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Teriflunomide is the active metabolite of leflunomide. It is an immunomodulatory agent used in the treatment of multiple sclerosis. UV spectrophotometric method has been developed for the estimation of teriflunomide in tablets using methanol as solvent. Teriflunomide has shown λmaxat293nm.The method hasbeen validated according to ICH Q2 (R1) guidelines. Alinear responseis observed(R2=0.9995) in therange of 4-20μg/ml, with recovery (100.68%) andprecision (% RSD is 0.07).This method is simpleand suitable for routine pharmaceutical analysis.

The present study focuses on, screening the anti-bacterial activities of methanol and chloroform extracts of the dried stem barks of Ziziphus xylopyrus. The anti-bacterial activities were evaluated against fifteen different bacterial strains by detecting minimum inhibitory concentration and zone of inhibition. The minimum inhibitory concentration (MIC) values were compared with control and zones of inhibition (ZOI) were compared with standard ciprofloxacin at concentration of 100 and 200 μg/mL. Among the two extracts, the methanolic extract showed better antibacterial activity compared to chloroform extract . The MIC values for different bacterial strains obtained were within the range of 100-300 μg/mL. The ZOI values showed that there was a little differences in the ZOI values between the standard and methanol extract within the range of 0.5 to 1mm. This was comparable with the standard drug. Anatomical, proximate analysis and chromatographic studies were also carried out to fulfill the botanical quality control standards.

BACKGROUND AND OBJECTIVE: Ruxolitinib is a tyrosine kinase inhibitor targeting the Janus kinase (JAK) and signal transducer and activator of transcription (STAT) pathways. Ruxolitinib is used to treat myelofibrosis, polycythemia vera and steroid-refractory graft-versus-host disease in the setting of allogeneic stem-cell transplantation. This review describes the pharmacokinetics and pharmacodynamics of ruxolitinib.METHODS: Pubmed, EMBASE, Cochrane Library and web of Science were searched from the time of database inception to march 15, 2021 and was repeated on November 16, 2021. Articles not written in English, animal or in vitro studies, letters to the editor, case reports, where ruxolitinib was not used for hematological diseases or not available as full text were excluded.RESULTS: Ruxolitinib is well absorbed, has 95% bio-availability, and is bound to albumin for 97%. Ruxolitinib pharmacokinetics can be described with a two-compartment model and linear elimination. Volume of distribution differs between men and women, likely related to bodyweight differences. Metabolism is mainly hepatic via CYP3A4 and can be altered by CYP3A4 inducers and inhibitors. The major metabolites of ruxolitinib are pharmacologically active. The main route of elimination of ruxolitinib metabolites is renal. Liver and renal dysfunction affect some of the pharmacokinetic variables and require dose reductions. Model-informed precision dosing might be a way to further optimize and individualize ruxolitinib treatment, but is not yet advised for routine care due to lack of information on target concentrations.CONCLUSION: Further research is needed to explain the interindividual variability of the ruxolitinib pharmacokinetic variables and to optimize individual treatment.

The current lack of insight into nanoparticle-cell membrane interactions hampers smart design strategies and thereby the development of effective nanodrugs. Quantitative and methodical approaches utilizing cell membrane models offer an opportunity to unravel particle-membrane interactions in a detailed manner under well controlled conditions. Here we use total internal reflection microscopy for real-time studies of the non-specific interactions between nanoparticles and a model cell membrane at 50 ms temporal resolution over a time course of several minutes. Maintaining a simple lipid bilayer system across conditions, adsorption and desorption were quantified as a function of biomolecular corona, particle size and fluid flow. The presence of a biomolecular corona reduced both the particle adsorption rate onto the membrane and the duration of adhesion, compared to pristine particle conditions. Particle size, on the other hand, was only observed to affect the adsorption rate. The introduction of flow reduced the number of adsorption events, but increased the residence time. Lastly, altering the composition of the membrane itself resulted in a decreased number of adsorption events onto negatively charged bilayers compared to neutral bilayers. Overall, a model membrane system offers a facile platform for real-time imaging of individual adsorption-desorption processes, revealing complex adsorption kinetics, governed by particle surface energy, size dependent interaction forces, flow and membrane composition.

Therapeutic drug monitoring (TDM) results for ganciclovir in 12 different treatment episodes showed large intraindividual and interindividual variabilities in the trough concentration and area under the 24-hour concentration-time curve (AUC24). Despite adequate valganciclovir dosing, subtherapeutic concentrations were found in 30% of the treatment episodes. A decrease in viral load was observed regardless of subtherapeutic exposure. These findings show the need for target concentration evaluation and assessment of the applicability of ganciclovir TDM in children.

BACKGROUND: Therapeutic Drug Monitoring (TDM) of immunosuppressive drugs is important for the prevention of allograft rejection in transplant patients. Several hospitals offer a microsampling service that provides patients the opportunity to sample a drop of blood from a fingerprick at home that can then be sent to the laboratory by mail. The aim of this study was to pilot an external quality control program.METHODS: Fourteen laboratories from seven countries participated (fully or partly) in three rounds of proficiency testing for the immunosuppressants tacrolimus, ciclosporin, everolimus, sirolimus and mycophenolic acid. The microsampling devices included the following: Whatman 903 and DMPK-C, HemaXis, Mitra and Capitainer-B. All assays were based on LC-MS/MS. In round 2, microsamples as well as liquid whole blood samples were sent, and one of these samples was a patient sample.RESULTS: Imprecision CV% values for the tacrolimus microsamples reported by individual laboratories ranged from 13.2% - 18.2%, 11.7% - 16.3%, and 12.2% - 18.6% for rounds 1, 2, and 3 respectively. For liquid whole blood (round 2), the imprecision CV% values ranged from 3.9% - 4.9%. For the other immunosuppressants, the results were similar. A great variety in analytical procedures was observed, especially the extraction method. For the patient sample, the microsample results led to different clinical decisions compared to that of the whole blood sample.CONCLUSIONS: Immunosuppressant microsampling methods show great interlaboratory variation compared to whole blood methods. This variation can influence clinical decision making. Thus, harmonization and standardization are needed. Proficiency testing should be performed regularly for laboratories that use immunosuppressant microsampling techniques in patient care.

RATIONALE & OBJECTIVE: Heavy metals are known to induce kidney damage and recent studies have linked minor exposures to cadmium and arsenic with increased risk of kidney allograft failure, yet the potential association of lead (Pb) with late graft failure in kidney transplant recipients (KTR) remains unknown.STUDY DESIGN: Prospective cohort study in the Netherlands.SETTING & PARTICIPANTS: We studied outpatient KTR (n=670) with a functioning graft for ≥1 year recruited at a university setting (2008-2011, NCT02811835) and followed, on average, for 4.9 (IQR, 3.4‒5.5) years. Additionally, end-stage kidney disease patients (n=46) enrolled in the ongoing TransplantLines Cohort and Biobank Study (2016-2017, NCT03272841) were studied at admission for transplantation and at 3, 6, 12, and 24 months after transplantation.EXPOSURE: Plasma Pb was log2 transformed to estimate the association with outcomes per doubling of plasma Pb concentration and also considered categorically as tertiles of the Pb distribution.OUTCOME: Kidney graft failure (restart of dialysis or re-transplantation) with the competing event of death with a functioning graft.ANALYTICAL APPROACH: Multivariable-adjusted cause-specific hazards models where follow-up of KTR who died with a functioning graft was censored.RESULTS: Median baseline plasma Pb was 0.31 (IQR, 0.22─0.45) μg/L among all KTRs. During follow-up, 78 (12%) KTR developed graft failure. Higher plasma Pb was associated with increased risk of graft failure (HR 1.59, 95% CI 1.14‒2.21 per doubling; P=0.006) independent of age, sex, transplant characteristics, eGFR, proteinuria, smoking status, alcohol intake, and plasma concentrations of cadmium and arsenic. These findings remained materially unchanged after additional adjustment for dietary intake and were consistent with those of analyses examining Pb categorically. In serial measurements, plasma Pb was significantly higher at admission for transplantation than at 3-months post-transplant (P=0.001), after which it remained stable over 2 years of follow-up (P=0.2).LIMITATIONS: Observational study design.CONCLUSIONS: Pretransplant plasma Pb concentrations, which fall after transplantation, are associated with increased risk of late kidney allograft failure. These findings warrant further studies to evaluate whether preventive or therapeutic interventions to decrease plasma Pb may represent novel risk-management strategies to decrease the rate of kidney allograft failure.

Bronchoscopic lung volume reduction using endobronchial valves (EBVs) is a treatment option for patients with severe emphysema. These EBVs are made out of a nitinol mesh covered by a silicone layer. Nitinol is an alloy of nickel and titanium and is commonly used in implantable medical devices because of its biocompatibility and memory-shape properties. However, there are some concerns that nickel ions can be released from nitinol-containing devices which might cause adverse health effects, especially in patients with a known nickel hypersensitivity. In vitro, it was found that EBV release significant amounts of nickel in the first hours. Our aim was to assess the nickel concentration in lung tissue from a patient who previously underwent EBV treatment but, due to treatment failure, underwent lung volume reduction surgery and to compare this to a reference sample. We found no significant difference in the median nickel concentration between the EBV-treated patient and the non-EBV-treated patient (0.270 vs. 0.328 μg/g, respectively, p = 0.693) and these concentrations were also comparable to previously published nickel concentrations in human lung tissue samples not having any medically implanted devices in the lung. Our results suggest that there is no significant long-term nickel deposition in lung tissue after EBV treatment.

How many nanoparticles are taken up by human cells is a key question for many applications, both within medicine and safety. While many methods have been developed and applied to this question, microscopy-based methods present some unique advantages. However, the laborious nature of microscopy, in particular the consequent image analysis, remains a bottleneck. Automated image analysis has been pursued to remedy this situation, but offers its own challenges. Here we tested the recently developed deep-learning based cell identification algorithm Cellpose on fluorescence microscopy images of HeLa cells. We found that the algorithm performed very well, and hence developed a workflow that allowed us to acquire, and analyse, thousands of cells in a relatively modest amount of time, without sacrificing cell identification accuracy. We subsequently tested the workflow on images of cells exposed to fluorescently-labelled polystyrene nanoparticles. This dataset was then used to study the relationship between cell size and nanoparticle uptake, a subject where high-throughput microscopy is of particular utility.

BACKGROUND: Voriconazole is an antifungal drug used for the treatment of invasive fungal infections. Due to highly variable drug exposure, therapeutic drug monitoring (TDM) has been recommended. TDM may be helpful to accurately predict exposure but covariates like severe inflammation influencing voriconazole metabolism have not been included in the population pharmacokinetic (popPK) models suitable for routine TDM.OBJECTIVES: The aim of this study was to investigate whether the effect of inflammation, reflected by C-reactive protein (CRP), could improve a popPK model that can be applied in clinical care.PATIENTS AND METHODS: Data from two previously conducted studies were included in the popPK modelling. PopPK modelling was performed using Edsim++. Different popPK models were compared by Akaike Information Criterion and goodness-of-fit plots.RESULTS: In total, 1060 voriconazole serum concentrations were included from 54 patients. The final model was a one-compartment model with nonlinear elimination. Only CRP was a significant covariate and was included in the final model and affected the maximum rate of enzyme activity (V max). For the final popPK model mean volume of distribution (Vd) was 145 L (CV%=61%), mean Michaelis-Menten constant (Km) was 5.7 mg/L (CV%=119%), mean V max was 86.4 mg/h (CV%=99%) and mean bioavailability (F) was 0.83 (CV%=143%). Internal validation using bootstrapping resulted in median values close to the population parameter estimates. CONCLUSIONS: This one compartment model with nonlinear elimination and CRP as a covariate adequately described voriconazole pharmacokinetics.

BACKGROUND: Post-transplant anaemia and reduced muscle mass and strength are highly prevalent in kidney transplant recipients (KTRs). Decreased haemoglobin levels, a marker of anaemia, could adversely affect muscle mass and strength through multiple mechanisms, among others, through diminished tissue oxygenation. We aimed to investigate the association between haemoglobin levels with muscle mass and strength in KTRs.METHODS: We included stable KTRs from the TransplantLines Biobank and Cohort study with a functional graft ≥1 year post-transplantation. Muscle mass was assessed using 24 h urinary creatinine excretion rate (CER) and bioelectrical impedance analysis (BIA). Muscle strength was assessed with a handgrip strength test using a dynamometer and, in a subgroup (n = 290), with the five-times sit-to-stand (FTSTS) test. We used multivariable linear and logistic regression analyses to investigate the associations of haemoglobin levels with muscle mass and strength.RESULTS: In 871 included KTRs [median age 58 (interquartile range (IQR), 48-66)] years; 60% men; eGFR 51 ± 18 mL/min/1.73 m2 ) who were 3.5 (1.0-10.2) years post-transplantation, the mean serum haemoglobin level was 13.9 ± 1.8 g/dL in men and 12.8 ± 1.5 g/dL in women. Lower haemoglobin levels were independently associated with a lower CER (std. β = 0.07, P = 0.01), BIA-derived skeletal muscle mass (std. β = 0.22, P < 0.001), handgrip strength (std. β = 0.15, P < 0.001), and worse FTSTS test scores (std. β = -0.17, P = 0.02). KTRs in the lowest age-specific and sex-specific quartile of haemoglobin levels had an increased risk of being in the worst age-specific and sex-specific quartile of CER (fully adjusted OR, 2.09; 95% CI 1.15-3.77; P = 0.02), handgrip strength (fully adjusted OR, 3.30; 95% CI 1.95-5.59; P < 0.001), and FTSTS test score (fully adjusted OR, 7.21; 95% CI 2.59-20.05; P < 0.001).CONCLUSIONS: Low haemoglobin levels are strongly associated with decreased muscle mass and strength in KTRs. Future investigation will need to investigate whether maintaining higher haemoglobin levels may improve muscle mass and strength in KTRs.

Background: To improve efficacy, therapeutic drug monitoring is often used in clozapine therapy. Trough level monitoring is regular, but trough levels provide limited information about the pharmacokinetics of clozapine and exposure in time. The area under the concentration time curve (AUC) is generally valued as better marker of drug exposure in time but calculating AUC needs multiple sampling. An alternative approach is a limited sampling scheme in combination with a population pharmacokinetic model meant for Bayesian forecasting. Furthermore, multiple venepunctions can be a burden for the patient, whereas collecting samples by means of dried blood spot (DBS) sampling can facilitate AUC-monitoring, making it more patient friendly. Objective: Development of a population pharmacokinetic model and limited sampling strategy for estimating AUC0-12h (a twice-daily dosage regimen) and AUC0-24h (a once-daily dosage regimen) of clozapine, using a combination of results from venepunctions and DBS sampling. Method: From 15 schizophrenia patients, plasma and DBS samples were obtained before administration and 2, 4, 6, and 8 h after clozapine intake. MwPharm® pharmacokinetic software was used to parameterize a population pharmacokinetic model and calculate limited sampling schemes. Results: A three-point sampling strategy with samples at 2, 6, and 8 h after clozapine intake gave the best estimation of the clozapine AUC0-12h and at 4, 10, and 11 h for the AUC0-24h. For clinical practice, however, a two-point sampling strategy with sampling points at 2 and 6 h was sufficient to estimate AUC0-12h and at 4 and 11 h for AUC0-24h. Conclusion: A pharmacokinetic model with a two–time point limited sampling strategy meant for Bayesian forecasting using DBS sampling gives a better prediction of the clozapine exposure in time, expressed as AUC, compared to trough level monitoring. This limited sampling strategy might therefore provide a more accurate prediction of effectiveness and occurrence of side effects compared to trough level monitoring. The use of DBS samples also makes the collection of clozapine samples easier and wider applicable.

AIM: To elucidate the relationship between serum selenium levels and the risk of mortality and new onset heart failure in the general adult population.METHODS AND RESULTS: Selenium was measured in a Dutch cohort and a retrospective analysis of prospectively assessed data was performed. Main outcome measures were all-cause mortality and incidence of new-onset heart failure (HF) separately, and combined as a composite endpoint. Serum selenium was measured in 5973 subjects and mean selenium concentration was 84.6 (±19.5) μg/L. Mean age was 53.6 (±12.1) years and 3103 subjects (52%) were females. Median follow-up period was 8.4 years. Selenium levels associated positively with female sex, higher total cholesterol and glucose concentrations, and associated negatively with incidence of anemia, iron deficiency, current smoking, increasing C-reactive protein levels, and higher body mass index. Univariate analysis on all subjects showed no association of continuous selenium concentrations, per 10 μg/L increase, with the composite endpoint (Hazard Ratio [HR]=0.96, 95% Confidence interval [CI]: 0.87 to 1.06, p = 0.407). However, significant interaction with smoking status was observed. In non-smoking subjects (N=4288), continuous selenium concentrations were independently associated with reduced mortality risk (HR=0.87, 95% CI: 0.79 to 0.96, p = 0.005), lower risk of new-onset HF (HR=0.82, 95% CI: 0.69 to 0.96, p = 0.017), as well as reduced risk of the composite endpoint (HR= 0.86, 95% CI: 0.79 to 0.94, p = 0.001). In smoking subjects, no associations were found.CONCLUSION: Serum selenium was independently associated with multiple indicators of the metabolic syndrome. In addition, high selenium levels were independently associated with reduced mortality and new-onset HF in non-smokers. Well-powered interventional studies are necessary to evaluate the potential benefit of repleting selenium, especially in non-smoking subjects.

Controlling the transmission of thin films with external stimuli is an important goal in functional optical materials and devices. Tuning is especially challenging where both broad band (neutral density filtering) and spectrally varied (colour) transmission are required. The external control provided by photochemically driven switching, between transmission levels and colours, is functionally simple from a device perspective. The limits due to the spectral ranges of individual photochromic compounds can be overcome by combining several photochromes within one material or device. Here we show that a combination of photochromic molecular switches immobilised in a PMMA polymer matrix enables tuning of colour and transparency. We show that only a single excitation wavelength is required through the use of the primary inner filter effect and the layered construction of the films in which the photochromes nitrospiropyran (NSP), and nitrothiospiropyran (TSP) or 1,2-bis-terthienyl-hexafluorocyclopentene (DTE) are separated spatially. The approach taken circumvents the need to match photochemical quantum yields and thermal reactivity of the component photochromes. The photochemical switching of the films was characterised by UV/vis absorption spectroscopy and shows that switching rates and photostationary states are limited by inner filter effects rather than the intrinsic properties of photochromes, such as photochemical quantum yields and thermal stability. The photochemical behaviour and stability of the photochromes in solution and in the PMMA films were compared and the concentration range over which self-inhibition of photochemical switching occurs was established. The rate of photochemical switching and the difference in transmission between the spiropyran and merocyanine forms in solution enable prediction of the performance in the films and enable rational design of colour tuning ranges and responsivity in thin film filters., A multilayer coating, with a different photochrome in each layer, enables predictable control over transmission and colour with a single wavelength of light, which is an important goal in functional optical materials and devices.

Solid organ transplant recipients (SOTR) frequently report tremor. Data concerning tremor-related impairment and its potential impact on health-related quality of life (HRQoL) are lacking. This cross-sectional study assesses impact of tremor on activities of daily living and HRQoL using validated questionnaires among SOTR enrolled in the TransplantLines Biobank and Cohort Study. We included 689 SOTR (38.5% female, mean [±SD] age 58 [±14] years) at median [interquartile range] 3 [1–9] years after transplantation, of which 287 (41.7%) reported mild or severe tremor. In multinomial logistic regression analyses, whole blood tacrolimus trough concentration was an independent determinant of mild tremor (OR per µg/L increase: 1.11, 95% CI: 1.02 to 1.21, p = 0.019). Furthermore, in linear regression analyses, severe tremor was strongly and independently associated with lower physical and mental HRQoL (β = −16.10, 95% CI: −22.23 to −9.98, p < 0.001 and β = −12.68, 95% CI: −18.23 to −7.14, p < 0.001 resp.). SOTR frequently report tremor-related impairment of activities of daily living. Tacrolimus trough concentrations appeared as a main determinant of tremor among SOTR. The strong and independent association of tremor-related impairment with lower HRQoL warrants further studies into the effects of tacrolimus on tremor. Clinical Trial Registration: ClinicalTrials.gov, Identifier NCT03272841.

BackgroundAlectinib is first-line therapy in patients with stage IV non-small cell lung carcinoma (NSCLC) and an anaplastic lymphoma kinase (ALK) fusion. A shorter median progression-free survival (mPFS) was observed when alectinib minimum plasma concentrations during steady state (Cmin,SS) were below 435 ng/mL. This may suggest that patients should have an alectinib Cmin,SS ≥ 435 ng/mL for a more favorable outcome. This potential target could be attained by using therapeutic drug monitoring (TDM), i.e. adjusting the dose based on measured plasma trough concentrations. Hypothetically, this will increase mPFS, but this has not yet been evaluated in a randomized controlled trial (RCT). Therefore, the ADAPT ALEC trial is designed, with the primary objective to prolong mPFS in NSCLC patients treated with alectinib by using TDM.MethodsADAPT ALEC is a multicenter, phase IV RCT, in which patients aged ≥ 18 years with advanced ALK positive (+) NSCLC eligible for alectinib in daily care are enrolled. Participants will be randomized (1:1 ratio) into intervention arm A (TDM) or B (control), stratified by brain metastases and prior ALK treatments. Starting dose in both arms is the approved flat fixed dose of alectinib 600 mg taken twice daily with food. In case of alectinib Cmin,SS < 435 ng/mL, arm A will receive increased doses of alectinib till Cmin,SS ≥ 435 ng/mL when considered tolerable. The primary outcome is mPFS, where progressive disease is defined according to RECIST v1.1 or all-cause death and assessed by CT-scans and MRI brain. Secondary endpoints are feasibility and tolerability of TDM, patient and physician adherence, overall response rate, median overall survival, intracranial PFS, quality of life, toxicity, alectinib-M4 concentrations and cost-effectiveness of TDM. Exploratory endpoints are circulating tumor DNA and body composition.DiscussionThe ADAPT ALEC will show whether treatment outcomes of patients with advanced ALK+ NSCLC improve when using TDM-guided dosing of alectinib instead of fixed dosing. The results will provide high quality evidence for deciding whether TDM should be implemented as standard of care and this will have important consequences for the prescribing of alectinib.Clinical trial registrationClinicalTrials.gov, identifier NCT05525338.

INTRODUCTION: Understanding the pharmacokinetics (PK) of antimicrobial drugs in pregnant women is crucial to provide effective and safe treatment. This study is part of a series that systematically reviews literature on the PK and analyzes if, based on the changed PK, evidence-based dosing regimens have been developed for adequate target attainment in pregnant women. This part focusses on antimicrobials other than penicillins and cephalosporins.METHODS: A literature search was conducted in PubMed according to the PRISMA guidelines. Search strategy, study selection, and data extraction were independently performed by two investigators. Studies were labeled as relevant when information on the PK of antimicrobial drugs in pregnant women was available. Extracted parameters included bioavailability for oral drugs, volume of distribution (Vd) and clearance (CL), trough and peak drug concentrations, time of maximum concentration, area under the curve and half-life, probability of target attainment, and minimal inhibitory concentration (MIC). In addition, if developed, evidence-based dosing regimens were also extracted.RESULTS: Of the 62 antimicrobials included in the search strategy, concentrations or PK data during pregnancy of 18 drugs were reported. Twenty-nine studies were included, of which three discussed aminoglycosides, one carbapenem, six quinolones, four glycopeptides, two rifamycines, one sulfonamide, five tuberculostatic drugs, and six others. Eleven out of 29 studies included information on both Vd and CL. For linezolid, gentamicin, tobramycin, and moxifloxacin, altered PK throughout pregnancy, especially in second and third trimester, has been reported. However, no target attainment was studied and no evidence-based dosing developed. On the other hand, the ability to reach adequate targets was assessed for vancomycin, clindamycin, rifampicin, rifapentine, ethambutol, pyrazinamide, and isoniazid. For the first six mentioned drugs, no dosage adaptations during pregnancy seem to be needed. Studies on isoniazid provide contradictory results.CONCLUSION: This systematic literature review shows that a very limited number of studies have been performed on the PK of antimicrobials drugs-other than cephalosporins and penicillins-in pregnant women.

The Dutch Pharmacogenetics Working Group (DPWG) aims to facilitate pharmacogenetics implementation in clinical practice by developing evidence-based guidelines to optimize pharmacotherapy. A guideline describing the gene-drug interaction between the genes CYP2D6, CYP3A4 and CYP1A2 and antipsychotics is presented here. The DPWG identified gene-drug interactions that require therapy adjustments when respective genotype is known for CYP2D6 with aripiprazole, brexpiprazole, haloperidol, pimozide, risperidone and zuclopenthixol, and for CYP3A4 with quetiapine. Evidence-based dose recommendations were obtained based on a systematic review of published literature. Reduction of the normal dose is recommended for aripiprazole, brexpiprazole, haloperidol, pimozide, risperidone and zuclopenthixol for CYP2D6-predicted PMs, and for pimozide and zuclopenthixol also for CYP2D6 IMs. For CYP2D6 UMs, a dose increase or an alternative drug is recommended for haloperidol and an alternative drug or titration of the dose for risperidone. In addition, in case of no or limited clinical effect, a dose increase is recommended for zuclopenthixol for CYP2D6 UMs. Even though evidence is limited, the DPWG recommends choosing an alternative drug to treat symptoms of depression or a dose reduction for other indications for quetiapine and CYP3A4 PMs. No therapy adjustments are recommended for the other CYP2D6 and CYP3A4 predicted phenotypes. In addition, no action is required for the gene-drug combinations CYP2D6 and clozapine, flupentixol, olanzapine or quetiapine and also not for CYP1A2 and clozapine or olanzapine. For identified gene-drug interactions requiring therapy adjustments, genotyping of CYP2D6 or CYP3A4 prior to treatment should not be considered for all patients, but on an individual patient basis only.

BACKGROUND AND OBJECTIVE: Pharmacokinetics (PK) are severely altered in pregnant women due to changes in volume of distribution (Vd) and/or drug clearance (CL), affecting target attainment of antibiotics in pregnant women. This review is part of a series that reviews literature on the description of PK and target attainment of antibiotics in pregnant women with specific focus on penicillins.METHODS: A systematic literature search was carried out in PubMed. Articles were labelled as relevant when information on PK of penicillins in pregnant women was available.RESULTS: Thirty-two relevant articles were included, 8 of which discussed amoxicillin (with and without clavulanic acid), 15 ampicillin, 4 benzylpenicillin, 1 phenoxymethylpenicillin, and 4 piperacillin (with and without tazobactam). No studies were found on pheneticillin and flucloxacillin in pregnant women. Ten out of 32 articles included information on both Vd and CL. During the second and third trimester of pregnancy, a higher CL and larger Vd was reported than in non-pregnant women and in pregnant women during first trimester. Reduced target attainment was described in second and third trimester pregnant women. Only 7 studies reported dosing advice, 4 of which were for amoxicillin.CONCLUSION: The larger Vd and higher CL in second and third trimester pregnant women might warrant a higher dosage or shortening of the dosing interval of penicillins to increase target attainment. Studies frequently fail to provide dosing advice for pregnant women, even if the necessary PK information was available.

Introduction: Maintaining adherence to antiretroviral therapy (ART) is critical to achieve and sustain viral suppression in HIV-infected patients. Aim: To assess adherence and treatment outcomes during the implementation of ART. Methods: A cross-sectional study was performed in adult HIV-infected patients receiving ART for at least 6 months in a teaching hospital in Surabaya, Indonesia. The Indonesian version of the validated self-reported adherence (SERAD) questionnaire was used to recall ART use during the last week, month, and three months. Logistic regression analysis was used to identify factors affecting adherence and treatment outcomes (HIV-1 RNA viral load ≤1000 copies/mL and CD4 >200 cells/µL) with pResults: Ninety five patients (male: 70.5%; duration of ART >24 months: 57.9%) completed the study. Viral suppression and improved CD4 were observed in 83.2% and 68.4% of the subjects, respectively. An adherence rate of ≥95% was considered highly adherent and observed in 89.5%, 88.4%, 95.8% of the subjects in the past week, month, and three months, respectively. WHO clinical stage III or IV and low adherence were significantly associated with detectable viral load and low CD4; ≥95% adherence rate was needed to achieve the outcomes. Forgetfulness and falling asleep were the most common reasons reported for missing doses or not respecting intake conditions. Conclusion: Self-report is useful to assess adherence and reasons for nonadherence; large scale studies are needed to evaluate the validity of the adherence threshold in this population.

Microperforated membranes are essential components of various organ-on-a-chip (OOC) barrier models devel-oped to study transport of molecular compounds and cells across cell layers in e.g. the intestine and blood-brainbarrier. These OOC membranes have two functions: 1) to support growth of cells on one or both sides, and 2) toact as a filter-like barrier to separate adjacent compartments. Thin, microperforated poly(dimethylsiloxane)(PDMS) membranes can be fabricated by micromolding from silicon molds comprising arrays of micropillars forthe formation of micropores. However, these molds are made by deep reactive ion etching (DRIE) and areexpensive to fabricate. We describe the micromolding of thin PDMS membranes with easier-to-make, SU-8 epoxyphotoresist molds. With a multilayer, SU-8, pillar microarray mold, massively parallel arrays of micropores canbe formed in a thin layer of PDMS, resulting in a flexible barrier membrane that can be easily incorporated andsealed between other layers making up the OOC device. The membranes we describe here have a 30-μmthickness, with 12-μm-diameter circular pores arranged at a 100-μm pitch in a square array. We show applicationof these membranes in gut-on-a-chip devices, and expect that the reported fabrication strategy will also besuitable for other membrane dimensions

Background Serum selenium levels have been associated with the incidence of heart failure (HF) and signs of the metabolic syndrome. In addition, notable differences have been reported between males and females in food intake and micronutrient metabolism, possibly explaining different health outcomes. Objective Our objective was to elucidate sex-specific, cross-sectional phenotypic differences in the association of serum selenium concentrations with parameters of metabolic syndrome and HF. Methods We investigated data from individuals from a community-based cohort (PREVEND; N = 4288) and heart failure cohort (BIOSTAT-CHF; N = 1994). In both populations, cross-sectional analyses were performed for potential interaction (p Results Baseline selenium levels of the total cohort were similar between PREVEND (85.7 μg/L) and BIOSTAT-CHF (89.1 μg/L). Females with lower selenium levels had a higher BMI and increased prevalence of diabetes than females with higher selenium, in both PREVEND (pinteraction interaction = 0.040, resp.) and BIOSTAT-CHF (pinteraction = 0.021; pinteraction = 0.024, resp.), while opposite associations were observed for males. Additionally, in females, but not in males, lower selenium was associated with a higher prevalence of myocardial infarction (MI) in PREVEND (pinteraction = 0.021) and BIOSTAT-CHF (pinteraction = 0.084). Conclusion Lower selenium was associated with a higher BMI and increased prevalence of diabetes in females, opposite to males, and was also associated with more MI in females. Interventional studies are needed to validate this observation.

Background and ObjectivesPharmacologic treatment of epilepsy in pregnant women is balancing between risks for the mother and fetus. Levetiracetam (LEV) is considered to be safe during pregnancy because of its low teratogenic potential and lack of drug-drug interaction with other antiseizure medications (ASMs). Recent studies have shown decline of ASM concentrations during pregnancy because of physiologically based pharmacokinetic changes. In this study, we established this decrease in LEV concentration during pregnancy. In addition, we aimed at investigating the effect of the low LEV levels during pregnancy and developing a target value for the level during pregnancy.MethodsPregnant patients using levetiracetam were studied in this retrospective cohort study. Blood samples were monthly collected through venous puncture or the dried blood spot method. ASM serum concentrations were determined at least 6 months before conception and for each month of pregnancy. Seizure frequency and ASM dosages during pregnancy were obtained from patient records. Patients were divided into 2 groups: a seizure-free group and a non–seizure-free group, which contained pregnancies in which the mother had experienced an epileptic seizure more than 12 months and less than 12 months before pregnancy, respectively.ResultsWe found decreased concentration/dose ratios in 29 pregnancies throughout all months of pregnancy. In the non–seizure-free group, it was found that low LEV concentrations were associated with seizure increase frequency (p= 0.022). For this group, the cutoff value with the highest sum of sensitivity and specificity was 0.466.DiscussionAll in all, we recommend therapeutic drug monitoring for all pregnant patients on LEV as the concentrations of LEV significantly decrease throughout most months of pregnancy. However, this decrease in LEV concentration was only significantly correlated with seizure deterioration in patients who had a seizure in the year preceding the pregnancy. Therefore, we suggest more careful monitoring of non–seizure-free patients as they are at higher risk for experiencing an increase of seizure frequency. For this group, we advise physicians to keep LEV concentration above 65% of the preconceptional concentration. For seizure-free patients, we recommend an LEV threshold value of approximately 46% of the preconceptional concentration.

Rationale & Objective: Prior studies report that the use of proton pump inhibitors (PPIs) can adversely affect gut microbiota and gastrointestinal uptake of micronutrients, in particular iron and magnesium, and are used frequently by kidney transplant recipients. Altered gut microbiota, iron deficiency, and magnesium deficiency have been implicated in the pathogenesis of chronic fatigue. Therefore, we hypothesized that PPI use may be an important and underappreciated cause of fatigue and reduced health-related quality of life (HRQoL) in this population. Study Design: Cross-sectional study. Setting & Participants: Kidney transplant recipients (≥1 year after transplantation) enrolled in the TransplantLines Biobank and Cohort Study. Exposure: PPI use, PPI type, PPI dosage, and duration of PPI use. Outcome: Fatigue and HRQoL, assessed using the validated Checklist Individual Strength 20 Revised questionnaire and Short Form-36 questionnaire. Analytical Approach: Logistic and linear regression. Results: We included 937 kidney transplant recipients (mean age 56 ± 13 years, 39% female) at a median of 3 (1-10) years after transplantation. PPI use was associated with fatigue severity (regression coefficient 4.02, 95% CI, 2.18 to 5.85, P < 0.001), a higher risk of severe fatigue (OR 2.05, 95% CI, 1.48 to 2.84, P < 0.001), lower physical HRQoL (regression coefficient −8.54, 95% CI, −11.54 to −5.54, P < 0.001), and lower mental HRQoL (regression coefficient −4.66, 95% CI, −7.15 to −2.17, P < 0.001). These associations were independent of potential confounders including age, time since transplantation, history of upper gastrointestinal disease, antiplatelet therapy, and the total number of medications. They were present among all individually assessed PPI types and were dose dependent. Duration of PPI exposure was only associated with fatigue severity. Limitations: Residual confounding and inability to assess causal relationships. Conclusions: PPI use is independently associated with fatigue and lower HRQoL among kidney transplant recipients. PPI use might be an easily accessible target for alleviating fatigue and improving HRQoL among kidney transplant recipients. Further studies examining the effect of PPI exposure in this population are warranted.

Often, medicines given by an injection must be treated before administration to patients. This can be a simple treatment, such as withdrawing a sterile solution from a vial into a syringe, or a complex treatment where different sterile fluids are mixed together. During the treatment the product must be kept sterile. Both, simple and complex treatments, are called aseptic handling. Simple aseptic handling is mostly performed by nurses in clinical areas (wards). Complex aseptic handling is mostly performed in the hospital pharmacy by trained operators. This thesis focusses on reducing the possibility of microbiological contamination of medicines during aseptic handling in hospital pharmacies. In a hospital pharmacy, aseptic handling is performed in a cabinet with a constant sterile air flow. This cabinet as well as all items entering it are potential sources of microbial contamination. We examined the risk of contamination per item by a systematic analysis. Also, measures to reduce these risks were assessed for effectivity by a model described in this thesis. Our study made clear that microorganisms mainly enter the cabinet on the surfaces of materials like ampules and vials, even after thorough disinfection. Inside the cabinet, ampoules and vials may contaminate the worktop and the sterile gloves of the operator. Subsequently, the contaminated gloves can contaminate critical spots* through touch and therefore the product. The most important preventive measures are keeping the contamination level of the gloves low and a good ‘aseptic non-touch technique’. Aseptic handling is controlled by microbiological controls. This thesis presents the results of these controls in about 40 hospital pharmacies and describes methods for evaluating and assessing the results. Microbiological controls alone do not cover all sources of contamination. Therefore, we encourage additional controls such as regular operator audits. * Critical spots: A surface that may come into contact with a sterile fluid.