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There are many challenges in use of dosage forms in medication of elderly people. Especially swallowing of solid dosage forms can be difficult. Dosage forms are often altered to enhance drug intake. Medication adherence is a major contributor to the success of therapy. Adherence is a multidimensional phenomenon which is also affected by properties of medicinal product. Theoretical framework of this thesis is World Health Organization's multidimensional adherence model. Only few studies exist on how properties of dosage forms affect to the success of medical treatment of elderly. The aim of this study was to find out what kind of difficulties related to dosage forms occur in medical treatment of elderly people living in nursing homes. Future goal is to develop dosage forms better suited to elderly and hence improve their medication adherence. This study consisted of interviews and e-survey. This study was carried out in six nursing homes where 322 elderly residents fulfilled the inclusion criteria of the study. Nurses (n = 48) were interviewed to explore their views on difficulties related to dosage forms. Other difficulties in use of dosage forms were also surveyed as well as frequency of tablet crushing. Difficulties in use of dosage forms on the medical treatment of the elderly were gathered in the e-survey. Also, the need to crush tablets and open capsules was surveyed as well as need to split tablets to obtain the dose needed. Difficulties in use of dosage forms are common in medical treatment of elderly people. Majority of the interviewed nurses has encountered these difficulties at least few times a week. The most common problematic dosage form was the tablet. About half of the nurses named the big size of tablets and capsules as the most important difficulty in the use of current oral or peroral dosage forms. Over half of the nurses have crushed or given crushed drug daily. The most common reason for dosage form altering was the big size of the medicinal product. Majority of the nurses has often encountered also other than dosage form related difficulties of which the most common challenges are related to suspiciousness. In e-survey, nurses submitted entries regarding 111 elder people. Most cases were related to splitting of a tablet to obtain the desired drug dose. Tablet crushing was reported for little less than one-fifth of the elderly people. Both the splitting and crushing entries were distributed over multiple different medicinal products. Some other difficulties related to dosage forms were reported for less than one-tenth of the elderly people. Based on this study more appropriate dosage forms should be developed for the medical treatment of elderly people. Oral solutions, orodispersible tablets as well as transdermal patches all have advantages. Pharmaceutical research and development can facilitate medical treatment of elderly people and hence improve their medication adherence by introducing more appropriate dosage forms.

The purpose of this qualitative material thesis was to describe and summarize the pharmaceutical industry of pharmaceutical company Orion Oyj years between 1899 and 1998 in form of historical study. Previous publications concerning Orion's history have not had precisely industrial point of view. The study is mostly arranged by pharmaceutical forms and additionally some Orion's pharmaceutical products are displayed exemplary and their characters are analyzed. Also development of excipients and package materials are examined briefly. The notices of development of Orion's industrial pharmacy are constantly put into perspective by comparing it to the international industrial pharmacy. Analysis begins in 1899 due to the first finnish pharmaceutical company establishment which also had influences on the starting points of Orion. The study ends in 1998 because of Finland's associaton of European Union in 1995 which also had influences on the Orion's business. The material of the study consist of Orion's public documents including among others Orion's personnel journals, product indexes, sheets, history books and the other produced material of Orion. The material was gathered in the archive of Orion in Espoo during some weeks between October 2013 and Juny 2014. The material of Orion was compared to scientific literature in order to emphasize their worldwide influence. The most of the scientific reference material includes articles but some industrial pharmacy handbooks have been also used because of difficulties of having historical articles. According to the hypothesis the significance of Orion's pharmaceutical industry was minor on the scale of international pharmaceutical industry. The contacts to the foreign industrial countries and compliance with the guidelines of FDA and European Pharmacopoeia were on focus in Orion's aim to accompany international development of industrial pharmacy. One of the important themes in Orion's business was the transform from multi industry to the special industry which was supported by rationalization of production introduced in 1950's. In the context of quality control there have been many projects put in practise especially in 1960's and 1970's, for example the GMP-guidelines introduction, the trading licence system of the pharmaceuticals and the renovations of all the production rooms.Though the pioner of the industrial pharmacy, The United States, was in the quality control even several decades in advance of Finland and consequently Orion. Orion's major products were in the company's program with a licence system. Maybe the most considerable efforts have been made to advance conventional tablet production for example by enhancing equipment and process conditions. Contrary to conventional tablets pharmaceutical formulations like patches and soft capsules have been in Orion's program mainly to complete the company's selection.Some pharmaceutical forms were possible to produce in Orion quite early, for example vaccinations since 1940's and sterile eye drop producing since 1950's. In the last decades of this study, 1980's and 1990's, Orion was focused on the projects like Easyhaler and some own brand name drugs.

Lääkkeen elinkaaren aikana on useita toimijoita, ja matka lääkkeen valmistuksesta käyttöön Suomessa on kirjallisuuden perusteella pitkä ja monimutkainen. Lisäksi lääkevalmisteita on lukuisia erilaisia. Vaikka lääkepakkausten materiaalit ja materiaalivaatimukset tunnetaan suhteellisen hyvin esimerkiksi lääkkeiden myyntilupien tuomien vaatimusten takia, on kvantitatiivista tietoa eri materiaalivirroista lääkepakkausten elinkaaren aikana vain vähän tietoa. Tämän tutkimuksen tavoitteena oli tutkia kuinka paljon ja millaista pakkausmateriaalia lääkevalmisteen elinkaaren aikana syntyy, ja miten ympäristöasiat on huomioitu lääkepakkausten elinkaaren aikaisissa materiaalivirroissa. Lisäksi pyrittiin löytämään ehdotuksia materiaalivirtojen kehittämiseksi sekä selvittämään, miten kuluttajaa tulisi ohjeistaa lääkepakkausten kierrätyksestä. Tutkimusmenetelmäksi valittiin teemahaastattelu. Toukokuun ja joulukuun välisenä aikana vuonna 2020 aineistoksi muodostui viisi puolistrukturoitua teemahaastattelua ja kaksi kirjallista vastausta. Aineisto analysoitiin aineistolähtöisellä sisällönanalyysillä. Tutkimustulosten perusteella lääkevalmisteiden elinkaaren aikana syntyviä materiaalivirtoja ei tunneta vielä kunnolla. Tutkimuksessa korostui apteekin rooli lääkkeitä jakavana toimijana sekä lääkejätteen kerääjänä. Tukkuliiketoiminnan havaittiin keskittyneen kahdelle suurelle toimijalle Suomessa. Esteinä materiaalivirtojen kehittämiselle nähtiin kankeat myyntilupakäytännöt, jotka tekevät varsinkin pitkään markkinoilla olleiden lääkevalmisteiden pakkausmateriaalimuutokset hankaliksi. Myyntilupaprosessi koettiin kalliiksi, mikä estää esimerkiksi vain sairaala-apteekkeihin tarkoitettujen pakkausten tarjoamisen markkinoille. Muita haasteita olivat esimerkiksi ympäristönäkökulman ja potilasturvallisuuden väliset ristiriidat. Lääkkeiden myyntilupa ei vaadi ohjeistamaan kuluttajaa pakkausmateriaalien kierrätyksessä. Tutkimuksen mukaan lääketeollisuudessa on mietitty, voisiko pakkauksen kierrätyksen mainita pakkausselosteessa ilman myyntilupaprosessin läpikäyntiä. Tulisi kuitenkin tutkia, olisiko merkinnällä vaikutusta lääkepakkausten kierrätykseen. Toinen huomio lääkepakkausten kierrättämisessä on se, ovatko esimerkiksi primääripakkaukset turvallisia kierrätyksen kannalta. Jatkotutkimusta tarvitaan lisää. Tämä Pro gradu on tehty SUDDEN-hankkeen viitekehyksessä, yhteistyössä Suomen ympäristökeskuksen kanssa. SUDDEN-hanke pyrkii löytämään ratkaisuja lääkkeiden elinkaaren aikana syntyvien ympäristöhaittojen vähentämiseksi ja edistämään kestävää lääketeollisuutta.

Tämän tutkimuksen päätavoitteena oli selvittää Bayer Oy:n Turun tuotantolaitoksella käytettävän CAPA-prosessin kehittämiskohteita. Tutkimuksessa pyrittiin erityisesti selvittämään, kuinka korjaavien ja ehkäisevien toimenpiteiden eli CAPA-toimenpiteiden toteuttamista voidaan tehostaa ja mitkä tekijät vaikeuttavat aikataulussa pysymistä. Lisäksi tavoitteena oli etsiä syitä myös sille, miksi juurisyyanalyysi ja todellisten juurisyiden löytäminen koetaan haastavaksi. Tutkimusmenetelmänä käytettiin puolistrukturoitua teemahaastattelua, johon valittiin tavoitteellisella otannalla 10 tuotantolaitoksella työskentelevää asiantuntijaa. Haastattelut toteutettiin videohaastatteluina etäyhteyden kautta. Aineiston laadullinen analyysi tehtiin deduktiivisesti ATLAS.ti -ohjelmaa apuna käyttäen. Tutkimuksen tulosten perusteella CAPA-prosessin kehittämiskohteet voidaan jakaa neljään pääkategoriaan: suunnittelu ja resurssit, järjestelmä, koulutus sekä yhteistyö ja merkitys. Keskeiseksi kehittämiskohteeksi nostettiin selvitys- ja toteuttamisvaiheiden suunnittelu, niiden toteutumisen seuranta sekä riittävien resurssien (aika, henkilöstö) varmistaminen. Lisäksi sähköistä Dev@com-dokumentointijärjestelmää tulisi kehittää niin, että se tukee CAPA-prosessin eri vaiheita ja on helppokäyttöinen sekä yhteinen kaikille CAPA-tapauksille. Juurisyyanalyysissä hyödynnettävien menetelmien ja työkalujen käyttöön toivottaisiin lisäkoulutusta, jonka lisäksi CAPA-prosessin tavoitteita tulisi selventää. Myös yhteistyön lisääminen yli osastorajojen ja vastuun jakaminen useammalle henkilölle koettiin tärkeiksi keinoiksi kehittää CAPA-prosessia ja lisätä sen merkitystä eri työtasoilla ja koko tuotantolaitoksella. Tutkimuksen tulokset ovat linjassa kirjallisuudessa esitettyjen havaintojen ja mielipiteiden kanssa ja siten mahdollisesti yleistettävissä muihin lääkeyrityksiin tai lääkinnällisiä laitteita valmistaviin yrityksiin. Yleistettävyyttä voitaisiin parantaa vielä laajentamalla tutkimusta muihin lääkeyrityksiin. Tämä tutkimus on yksi ensimmäisistä julkaistuista laadullisista tutkimuksista, jossa saatiin hyödyllistä tietoa siitä, mikä auttaa lääkeyrityksiä tehostamaan CAPA-prosessia ja tukemaan toiminnan jatkuvaa parantamista.

Between 5% and 57% of patients experience an adverse drug event during their hospitalization. Reducing medication errors can help prevent adverse drug events. A particular risk for medication errors arises when a patient moves between home and care centers if accurate medication information is not transferred with the patient. Medication reconciliation is a process to ensure accurate and comprehensive medication information across transitions of care. The aim of the study was to find out how many and what kind of discrepancies can be detected by performing medication reconciliation in a primary care unit. In addition, pharmacists and nurses experiences of the medication reconciliation process and the medication reconciliation form were examined. Both quantitative and qualitative data were used in the study. Quantitative study data consisted of all Medication reconciliation forms (PASQ) completed in January-June 2014. Data were analyzed using quantitative descriptive methods. The qualitative research material consisted of six individual interviews conducted in June 2014. The material was subjected to inductive thematic content analysis. Patients (n = 117) had a mean age of 81 years and almost all (n = 105) had at least six regularly used medications after medications were reconciled. Almost every patient (n = 115, 98.3%) had at least one discrepancy in their medication compared to the patient information system. On average, patients had seven discrepancies in their medication lists. The most discrepancies were associated with psycholeptics (9.5% of all discrepncies). The most common types of discrepancies were new drug (45.4% of all discrepancies) and discontinued drug (19.6%). Nurses and pharmacists saw the medication reconciliation process as an important part of successful patient care. Challenges associated with reconciling medications were caused by lack of time, the fragmentation of information systems and the health status of patients (information given by patients could not be trusted). Only one-third of the patients were interviewed, although international publications on medication reconciliation strongly emphasize patient involvement. The results of this study are in line with previous research and confirm the view that medication reconciliation should always be done across all transitions in care. The role of the patient as part of the medication reconciliation process should be further emphasized in the future, as only interviewing the patient can provide a true picture of the patient's medication.

A large part of patient safety incidents in health care is related to medicines and medication treatment. Medication safety is an important part of patient safety. In particular, transitions of care endangers continuity of care and patient safety. A poor flow of information between health care units increases a risk of medication errors. An accurate and up-to-date medication list can improve transfer of correct medical information with the patient. In addition to the medication list other organization-level defences are important to patient and medication safety. This study is part of a larger regional development project concerning reformation of service delivery in health and social care. One of the purposes of the project is to integrate health and social services of municipalities in central Uusimaa (Hyvinkää, Mäntsälä, Pornainen, Järvenpää, Nurmijärvi and Tuusula). The aim of this study was to investigate what kinds of medication lists are available in these municipalities and to design a medication list maintained by the patient which is regionally shared. The second aim of the study was to identify defences used by the municipal healthcare systems and to develop a medication management process model for the municipalities. The material consisted of medication lists from the municipalities participating in the study. Twelve (12) lists were selected for analysis. The medication list of Lääkekortti.fi was also included in the analysis (N=13). Data of the defences was collected by a questionnaire. In Hyvinkää the material was collected from primary health care and Hyvinkää hospital. Both the medication list and the defence data were systematically reviewed and collected in a Microsoft Excel table. The regional medication list for patients was developed based on the medication list data and the existing literature. The process model for medical treatment was developed based on the defence data. Almost every medication list contained space for personal data (n=11) and basic medication information, such as the name of the drug (n=12), strength (n=12) and dosage (n=13). Regular medication was usually separated from as-needed medication (n=8). Only two of the lists had a column for periodic medication. There were only two lists with columns for over-the-counter medicines and herbal products. Less than half of the lists (n=5) had space for indication. According to the survey, most of the defences listed in the questionnaire were used in all or almost all municipalities. According to the responses, medication lists, for example, are regularly reviewed. Some gaps in defences also emerged. Only in two municipalities high-alert medications were identified. Also only in two municipalities attention was paid to the storage of look-alike medicines. Written instructions for managing medication errors was available only in two municipalities. There are many different medication lists available in health care. A regionally shared medication list maintained by the patient can improve the transfer of the up-to-date medical information with the patient. The list must be comprehensive and easy to use. Both the patient and the healthcare professionals should be responsible for maintaining the accurate medication list. Most of the defences asked in the questionnaire have been taken into account in pharmacotherapy plans. In practice, however, the implementation of defences is unclear. For example patients' medication lists often contain errors even though lists should be reviewed regularly. There should be exact instructions as well as clearly defined roles and responsibilities for medication reconciliation. More attention should also be paid to the use of high-alert and look-alike medicines. Since errors occur despite the defenses, every health care unit should have written instructions in case of medication errors.

Background: Medication errors are the most important individual factor that jeopardizes patient safety in human care. The patient's medication process is a chain of successive operations which involves different health care providers and the medicine user. All the stages of the medication process are susceptible to the medication errors. Medication errors are approached from the system's point of view by James Reason`s (1990) theory of Human Error. Instead of blaming individuals the theory concentrates on developing operations models which enable identification of medication errors in the organizations. The development of medication safety culture in the human medication has led to systems which tolerate human mistakes and prevent errors. The increasing number of animals and pets and their changing status in the society have raised discussion about the medication safety in veterinary care. Little research has been conducted in this field. Objective: The objective of the study was to identify the most typical veterinary medication errors and their root causes. The medication management processes of veterinary care can be developed safer by becoming aware of the root causes of medication errors. Study design and data: All the cases investigated by the Assessment Board for Damages in Veterinary Practice in 2002-2013 considering medication errors (n=79) were analysed with the help of the structured data collection sheet by using descriptive statistics. The most typical cases were studied more in detail by using simplified Root Cause Analysis (RCA). Results: The medication errors found were related to the care of dogs (n=34), horses (n=26), bovines (n=10), cats (n=7) and pigs (n=2). The most general therapeutic groups that had caused medication errors were antibacterials for systemic use (17% of all the medicines related to the medication errors), NSAIDs and antirheumatic drugs (12%), neuroleptics and tranquillizers (12%), and analgesics (12%). Of the drugs, 39% were high alert medicines. Of the errors, 36% were related to the off label use (usage deviating from the summary of product characteristics, SPC). The error types which appeared most commonly in the cases were wrong route of administration (18% of all the medication errors), wrong dose (16%) and untreated diagnosed conditions left without the medicine by the veterinarian (15%). Because of the character of the data the majority of the medication errors occurred in the beginning of the medication process. It was estimated that 81% of the medication errors would have been preventable. Some of the root causes found were the lack of the commitment to the established care practice, environmental factors, communication problems, availability of tools, hurry and factors related to management, information and staff. Conclusion: The material of Assessment Board for Damages in Veterinary Practice gives valuable information about the veterinary medication errors. It is possible to influence the root causes of veterinary medication errors by paying attention to the management related factors and communication in veterinary care and improving access to therapeutic guidelines and electronic databases, and by expanding the electronic prescribing to veterinary care. The highest priority is to get Pharmaca Fennica Veterinaria to an electronic form.

Tausta: Lääkehoitoon liittyvät haittatapahtumat aiheuttavat merkittävää inhimillistä kärsimystä ja taloudellista taakkaa yhteiskunnalle. Lääkitykseen liittyviä haittatapahtumia voidaan ehkäistä tunnistamalla ja puuttumalla lääkitysriskejä aiheuttaviin tekijöihin. Tavoitteet: Tutkimuksen tavoitteena oli tutkia lääkitysriskien hallintakeinoja lääkkeen toimittamisen yhteydessä suomalaisissa avohuollon apteekeissa. Tavoitteena oli selvittää, miten apteekeissa tunnistetaan ja puututaan asiakkaan lääkehoitoon liittyviin ongelmiin ja millaista lääkitysriskien hallintaan liittyvää osaamista ja lisäkoulutustarvetta apteekeissa työskentelevillä farmaseuteilla ja proviisoreilla on. Aineisto ja menetelmät: Tutkimus oli valtakunnallinen poikkileikkaustutkimus, jonka aineisto kerättiin syksyllä 2022 sähköisellä kyselyllä. Alkuperäinen kyselylomake luotiin vuonna 2015 kirjallisuuden ja järjestelmälähtöisen riskien hallinnan teorian pohjalta ja päivitettiin tätä tutkimusta varten. Tulokset: Kyselyyn vastasi 192 apteekkia (n=610). Apteekeissa tunnistettiin ja puututtiin lääkehoito-ongelmiin, mutta toimintatavat olivat harvoin systemaattisia. Yleisin puuttumistapa oli keskustelu asiakkaan kanssa ja kehotus ottaa yhteyttä lääkäriin, näin toimi 78 % apteekeista tilanteessa, joissa asiakkaan lääkitys ei toiminut toivotulla tavalla. Suurimmalla osalla apteekeista ei ollut muun terveydenhuollon kanssa yhteisesti sovittuja toimintatapoja lääkehoito-ongelmien ratkaisemiseksi. Myös apteekin sisäiset toimintaohjeet olivat puutteellisia Johtopäätökset: Apteekkien ja muun terveydenhuollon välinen nopea viestintäkanava ja yhteisesti sovitut toimintatavat voisivat parantaa apteekkien mahdollisuuksia puuttua lääkehoito-ongelmiin. Apteekkien rooli lääkitysriskien hallinnassa tulee määritellä tarkemmin. Apteekkien ja muun terveydenhuollon välisessä yhteistyössä on paljon hyödyntämätöntä potentiaalia.

According to international studies, medication records are often incomplete in hospitals' patient information system. Medication reconciliation is an effective method to prevent medication errors and improve medication safety. A medication review is a useful tool in the assessment of drug-related problems (DRPs). DRPs can cause severe patient harm and even cause death. Approximately one third of Finnish people are diagnosed with cancer during their lifetime. About 16 000 patients receive cancer treatments in the Helsinki University Central Hospital Cancer Centre (HUCHCC). There are no clinical pharmacy services in the division of the solid tumors of HUCHCC. Internationally clinical pharmacy services in oncology are patient oriented and often include medication reconciliations and reviews. The clinical pharmacy services have increased patient safety also in the oncological specialty. The aim of this study was to find out the accuracy of the medication charts and identify the DRPs among 70-80-year-old patients with 6 or more medicines in uro-oncological outpatient clinic of HUCHCC. Accuracy of the medication charts was assessed by pharmacist-led medication reconciliation with patient interview. Information concerning patient's medication was also searched from the national electronical prescription centre and from the records of previous hospital visits. DRPs, such as drug-drug interactions, adverse drug reactions and overlapping medications, were identified with the pharmacist-led medication review. Special attention was paid to renal insuffiency, high-alert medications and potentially inappropriate medication for patients over 75 years old. Pharmacist discussed the DRPs with the oncology specialist. The theoretical framework of this study was the theory of human error, where patient safety hazards can be prevented by using safety defences such as medication reconciliation and medication review. Altogether 30 patients with urological cancer were included in this study. On average, they were 74.3 years old and used 12.4 medications. On average, there were 6.8 discrepancies per patient in the hospital medication chart. Only one patient had the accurate medication chart. The discrepancies were most commonly related to paracetamol (n = 10), vitamin-D (n = 9) and the combination of calcium and vitamin-D (n = 8). The most common discrepancies of high-alert medications were related to enoxaparin (n=6) and oxycodone (n=6). Of the potentially inappropriate medications for over 75 years old, the most common discrepancies were related magnesium (n=8) and metoclopramide (n=5). In the medication review process, 4 acute and 44 non-acute DRPs were identified with 22 patients (2,2 per patient). 60 % of these were regarded clinically relevant and lead to actions by the oncology specialist. Reconsidering the need or efficacy of the medication was recommended 19 times and inappropriate dose or medication with renal insufficiency were identified six times in medication reviews. DRPs were usually related to non-oncological medications such as pantoprazol (n=8), the combination of calcium and vitamin-D (n=4) ja bisoprolol (n=3). The medication reconciliation process should be developed in the urology-oncology outpatient clinic. Multiprofessional medication review can be used to detect and resolve DRPs of patients with urological cancer. The results of this study can be exploited when clinical pharmacy services will be created and developed in HUCHCC.

Immunoglobulin G is very unstable and that is why it is very challenging to formulate and process it. Because of the unstability, IgG is vulnerable to changes in pH, heat and mechanical stress. Exposure to these stresses makes IgG aggregate more easily and lose its biological activity. To restore stability, IgG is formulated to a solid product from which it can be regenerated. With TFF (Tangential Flow Filtration) IgG can be purified from other components. The filtration is based on a half-permeable membrane which permeates the other components except for the IgG. The filtration pressure is the force which keeps the liquid flowing. It is important to control this pressure, too high or too low pressure will damage the IgG. IgG can also be protected with polysorbate which is a surfactant going to the protein/liquid interface and therefore stabilizing IgG. IgG does not stay stable in liquid very long so it has to be lyophilized to improve its process- and storage stability. Lyophilization is a long and energy consuming process. Optimisation of the process is therefore essential to save time and resources. First IgG is freezed to produce ice. Primary drying is the second step, sublimation will change ice to water vapor. Secondary drying is based on water desorption, that way residual water is removed from the lyophilizate. The drying process is carried out altering shelf temperature on which the samples are placed. Chamber pressure is also an important factor in IgG stabilisation. These factors have their impact on IgG stability. Also adding disaccharide, trehalose, in the formulation increases the stability of IgG. The purpose of this work was to optimise both the filtration and lyophilisation process so that IgG would remain as stable as possible. During preliminary testing the results showed that magnetic stirring prior to filtration will damage the IgG, showing aggregation and less biological activity. Aggregation was measured with DLS and biological activity with ELISA. Changes in the secondary structure after lyophilisation were measured with CD. The actual filtration tests were carried out using three different filtration pressures and two different polysorbate 20 concentrations, and water. The results showed that IgG is most stable in 1,25 bar filtration pressure and 0,01 % polysorbate concentration. There was less aggregation and more biological activity. The filtration tests proved to be challenging because there were several parameters that were difficult to control. The same challenge was faced when analysing the results. Lyophilisation tests were carried out using three different pressures during primary drying and three different heating rates during secondary drying. The analysis methods were the same as during filtration tests. In addition, the IgG secondary structure changes were under investigation. The lyophilisation tests showed that trehalose clearly protects the IgG. Visually lyophilised samples which contained trehalose were mechanically more stable than those which did not contain trehalose. The analysis showed that the pressure of 60 mTorr and low heating rate (5 °C/h) resulted in better stability of IgG, aggregation was lower and biological activity higher. During lyophilisation no changes in the secondary structure was seen in CD. This was possibly due to lack of sensitivity of the analysis method.