soft tissue abscesses have higher rates of smoking, unemployment, infection with hepatitis C and HIV compared to a control group. We have suggested several recommendations to optimise the management of these patients including the implementation of an additional code to compensate for the complexity of their management.

Increasing compliance with the World Health Organisation's Surgical Safety Checklist.

The World Health Organisation Surgical Safety Checklist (WHO SSC) is a validated tool for reducing in-patient surgical morbidity and mortality. It is not performed universally with full compliance. Two audit cycles were completed at two different trauma and orthopaedic units and compliance was measured. Site 1 was found to have a significantly lower compliance with the team-brief (p<0.001). Following a change in practice the compliance significantly increased (p>0.00001) at Site 1. The team de-brief was found to be consistently poorly complied with. We recommend regular audit of compliance and change in practice for all surgical units, and suggest national monitoring to ensure the benefits of the WHO checklist are applied to all in-patient surgery.

Preparation and characterization of spray-dried mucoadhesive microspheres of ketorolac for nasal administration.

The objective of this investigation was to prepare mucoadhesive microspheres of ketorolac for nasal delivery to avoid gastrointestinal side effects of conventional dosage form. Mucoadhesive microspheres were prepared using carbopol, polycarbophil and chitosan as polymer by spray drying method. The process and formulation parameters were varied to study the effect on the yield and particle size. Microspheres were characterized for surface morphology, encapsulation efficiency, swelling behavior, mucoahesion properties, interaction studies using FTIR and DSC, in vitro drug release, ex vivo nasal cilio toxicity studies and in vivo anti-inflammatory and analgesic activity. Prepared microspheres were discrete, bulky, free flowing and showed an average encapsulation efficiency ranging from 79-92%. The results showed that the process parameters significantly affect the particle size (10.29-16.75 µm) and yield of microspheres (36.53-56.69%). Interaction studies revealed that there were no drug to polymer interactions. Prepared microspheres exhibited good swelling and mucoadhesion strength which confined the strong mucoadhesive property of microspheres. Ketorolac release from the microspheres was extended up to 8 h and exhibited fickian drug release kinetics with best fit to higuchi model. The drug loaded microspheres were found to be nontoxic to nasal mucosa. The anti-inflammatory and analgesic effects of formulation showed a significant increase (p < 0.05) in percent inhibition value of up to 8 h when compared with ketorolac. In conclusion, spray dried microspheres based on chitosan could be suitable nasal delivery system for the administration of ketorolac.

Imaging in index finger radial collateral ligament injury: attention to detail really pays....

Radial collateral ligament of the index finger is a rare ligament to rupture. X-ray is generally normal, except for subtle findings of soft tissue swelling and occasionally a small fracture. With continuous advances in imaging, ultrasound and high quality MRI allow clear depiction of small structures including joint capsule and collateral ligaments of even the small joints. This helps in definitive diagnosis and determines the extent of injury, which may affect the treatment options and final outcome. We report a rare case of index finger metacarpo-phalangeal joint radial collateral ligament tear. The subtle X-ray abnormality was chased on ultrasound and the diagnosis was proposed on ultrasound and later confirmed on MRI. We also discuss the imaging findings of this rare entity.

Development and characterization of mucoadhesive microspheres for nasal delivery of ketorolac.

The objective of the present investigation was to prepare mucoadhesive microspheres of ketorolac for nasal administration by means of a solvent evaporation technique using carbopol (CP), polycarbophil (PL) and chitosan (CS) as mucoadhesive polymers. The prepared microspheres were characterized for morphology, swelling behavior, mucoadhesion, interaction studies, drug encapsulation efficiency, in vitro drug release, release kinetics, and ex vivo nasal cilio toxicity studies. The effects of various process variables on the particle size of the microspheres were investigated. Drug encapsulation efficiency and particle size of the microspheres ranged from 52-78% w/w and 14-46 microm respectively. Interaction studies revealed that there were no drug-polymer interactions. The in vitro release profiles showed prolonged-release of the drug. In vitro release data showed a good fit with the Higuchi model, and indicated Fickian diffusion. No severe damage was found to the integrity of nasal mucosa after ex vivo experiments.

Primitive neuroectodermal tumour metastases mimicking neurofibromatosis type 2.

Bilateral vestibular schwannomas are the diagnostic features of neurofibromatosis type 2 (NF-2), and are the most common findings associated with the disorder. We report a three-year-old boy who presented with left facial nerve palsy and weight loss with bilateral large cerebellopontine (CP) angle masses that extended into the internal auditory canal on magnetic resonance imaging. The patient also had synchronous tumours in the lateral ventricle and intradural extramedullary spinal canal. The above findings were misinterpreted as NF-2 with bilateral vestibular schwannomas, ventricular meningioma and spinal schwannomas/meningiomas. However, histological examination of the spinal masses revealed a primitive neuroectodermal tumour. Although bilateral CP angle masses are characteristic of NF-2, the possibility of diffuse craniospinal malignancy should be considered in a very young child who presents with weight loss and extensive tumours.

Assessment of dissolution profile of marketed aceclofenac formulations.

Statistical comparison of dissolution profiles under a variety of conditions relating to formulation characteristics, lot-to-lot, and brand-to-brand variation attracts interest of pharmaceutical scientist. The objective of this work is to apply several profile comparison approaches to the dissolution data of five-marketed aceclofenac tablet formulations. Model-independent approaches including ANOVA-based procedures, ratio test procedure, and pair wise procedure. The ratio test includes percentage, area under the curve, mean dissolution time, while the pair wise procedure includes difference factor (f(1)), similarity factor (f(2)), and Rescigno index. In the model-dependent approach, zero order, first order, Hixson-Crowell, Higuchi, and Weibull models were applied to the utilization of fit factors. All the approaches were applicable and useful. ANOVA with multiple comparison tests was found to be sensitive and discriminating for comparing the profiles. Weibull parameters were more sensitive to the difference between two release kinetic data in terms of curve shape and level.

MR Tractography in Horizontal Gaze Palsy and Progressive Scoliosis. A Case Report.

Congenital brainstem malformation without associated cerebellar disorder is uncommon. Horizontal gaze palsy with progressive scoliosis is one such rare syndrome with brainstem hypoplasia without any disorder of the cerebellum. It has an autosomal recessive inheritance and is characterised by absent horizontal gaze and severe progressive scoliosis from birth. We describe a 58-year-old man with horizontal gaze palsy and severe thoracolumbar scoliosis with typical MR imaging findings of brainstem hypoplasia, and MR tractography confirmation of complete absence of decussation of the pyramidal tract fibers.

Pharmaceutical GMP: past, present, and future--a review.

Good Manufacturing Practice (GMP) is a set of regulations, codes, and guidelines for the manufacture of drug substances and drug products, medical devices, in vivo and in vitro diagnostic products, and foods. GMP term that is recognized worldwide for the control and management of manufacturing and quality control testing of pharmaceutical products. Everyone in the pharmaceutical industry should know the story of how the good manufacturing practices (GMPs) have come to be. Most requirements were put in place as responses to tragic circumstances and to prevent future tragedies. To obtain and maintain GMP compliance, one should know the precedent of the GMP. The present review highlights past, present and future of GMP.

Tablet formulation studies on an oxcarbazepine-beta cyclodextrin binary system.

Oxcarbazepine is a poorly water-soluble (0.083 mg/ml) anti-epileptic drug according to the BCS system (class II) and its dissolution is rate-limiting step for its absorption. The objective of this work was to develop tablet formulations of oxcarbazepine-beta-cyclodextrin (OX-beta-CD) binary systems. Three types of binary systems--physical mixtures, kneaded systems, and coevaporated systems--were studied. Phase solubility studies indicated 1:1 M complexation of oxcarbazepine with beta-cyclodextrin. Drug-beta-CD binary systems were prepared at 1:1 molar ratios and used in formulation studies. The dissolution properties of OX-beta-CD KS (kneaded system, 100.10% drug release in 15 min) were superior than those of the other binary system and pure oxcarbazepine. The tablet formulations containing drug-beta-CD binary systems prepared by wet granulation and direct compression showed superior dissolution properties when compared with the formulations of the corresponding pure drug formulations. Tablet formulations containing drug-beta-CD binary systems prepared by the kneading method showed good dissolution properties (100% drug release in 15 min in direct compression method and 99.9% drug release in 20 min in wet granulation method). Overall, the dissolution properties of tablet formulations prepared by the direct compression method were superior to those of tablets prepared by the wet granulation method. Accelerated stability studies on some selected tablet formulations were also conducted by keeping the samples at 40 +/- 2 degrees C and 75% relative humidity. There were no statistical differences in the percentage of drug dissolved at 15 and 20 min between fresh and stored samples at the different time points (P < 0.05). Drug content also remained within acceptable limits. Thus, drug-beta-CD binary systems are useful in developing tablet formulations of oxcarbazepine with improved dissolution properties.

Mathematical evaluation of similarity factor using various weighing approaches on aceclofenac marketed formulations by model-independent method.

The US Food and Drug Administration's (FDA's) guidance for industry on dissolution testing of immediate-release solid oral dosage forms describes that drug dissolution may be the rate limiting step for drug absorption in the case of low solubility/high permeability drugs (BCS class II drugs). US FDA Guidance describes the model-independent mathematical approach proposed by Moore and Flanner for calculating a similarity factor (f2) of dissolution across a suitable time interval. In the present study, the similarity factor was calculated on dissolution data of two marketed aceclofenac tablets (a BCS class II drug) using various weighing approaches proposed by Gohel et al. The proposed approaches were compared with a conventional approach (W = 1). On the basis of consideration of variability, preference is given in the order of approach 3 > approach 2 > approach 1 as approach 3 considers batch-to-batch as well as within-samples variability and shows best similarity profile. Approach 2 considers batch-to batch variability with higher specificity than approach 1.

Pancreatic lymphoma masquerading as adenocarcinoma.

Primary pancreatic lymphoma is rare. We report a young man with primary lymphoma in the pancreatic head who presented with obstructive jaundice.