Intravitreal injections (IVI) of biologics targeting vascular endothelial growth factor (anti-VEGF) led to a paradigm shift in the management and prognosis of prevalent retinal conditions. Yet, IVI are typically performed with syringes that are neither developed nor approved for this purpose. Notably, syringes lubricated with silicone oil (SiO) are extensively used despite multiple reports showing that such syringes can cause deposition of SiO droplets in the vitreous body and patient discomfort. Thus, there is a need for SiO-free substitutes specifically tailored for IVI. Here, we report on the development and testing of such a syringe. This syringe has no dead volume, and its design allows for high-accuracy dosing. Also, it permits pharmaceutical compounding and storage of bevacizumab, ranibizumab, and aflibercept for up to 30 days without compromising their functional binding or transport properties. Finally, the new syringe demonstrated a favorable safety profile regarding release of SiO compared to SiO lubricated alternatives, including commercially prefilled syringes. Accordingly, the newly developed syringe is an appealing alternative for IVI.

OBJECTIVE: Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert medication that is susceptible to errors that may affect patient safety. Over time, considerable progress has been made to make PN practices safer. The purpose of this article is to address ongoing challenges to improve the PN use process from prescription to administration and monitoring, and to outline practical aspects fostering the safety, quality, and cost-effectiveness of PN, as discussed at the International Safety and Quality of PN Summit.
CONCLUSIONS: Opportunities to improve the PN use process in clinical practice include the promotion of inter-disciplinary communication, vigilant surveillance for complications, staff education to increase competency, and more consistent use of advanced technologies that allow automated safety checks throughout the PN process. Topics covered include considerations on PN formulations, including the value of intravenous lipid emulsions (ILEs), trends in compounding PN, the current and future role of market-authorized multi-chamber PN bags containing all 3 macronutrients (amino acids, glucose/dextrose, and ILE) in the United States and in Europe, and strategies to cope with the increasing global problem of PN product shortages.
CONCLUSIONS: This review outlines potential strategies to use in clinical practice to overcome ongoing challenges throughout the PN use process, and ultimately promote PN patient safety.

OBJECTIVE: This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care setting. Some European practices presented in this article do not conform with USP general chapter <797> requirements. Nevertheless, the purpose is to cover the challenges experienced in delivering high-quality PN within hospitals in the United States and Europe, in order to share best practices and experiences more widely.
CONCLUSIONS: Core issues regarding the PN process within an acute care setting are largely the same everywhere: There are ongoing pressures for greater efficiency, optimization, and also concurrent commitments to make PN safer for patients. Within Europe, in recent years, the use of market-authorized multi-chamber bags (MCBs) has increased greatly, mainly for safety, cost-effectiveness, and efficiency purposes. However, in the US, hospitals with low PN volumes may face particular challenges, as automated compounding equipment is often unaffordable in this setting and the variety of available MCBs is limited. This can result in the need to operate several PN systems in parallel, adding to the complexity of the PN use process. Ongoing PN quality and safety initiatives from US institutions with various PN volumes are presented. In the future, the availability of a greater selection of MCBs in the US may increase, leading to a reduction in dependence on compounded PN, as has been seen in many European countries.
CONCLUSIONS: The examples presented may encourage improvements in the safety and quality of PN within the acute care setting worldwide.

The kind of compounding emulsifier used and the amount of compounding have a significant impact on the emulsion\'s stability. In this study, the average particle size, Zeta potential, emulsification index, laser confocal microstructure, and rheological properties shows that the ratio of monoglyceride-xanthan gum and sucrose ester-xanthan gum could maintain the good stability of the emulsion in a certain range, and the monoglyceride and sucrose ester compounding could effectively improve the stability of the emulsion in a specific ratio (7:3). The results of fluorescence spectroscopy, Fourier transform infrared spectroscopy and sodium dodecyl sulfate polyacrylamide gel electrophoresis indicated that the simultaneous complexation of three substances was more likely to produce hydrophobic interactions with walnut proteins than the simultaneous complexation of two substances. Also confirmed were the hydrogen bonding connections between the proteins and the monoglyceride, sucrose ester, and xanthan gum. Monoglyceride and xanthan gum complexes were also found to stabilize more proteins.

Itraconazole is a drug used in veterinary medicine for the treatment of different varieties of dermatophytosis at doses between 3-5 mg/kg/day in cats. Nevertheless, in Spain, it is only available in the market as a 52 mL suspension at 10 mg/mL. The lack of alternative formulations, which provide sufficient formulation to cover the treatment of large animals or allow the treatment of a group of them, can be overcome with compounding. For this purpose, it has to be considered that itraconazole is a weak base, class II compound, according to the Biopharmaceutics Classification System, that can precipitate when reaching the duodenum. The aim of this work is to develop alternative oral formulations of itraconazole for the treatment of dermatophytosis. Several oral compounds of itraconazole were prepared and compared, in terms of dissolution rate, permeability, and stability, in order to provide alternatives to the medicine commercialized. The most promising formulation contained hydroxypropyl methylcellulose and β-cyclodextrin. This combination of excipients was capable of dissolving the same concentration as the reference product and delaying the precipitation of itraconazole upon leaving the stomach. Moreover, the intestinal permeability of itraconazole was increased more than two-fold.

Background: Extemporaneous compounding is the preparation of medicines for individual patients when no commercially available authorized form exists. Unlike registered medications, these products are not subjected to various tests for quality by Regulatory Authorities. Data on compounded medications in Ghana is currently inadequate or unavailable. There is the need to collate data that can be used to influence policy and to regulate preparation of extemporaneous products. Aim: To establish the prevalence, scope and quality of extemporaneously compounded medicines at selected hospitals in Accra, Ghana. Methodology: Prescriptions presented at the pharmacies in selected hospitals were reviewed to determine the requests that needed to be extemporaneously prepared as well as the prevalence and the scope of formulations. Three of the most frequently compounded medications were procured and subjected to microbial contamination tests using the pour plate method followed by differential tests if microbes were present. Content analysis of the active ingredients was determined using High Performance Liquid Chromatography (HPLC). Results: 641 requests comprising 49 different extemporaneous products were collated from the hospitals studied. Hydroxyurea, furosemide and spironolactone suspensions were the three most frequently prescribed. Patients aged from 0-2 years had majority of the prescriptions. Conclusion: A population of patients still exist who depend on compounding for their drug needs. 49 different formulations were prepared at one of the hospitals visited. Samples of products analyzed were of good quality.

To improve the wettability of surfactants on bituminous coal and to explore its wettability and wettability mechanism on bituminous coal, taking the Sandaogou bituminous coal as an example, a single factor experiment was carried out first. Through contact angle and surface tension experiments, three surfactants with good wettability were selected from among the nine surfactants and mixed in equal proportions two by two to determine the optimal compounding method and compounding concentration. The experimental results show that the compounding of nonionic and anionic, nonionic and zwitterionic, anionic and zwitterionic surfactants can have synergistic effects and significantly improve the wettability of bituminous coal. Among them, the 0.5 wt% SDS + 0.5 wt% CAB-50 (R2) compound surfactant had the best wettability on bituminous coal, and the contact angle and surface tension were only 15.24° and 23.62 mN/m, respectively. The surface electrostatic potential values of each material molecule were calculated by Materials Studio software based on the quantum chemistry method, and correlation analysis was carried out with wettability. The results show that the surface electrostatic potentials of CDEA, SDS and CAB-50 were greater than those of water and bituminous coal, and the region of maximum negative electrostatic potential corresponded to oxygen atoms, which are easier to adsorb on bituminous coal and water molecules. Then, through molecular dynamics simulation, the interaction energy and the distribution of contributions along the Z-axis of the water/compound surfactant/bituminous coal system at equilibrium were investigated, and finally, a spray dust reduction test was carried out in the Sandaogou Coal Mine. The results showed that the 0.5 wt% SDS + 0.5 wt% CAB-50 compound solution can be used as a water molecule adsorption carrier, prompting more water molecules to be embedded into coal molecules, increasing the relative concentration of water molecules on the surface of bituminous coal, restricting the diffusion of water molecules, and greatly improving the wettability. After the addition of 0.5 wt% SDS + 0.5 wt% CAB-50 as a spray agent, the concentration of total dust at the driver\'s position decreased from 65.14 to 9.11 mg/m3, the concentration of exhaled dust decreased from 30.07 to 3.35 mg/m3, and the efficiency of total and exhaled dust reduction compared with that of pure water was 86.01% and 89.35%, respectively.

The current experimental work aimed at developing PCC through two major process steps: dissolution and precipitation, using raw materials domestically available as SL, which are intensively used in construction inputs. The pH level was the decisive parameter used to determine the time required to complete the dissolution and carbonation processes during precipitation. The optimal pH levels were found to be 13 for dissolution and 7.1 for precipitation, respectively. The produced PCC was characterized based on chemical analysis, crystallinity, and morphology, showing an increment of CaCO3 content exceeding 99%, sharper crystal peaks, and predominantly calcite PCC. The compatibility of the PCC was assessed by incorporating 25%, 50%, 75%, and 100% of PCC with commercial filler, followed by selected mechanical tests, such as stress at yield, density, and elongation at break. The results indicated that mixing ratios of 25%, 50%, and 75% of PCC with the commercial filler met the standards, with stress at a yield above 45 MPa and density within the range of 1.35 to 1.46 g/cm3. However, complete substitution slightly lowered these properties. Nevertheless, the elongation at break was acceptable at all treatment levels.

Liposomal amphotericin B (Ambisome®) is the gold standard for the treatment and prevention of fungal infections both in the adult and pediatric populations. The lyophilized dosage form has to be reconstituted and diluted by hospital staff, but its management can be challenging due to the spontaneous tendency of amphotericin B to form aggregates with different biological activity. In this study, the colloidal stability of the liposomes and the chemical stability of amphotericin B were investigated over time at storage conditions. Three liposomal formulations of amphotericin B at 4.0 mg/mL, 2.0 mg/mL, and 0.2 mg/mL were prepared and assayed for changes regarding the dimensional distribution, zeta potential, drug aggregation state, and onset of by-products. Our analyses highlighted that the most diluted formulation, kept at room temperature, showed the greatest changes in the aggregation state of the drug and accordingly the highest cytotoxicity. These findings are clinically relevant since the lower dosages are addressed to the more vulnerable patients. Therefore, the centralization of the dilution of AmBisome® at the pharmacy is of fundamental importance for assuring patient safety, and at the same time for reducing medication waste, as we demonstrated using the cost-saving analysis of drug expense per therapy carried out at the G. Gaslini children hospital.

BACKGROUND: Makena (17-hydroxyprogesterone caproate) was approved by the United States Food and Drug Administration for the prevention of recurrent spontaneous preterm birth in 2011 under the accelerated approval pathway, but fundamental pharmacokinetic or pharmacodynamic (Phase 1 and Phase 2) studies were not performed. At the time, there were no dose-response or concentration-response data. The therapeutic concentration was not known. The lack of such data brings into question the dosing regimen for 17-hydroxyprogesterone caproate and if it was optimized.
OBJECTIVE: The purpose of this study was to evaluate the dosing regimen for 17-hydroxyprogesterone by analyzing 3 data sets in which the 17-hydroxyprogesterone caproate pharmacology was evaluated, namely the Maternal-Fetal Medicine Omega 3 study, the Obstetric-Fetal Pharmacology Research Units study, and the Obstetrical-Fetal Pharmacology Research Centers study. If an inappropriate dosing regimen could be identified, such information could inform future studies of pharmacotherapy in pregnancy.
METHODS: Data from the Omega 3 study were used to determine if plasma concentration was related to spontaneous preterm birth risk and if a threshold concentration could be identified. Data from the Obstetric-Fetal Pharmacology Research Units study were used to determine the half-life of 17-hydroxyprogesterone caproate and to develop a model to simulate drug concentrations with various dosing regimens. Data from the Obstetrical-Fetal Pharmacology Research Centers study were used to determine the relationship between dose and safety outcomes.
RESULTS: Analysis of the Omega 3 data set indicated that the risk for spontaneous preterm birth decreased as the log concentration of 17-hydroxyprogesterone caproate increased (odds ratio, 0.04; 95% confidence interval, 0.00-0.90). A steady state concentration of >9 ng/mL (equivalent to >8 ng/mL at 25-28 weeks) was associated with the lowest risk for spontaneous preterm birth (hazard ratio, 0.52; 95% confidence interval, 0.27-0.98; P=.04); this concentration was not achieved in 25% of subjects who received the 250 mg weekly dose. In the Obstetrical-Fetal Pharmacology Research Units study, the adjusted half-life (median and interquartile range) of 17-hydroxyprogesterone caproate was 14.0 (11.5-17.2) days. Simulations indicated that with the 250 mg weekly dose, >5 weekly injections were required to reach the 9 ng/mL target; however, those with the shortest half-life (corresponding to higher clearance), never reached the targeted 9 ng/mL concentration. In 75% of subjects, a loading dose of 500 mg weekly for 2 weeks followed by 250 mg weekly achieved and maintained the 9 ng/mL concentration within 2 weeks but in those 25% with the shortest half-life, concentrations exceeded the 9 ng/mL target for only 3 weeks. In the Obstetrical-Fetal Pharmacology Research Centers study, all 65 subjects who received a weekly dose of 500 mg exceeded the 9 ng/mL steady state.
CONCLUSIONS: The dosing regimen for 17-hydroxyprogesterone caproate was inadequate. There is a significant inverse relationship between drug concentration and spontaneous preterm birth. The risk was lowest when the concentration exceeded 9 ng/mL, but 25% of women who received the 250 mg weekly dose never reached or maintained this concentration. The drug\'s long half-life necessitates a loading dose to achieve therapeutic concentrations rapidly. The omission of basic pharmacologic studies to determine the proper dosing may have compromised the effectiveness of 17-hydroxyprogesterone caproate. Future pharmacotherapy trials in pregnancy must first complete fundamental pharmacology studies.