Machine-Learning vs. Expert-Opinion Driven Logistic Regression Modelling for Predicting 30-Day Unplanned Rehospitalisation in Preterm Babies: A Prospective, Population-Based Study (EPIPAGE 2).

Introduction: Preterm babies are a vulnerable population that experience significant short and long-term morbidity. Rehospitalisations constitute an important, potentially modifiable adverse event in this population. Improving the ability of clinicians to identify those patients at the greatest risk of rehospitalisation has the potential to improve outcomes and reduce costs. Machine-learning algorithms can provide potentially advantageous methods of prediction compared to conventional approaches like logistic regression. Objective: To compare two machine-learning methods (least absolute shrinkage and selection operator (LASSO) and random forest) to expert-opinion driven logistic regression modelling for predicting unplanned rehospitalisation within 30 days in a large French cohort of preterm babies. Design, Setting and Participants: This study used data derived exclusively from the population-based prospective cohort study of French preterm babies, EPIPAGE 2. Only those babies discharged home alive and whose parents completed the 1-year survey were eligible for inclusion in our study. All predictive models used a binary outcome, denoting a baby's status for an unplanned rehospitalisation within 30 days of discharge. Predictors included those quantifying clinical, treatment, maternal and socio-demographic factors. The predictive abilities of models constructed using LASSO and random forest algorithms were compared with a traditional logistic regression model. The logistic regression model comprised 10 predictors, selected by expert clinicians, while the LASSO and random forest included 75 predictors. Performance measures were derived using 10-fold cross-validation. Performance was quantified using area under the receiver operator characteristic curve, sensitivity, specificity, Tjur's coefficient of determination and calibration measures. Results: The rate of 30-day unplanned rehospitalisation in the eligible population used to construct the models was 9.1% (95% CI 8.2-10.1) (350/3,841). The random forest model demonstrated both an improved AUROC (0.65; 95% CI 0.59-0.7; p = 0.03) and specificity vs. logistic regression (AUROC 0.57; 95% CI 0.51-0.62, p = 0.04). The LASSO performed similarly (AUROC 0.59; 95% CI 0.53-0.65; p = 0.68) to logistic regression. Conclusions: Compared to an expert-specified logistic regression model, random forest offered improved prediction of 30-day unplanned rehospitalisation in preterm babies. However, all models offered relatively low levels of predictive ability, regardless of modelling method.

Implications of In-Use Photostability: Proposed Guidance for Photostability Testing and Labeling to Support the Administration of Photosensitive Pharmaceutical Products, Part 3. Oral Drug Products.

The ICH Q1B guidance and additional clarifying manuscripts provide the essential information needed to conduct photostability testing for pharmaceutical drug products in the context of manufacturing, packaging, and storage. As the previous 2 papers in this series highlight for drug products administered by injection (part 1) and drug products administered via topical application (part 2), there remains a paucity of guidance and methodological approaches to conducting photostability testing to ensure effective product administration. Part 3 in the series is presented here to provide a similar approach and commentary for photostability testing for oral drug products. The approach taken, as was done previously, is to examine "worst case" photoexposure scenarios in combination with ICH-defined light sources to derive a set of practical experimental approaches to support the safe and effective administration of photosensitive oral drug products.

Influence of Ionizing Radiation and the Role of Thiol Ligands on the Reversible Photodarkening of CdTe/CdS Quantum Dots.

We investigate the influence of high energy photons and thiol ligands on the photophysical properties of sub-monolayer CdTe/CdS quantum dots (QDs) immobilized in porous silica (PSiO2) scaffolds. The highly disperse, uniform distributions of QDs in a three-dimensional PSiO2 framework ensure uniform interaction of not only radiation but also subsequent surface repassivation solutions to all immobilized QDs. The high optical densities of QDs achieved using PSiO2 enable straightforward monitoring of the QD photoluminescence intensities and carrier lifetimes. Irradiation of QDs in PSiO2 by high energy photons, X-rays, and γ-rays leads to dose-dependent QD photodarkening, which is accompanied by accelerated photooxidative effects in ambient environments that give rise to blue-shifts in the peak QD emission wavelength. Irradiation in an oxygen-free environment also leads to QD photodarkening but with no accompanying blue-shift of the QD emission. Significant reversal of QD photodarkening is demonstrated following QD surface repassivation with a solution containing free-thiols, suggesting reformation of a CdS shell, etching of surface oxidized species, and possible reduction of photoionized dark QDs to a neutral, bright state. Permanent lattice displacement damage effects may contribute toward some irreversible γ radiation damage. This work contributes to an improved understanding of the influence of surface ligands on the optical properties of QDs and opens up the possibilities of engineering large area, low-cost, reuseable, and flexible QD-based optical radiation sensors.

Increased Duration of Heating Boosts Local Drug Deposition during Radiofrequency Ablation in Combination with Thermally Sensitive Liposomes (ThermoDox) in a Porcine Model.

INTRODUCTION: Radiofrequency ablation (RFA) is used for the local treatment of liver cancer. RFA is effective for small (<3 cm) tumors, but for tumors > 3 cm, there is a tendency to leave viable tumor cells in the margins or clefts of overlapping ablation zones. This increases the possibility of incomplete ablation or local recurrence. Lyso-Thermosensitive Liposomal Doxorubicin (LTLD), is a thermally sensitive liposomal doxorubicin formulation for intravenous administration, that rapidly releases its drug content when exposed to temperatures >40°C. When used with RFA, LTLD releases its doxorubicin in the vasculature around the zone of ablation-induced tumor cell necrosis, killing micrometastases in the ablation margin. This may reduce recurrence and be more effective than thermal ablation alone. PURPOSE: The purpose of this study was to optimize the RFA procedure used in combination with LTLD to maximize the local deposition of doxorubicin in a swine liver model. Pigs were anaesthetized and the liver was surgically exposed. Each pig received a single, 50 mg/m2 dose of the clinical LTLD formulation (ThermoDox®). Subsequently, ablations were performed with either 1, 3 or 6 sequential, overlapping needle insertions in the left medial lobe with total ablation time of 15, 45 or 90 minutes respectively. Two different RFA generators and probes were evaluated. After the final ablation, the ablation zone (plus 3 cm margin) was dissected out and examined for doxorubicin concentration by LC/MS and fluorescence. CONCLUSION: The mean Cmax of plasma total doxorubicin was 26.5 µg/ml at the end of the infusion. Overall, increased heat time from 15 to 45 to 90 minutes shows an increase in both the amount of doxorubicin deposited (up to ~100 µg/g) and the width of the ablation target margin to which doxorubicin is delivered as determined by tissue homogenization and LC/MS detection of doxorubicin and by fluorescent imaging of tissues.

Implications of In-Use Photostability: Proposed Guidance for Photostability Testing and Labeling to Support the Administration of Photosensitive Pharmaceutical Products, Part 2: Topical Drug Product.

Although essential guidance to cover the photostability testing of pharmaceuticals for manufacturing and storage is well-established, there continues to be a significant gap in guidance regarding testing to support the effective administration of photosensitive drug products. Continuing from Part 1, (Baertschi SW, Clapham D, Foti C, Jansen PJ, Kristensen S, Reed RA, Templeton AC, Tønnesen HH. 2013. J Pharm Sci 102:3888-3899) where the focus was drug products administered by injection, this commentary proposes guidance for testing topical drug products in order to support administration. As with the previous commentary, the approach taken is to examine "worst case" photoexposure scenarios in comparison with ICH testing conditions to provide practical guidance for the safe and effective administration of photosensitive topical drug products.

Implications of in-use photostability: proposed guidance for photostability testing and labeling to support the administration of photosensitive pharmaceutical products, part 1: drug products administered by injection.

Basic guidance on the photostability testing of pharmaceuticals, designed to cover manufacturing and storage over shelf life, has long been established within ICH Q1(ICH,B(10) , but the guideline does not cover the photostability of drugs during or after administration (i.e., under conditions of use). To date, there has been a paucity of guidance covering the additional testing that would be of value during the clinical preparation and use of products. This commentary suggests a systematic approach, based on realistic "worst case" photoexposure scenarios and the existing ICH Option 1 and 2 light sources, to provide valuable data to pharmaceutical manufacturers and compounding pharmacists for the safe and effective use of photosensitive injection products.

A tale of two cities: restoring water services in Kabul and Monrovia.

Kabul and Monrovia, the respective capitals of Afghanistan and Liberia, have recently emerged from long-lasting armed conflicts. In both cities, a large number of organisations took part in emergency water supply provision and later in the rehabilitation of water systems. Based on field research, this paper establishes a parallel between the operations carried out in the two settings, highlighting similarities and analysing the two most common strategies. The first strategy involves international financial institutions, which fund large-scale projects focusing on infrastructural rehabilitation and on the institutional development of the water utility, sometimes envisaging private-sector participation. The second strategy involves humanitarian agencies, which run community-based projects, in most cases independently of the water utilities, and targeting low-income areas. Neither of these approaches manages to combine sustainability and universal service. The paper assesses their respective strengths and weaknesses and suggests ways of improving the quality of assistance provided.

Evaluation of hydroperoxides in common pharmaceutical excipients.

While the physical properties of pharmaceutical excipients have been well characterized, impurities that may influence the chemical stability of formulated drug product have not been well studied. In this work, the hydroperoxide (HPO) impurity levels of common pharmaceutical excipients are measured and presented for both soluble and insoluble excipients. Povidone, polysorbate 80 (PS80), polyethylene glycol (PEG) 400, and hydroxypropyl cellulose (HPC) were found to contain substantial concentrations of HPOs with significant lot-to-lot and manufacturer-to-manufacturer variation. Much lower HPO levels were found in the common fillers, like microcrystalline cellulose and lactose, and in high molecular weight PEG, medium chain glyceride (MCG), and poloxamer. The findings are discussed within the context of HPO-mediated oxidation and formulating drug substance sensitive to oxidation. Of the four excipients with substantial HPO levels, povidone, PEG 400, and HPC contain a mixture of hydrogen peroxide and organic HPOs while PS80 contains predominantly organic HPOs. The implications of these findings are discussed with respect to the known manufacturing processes and chemistry of HPO reactivity and degradation kinetics. Defining critical HPO limits for excipients should be driven by the chemistry of a specific drug substance or product and can only be defined within this context.

Nucleophilic group transfer reactivity for fibric acid derived drug molecules.

A novel group transfer reaction is reported in which a drug molecule undergoes a thermally induced 2-methyl-2-yl-propionic acid group transfer from one drug molecule to the carboxylic acid functional group of another. The resulting product, the 2-carboxy isopropyl ester of the parent compound, can itself participate in further reactions to yield a series of homologous products. The structural requirements and solvent dependence of this reactivity were investigated, and the resulting implications for the reaction mechanism were discussed. The experimental data is consistent with solvent-assisted nucleophilic substitution reaction mechanism, where the solvent is a small molecule or a second drug molecule. Hydrogen bonding appears to play an important role in both intramolecular activation of the leaving group, as well as intermolecular interaction with the attacking nucleophile. The reactivity is found to be intrinsic to the 2-arenoxy-2-methylpropionic acid structure, which is common to the extended class of fibrate PPAR drug molecules, suggesting that the potential for this reactivity exists for many of these drug molecules as well.

A novel peroxy radical based oxidative stressing system for ranking the oxidizability of drug substances.

A novel oxidative stressing system is described which generates high levels of peroxy radicals in solution at room temperature, without the use of azonitrile initiators. The oxidative stressing system is composed of a 10% solution of Tween 80 in water to which FeCl3 x 6H2O is added. The Tween 80 acts as a solubilizing agent for drug compounds, and also contains substantial amounts of organic hydroperoxides. It is shown that the Fe III/ Fe II couple operates on the hydroperoxide concentration to effectively generate new peroxy radicals, which then propagate in the Tween 80 solution. Key features of the Tween 80/Fe III system are investigated, and the oxidizability of seven known compounds and ten developmental compounds are examined. Relative reaction rates span a 300-fold range, from benzoic acid (nonreactive, defined as <0.5% reacted per day) to Vitamin D3 (7% reacted per hour). Oxidizability "rankings" thus generated are shown to agree well with azonitrile initiated oxidative stress. The potential for general correlations between this type of oxidizability data and actual oxidative performance in LFC and solid oral dosage forms is discussed.

Evaluation of solution oxygenation requirements for azonitrile-based oxidative forced degradation studies of pharmaceutical compounds.

AIBN and ACVA oxidative forced degradation models are examined for two drug molecules whose predominant oxidation chemistries arise from different reaction mechanisms (i.e., free radical vs. nucleophilic). Stress was conducted under a variety of initiator concentrations, and under ambient and pressurized oxygen atmospheres. In each case examined, the azonitrile initiator solutions served as a good predictive model of the major oxidative degradation products observed in pharmaceutical formulations. At low to moderate inititator concentrations, the degradation product distributions and degree of reactivity were similar for samples stored in ambient and pressurized oxygen environments. These results are rationalized with reference to the oxygen consumption kinetics of AIBN and ACVA solutions as a function of initiator concentration. The data suggests that ambient air provides sufficient oxygen to enable chain propagation of peroxy radicals in azonitrile solutions of concentrations appropriate to the forced degradation of pharmaceutical compounds.

Polysorbate 80 UV/vis spectral and chromatographic characteristics--defining boundary conditions for use of the surfactant in dissolution analysis.

Polysorbate 80 is used in the pharmaceutical industry as an additive to enhance the solubility of non-polar compounds in formulation design and during dissolution analysis. In this paper we present the spectroscopic and chromatographic characteristics for a series of commercially available sources of this non-ionic surfactant. The large UV/vis absorbance and broad chromatographic elution of Polysorbate 80 often makes it difficult to accurately quantitate pharmaceutically active compounds in solutions where the surfactant is present. Boundary conditions have been established where analytical interferences can be avoided in spectrophotometric analysis by choice of analysis wavelength and solution concentrations. Chromatographic method development is also presented enabling the removal of Polysorbate interference in instances where spectroscopic interference is too great.

Identification of impurities in ivermectin bulk material by mass spectrometry and NMR.

The identification and characterization of four process impurities in bulk ivermectin and four process impurities in bulk avermectin, using a combination of MS and NMR, are discussed herein. These process impurities were shown to be 24-demethyl H2B1a, 3'-demethyl H2B1a, 3''-demethyl H2B1a and 24a-hydroxy B2a isomer. The impurities were shown to be process impurities and are present in avermectin bulk also.

Detection and quantification of low-molecular-weight aldehydes in pharmaceutical excipients by headspace gas chromatography.

The adverse effect of reactive chemical residues on the quality of drug products has necessitated the determination of low-molecular-weight aldehydes in pharmaceutical excipients. An analytical methodology for the detection of trace amounts of C1-C8 aliphatic aldehydes and benzaldehyde in excipients is described. The proposed procedure is based on the derivatization of aldehydes in aqueous solution with O-2,3,4,5,6-(pentafluorobenzyl) hydroxylamine hydrochloride (PFBHA), followed by static headspace gas chromatographic (SHS-GC) analysis of PFBHA aldehyde oximes with negative chemical ionization (NCI) MS detection. The method developed was demonstrated to be simple, selective, sensitive, and was successfully applied to the screening of aldehydes at sub-microg/g levels in over 30 typical excipients. The most abundant aldehydes found in the samples were formaldehyde and acetaldehyde, for which a rapid and reliable routine quantification method by readily available SHS-GC instrumentation coupled with flame-ionization detection was also developed and validated.

Profiling of medium chain glycerides used in pharmaceutical formulation development by reversed-phase HPLC.

Medium chain length (C8, C10) mono-, di- and triacylglycerols (MCGs) are used in pharmaceutical formulation development of poorly soluble compounds, as a means to increase their oral bioavailability. The ratios of C8 and C10 fatty acid components along with the ratio of monoglycerides, diglycerides and triglycerides can significantly impact overall solubilizing characteristics both in vitro and in vivo. Existing literature methods either do not have the desired selectivity or simplicity to adequately characterize these MCGs. A reversed-phase HPLC method has been developed utilizing a Waters Symmetry C18 (150 mm x 4.6 mm, 3.5 microm particle size) column with a gradient of acetonitrile and water. The effluent was monitored using a UV detector at 220 nm and relative response factors were determined for all components with available standards to allow for accurate quantitation. The RP-HPLC method was optimized for selectivity, sensitivity and efficiency and was successfully applied to the characterization of commercial samples yielding superior sensitivity and ease of preparation compared to existing compendial methods.

Mechanism of the solution oxidation of rofecoxib under alkaline conditions.

PURPOSE: The rapid oxidation of rofecoxib under alkaline conditions has been previously reported. The oxidation was reported to involve gamma-lactone ring opening to an alcohol, which further oxidized to a dicarboxyclic acid. The oxidation was suspected to be mediated by peroxy radicals. This work further investigates the mechanism of oxidation under the alkaline solution conditions. METHODS: The pH dependence of the oxidation reaction was determined in 50% acetonitrile/50% aqueous phosphate buffer (pH 9-12). The oxidation reaction products were also examined at early timepoints (from 40 s to several minutes) with only 5% water content. The evolution of hydrogen peroxide by the oxidation reaction was quantitatively followed by reaction with triphenylphosphine (TPP) and high-pressure liquid chromatography determination of the resultant triphenylphosphine oxideformed. Rofecoxib was exposed to the alkaline pH conditions in the presence of formaldehyde, and the primary reaction product was isolated and characterized by liquid chromatography-mass spectrometry and proton 1D, heteronuclear multiple quantum coherence (HMQC), gradient heteronuclear multiple bond correlation (gHMBC), and carbon 1D nuclear magnetic resonance techniques. Transient reaction products were examined for hydroperoxide groups by reaction with TPP. RESULTS: The oxidation reaction occurs only near pH 11 and above. In the presence of excess formaldehyde, oxidation products are no longer observed but a new product is observed in which two formaldehyde molecules have added to the methylene carbon atom of the gamma-lactone ring. The evolution of hydrogen peroxide corresponds quantitatively to the molar amount of the (minor) aldehyde oxidation product formed. It is demonstrated that the rofecoxib anhydride species is actually the primary product of the oxidation reaction. The existence of a transient hydroperoxide species is shown by reaction with TPP and concomitant conversion to a previously identified alcohol. CONCLUSIONS: The oxidation of rofecoxib under these high pH conditions is mediated by rofecoxib enolate ion formation. The enolate ion reacts with either formaldehyde or dissolved oxygen at the C5 position. In the case of oxygen, a transient hydroperoxide species is formed. The major and minor products of the oxidation derive from competitive routes of decomposition of this hydroperoxide. The major route involves a second enolate ion formation, which decomposes with heterolytic cleavage of the RO-OH bond to give the rofeocoxib anhydride and hydroxide ion. The anhydride is rapidly hydrolyzed under the alkaline conditions to give the observed rofecoxib dicarboxylate product. The minor hydroxy-furanone product is formed from hydroxide ion attack on the hydroperoxide intermediate.

Restoring sanitation services after an earthquake: field experience in Bam, Iran.

A powerful earthquake hit the city of Bam in southeast Iran on 26 December 2003. In its aftermath, a number of international relief agencies, including Oxfam, assisted in providing emergency sanitation services. Oxfam's programme consisted of constructing and repairing toilets and showers in villages located outside of the city. In contrast with other organisations, Oxfam opted for brick-work structures, using local materials and human resources rather than prefabricated cubicles. The choice illustrates the dilemmas faced by agencies involved in emergency sanitation: responding to needs in a manner consistent with international standards and offering assistance in a timely fashion while involving beneficiaries. Following a preliminary survey, Oxfam concluded that the provision of showers and latrines, in addition to utilisation of local materials and human resources, was essential for ensuring well-being, empowerment and dignity among members of the affected population, thereby maximising the benefits.

In-line monitoring of moisture content in fluid bed dryers using near-IR spectroscopy with consideration of sampling effects on method accuracy.

In-line near-IR moisture monitoring of the dynamic, fluid bed drying environment has been reported in recent years by several research groups; however, analytical figures of merit with regard to prediction accuracy are discussed in only a subset of this work, and issues with sampling and sample presentation are scarcely addressed at all. In this study, experiments were performed at 65-, 300-, and 600-L drying scales using several different sampling configurations in an effort to better understand and improve in-line near-IR method accuracy. Findings from this work demonstrate that process heterogeneity plays a major role in determination of apparent prediction accuracy. This aspect is general to all in-line measurements and plays an especially important role in solids and slurry systems that are prone to heterogeneity. In addition to experimental results, simulations based on these findings and sampling theory demonstrate an interesting paradox: depending on the sampling configuration employed, the method with the smallest apparent error is not necessarily optimal for process monitoring and control. Furthermore, sampling configuration influences the number of samples necessary to define an adequate calibration set. Finally, process understanding that was gained as a result of temporally rich, in-line measurements will be presented.