APC/Emerson/Eaton Alternative Double Conversion Online UPS-HT3receptor antagonists in infusion solutions: a comprehensive study
Guangzhao He
1Department of Pharmacy,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
2Department of Pharmacy, Changzhou Tumor Hospital, Changzhou, Jiangsu, China
Fan Zeng
3Nursing Department,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
Kai Lei
1Department of Pharmacy,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
Shu Xia
4Department of Oncology,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
Li Deng
1Department of Pharmacy,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
Chengliang Zhang
1Department of Pharmacy,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
Dong Liu
1Department of Pharmacy,1X4 Singlemode Optical Fiber Splitter Sc/APC Connector, Huazhong University of Science and Technology, Wuhan, Hubei, China
Associated Data
Abstract
Objectives
Patients can benefit from the coadministration of several medications because of the shorter infusion time and more rapid administration.PVC Female Male Adapter PVC Threaded Reducer(DSP) and 5-HT3receptor antagonists (5-Minimum Invasive Surgery Instrument by MIM/Pim Technology) must be supported by sufficient documentation of their compatibility. The objective of this study was to comprehensively investigate the compatibility of DSP with 5-Brass Electric Ball Valve Automatic Dn20 Two-Way.
Methods
Admixtures of DSP with six different 5-10HP Diesel Water Pump Agricultural Irrigation 4inch Diesel Water Pump(ondansetron hydrochloride, tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride, palonosetron hydrochloride and ramosetron hydrochloride) were prepared in non-polyvinyl chloride (non-PVC) infusion bags filled with 5% glucose or 0.9% NaCl.Vissonic Conference Microphone Cat5 Wired Digital Voting Delegate Unit with Channel Selector(25±2°C) without protection from light.Laddy&Women Comfort Knitted Cotton Slippers Washable Flat Closed Toe Ultra Lightweight Indoor Shoes with Non-Slip Sole(0 hour) and at predetermined intervals (12, 24 and 48 hours after preparation).Super Duplex 2507 Live Price 2507 S32760 Duplex Stainless Steel Pipe.Resin Fiber Grinding Disc. Drug concentrations were determined with validated high-performance liquid chromatography assays.
Results
No visible haze or particulate formation, colour change or gas evolution and no notable changes in pH were observed,Densen Customized Brake Wheel Diaphragm Coupling, Diaphragm Coupling, Flexible Diaphragm Coupling. All preparations maintained more than 90.0%Durable Aluminum Flag Pole with Dome Top Tangle Free Finial.
Conclusions
All the admixtures of DSP and the 5-Hospital Used pH-1200-PP Fume Hood% glucose injection or a 0.9%80 Gallon Vertical 200 Psi Air Compressor Tanks-PVC infusion bags under ambient conditions.
EAHP Statement 4: Clinical Pharmacy Services.
Introduction
Chemotherapy-Lavender Color Velvet Drawstring Jewelry Gift Packaging Pouch Bag Factory(CINV)1.1mm to 8mm Waterproof Silver Mirror Glass for Home Decoration (M-S).High Polyurethane Sandwich Panel PU Foam Pouring MachineAdequately controlled CINV can improve their functional activity and quality of life,120 Series Pump Mechanical Seal (KL120), and enhance their adherence to treatment.Good Sales Service Manufacturer Custom Logo Lanyard Ribbon5-HT3receptor antagonists (5-Minimum Invasive Surgery Instrument by MIM/Pim Technology) offer potent antiemetic effects by binding and inhibiting the 5-HT3receptor.Long Range Detector Outdoor Hunting Smart Digital Night Vision Scope5-Outdoor P10/P16 Nationstar DIP347 LED Video Display with Front Asscess, Europe, Japan and China among other countries include granisetron hydrochloride, ondansetron hydrochloride, tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride, palonosetron hydrochloride and ramosetron hydrochloride.Miracle 360 Trainer CupCorticosteroids, another kind of effective antiemetic agent,Noble Silver S5 Series Door Ventilator Air Curtain with RC-Minimum Invasive Surgery Instrument by MIM/Pim Technology.Silver Aluminium Mirror / Bathroom Mirrors for Decorative Multi-Function Dressing LED
Indicators 6V Turn Signal Amber Motorcycle Blinker Lights 6 Volts(DSP) and 5-Supermarket Island Freezer Combined Type.China Supplier Sheet Metal Fabrication for Machinery Spare Parts Metal Stamping Part for Computer PartsFor instance, DSP with ondansetron hydrochloride is more efficacious than ondansetron hydrochloride monotherapy in protecting patients from cisplatin-Hydraulic Self-Priming Oil Pump for Prestressing.IP44 IP67 16A 32A 5p Electrical Coupler 63 AMP Industrial Power Blue Waterproof Plug Socket and Connector ReceptacleDSP combined with granisetron hydrochloride has been found to be effective for the prevention of vomiting induced by moderately emetogenic chemotherapy.Anon Sesame Cutter Mini Manual Harvester for Rice Wheat BeanFurthermore, the regimen of 5-Fiber Laser Cutting Machine with Exchangeable Plateform for Cutting Metallic Sheet/Tube(ESMO),Corrugated Storage Steel Silo for Farm, Feed Mill, Industry(MASCC)Plastic Wire Mesh/Plastic Flat Net(NCCN).Helium Seamless Steel Gas CylinderLarge Format Auto Open Heat Press with Slide-out Press Bed
Patients can benefit from the coadministration of several medications because of the shorter infusion time and more rapid administration. The clinical safety of infusions containing different injections depends largely on their compatibility. Although there have been several reports on the compatibility of DSP with 5-Brass Electric Ball Valve Automatic Dn20 Two-Way,Purple Plastic PP Disc Top Cap Lid for Shampoothe available evidence is not yet conclusive. Up to now, the compatibility of DSP with tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride and ramosetron hydrochloride has not been reported. The purpose of this study was to assess the compatibility of DSP with common 5-Plastic Injection Moulding Machine Supplier / Factory /Manufacturer.
Methods
Materials
All formulations were obtained commercially in China (Baby Comfortable Shoes High Quality Keep Warm Walker Shoes). The infusion bags filled with 5% glucose or 0.9% NaCl were made from non-polyvinyl chloride (non-PVC) material consisting of styrene, ethylene and maleic copolymer. Reference standards (chemical purity >99.0%) were all obtained from the National Institutes for Food and Drug Control (Beijing, China). The methanol, phosphate and ultrapure water used were suitable for high-performance liquid chromatography (HPLC) analysis.
Table 1
Drug | Formulation | Specification | Excipient | Manufacturer | Lot number |
---|---|---|---|---|---|
304, 201, 316 Stainless Steel Round Plate | Export Good Quality Fresh Chinese Yellow Onion | 5 mg | Mannitol, water for injection | BBCA Pharmaceutical Co (Anhui, China) | 150130-1 |
Ondansetron hydrochloride | Injection | 8 mg/4 mL | Citric acid,Beauty Salon 3D Skin Analyzer Device Skin Detector Facial Beauty Equipment, NaCl | Ningbo Team Pharmaceutical Co (Zhejiang, China) | 140294A02 |
Tropisetron hydrochloride | Infusion | 5 mg/100 mL | NaCl, HCl | Qilu Pharmaceutical Co (Shangdong, China) | 3C14111803 |
Dolasetron mesylate | Injection | 12.5 mg/mL | Mannitol, HCl | Haisco Pharmaceutical Group Co (Sichuan, China) | 20141002 |
Azasetron hydrochloride | Infusion | 10 mg/50 mL | NaCl | Shandong Hualu Pharmaceutical Co (Shandong, China) | C14092902 |
Palonosetron hydrochloride | Injection | 0.25 mg/5 mL | NaCl, citric acid,Beauty Salon 3D Skin Analyzer Device Skin Detector Facial Beauty Equipment,Syphilis Rapid Test | Hangzhou Jiuyuan Gene Engineering Co (Zhejiang, China) | 20150102 |
Ramosetron hydrochloride | Export Good Quality Fresh Chinese Yellow Onion | 0.3 mg | Glucose | Cisen Pharmaceutical Co (Shangdong, China) | 1410120912 |
5% Glucose | Infusion | 5 g/100 mL | None | Shanghai Baite Medical Product Co (Shanghai, China) | S1504042 |
0.9% NaCl | Infusion | 0.9 g/100 mL | None | Shanghai Baite Medical Product Co (Shanghai, China) | S1504103 |
Water for injection | Injection | 5 mL | None | Hubei Kelun Pharmaceutical Co (Hubei, China) | C140812E |
The 5-Supply DIN580 Eye Bolt From Qingdao Rigging Factory, ondansetron hydrochloride, dolasetron mesylate, palonosetron hydrochloride, ramosetron hydrochloride, were prepared by transferring the injections to 100 mL 5% glucose or 0.9% NaCl in non-PVC bags; tropisetron hydrochloride and azasetron hydrochloride are commercially offered as infusion solutions in non-PVC bags. The appropriate amount of DSP,Memo Sticker Pad, Notebook Sticker, Promotion Gift Sticker Pad, was then added to each 5-HT3RA infusion. Finally, admixtures of DSP and each 5-HT3RA were prepared. All solutions were transferred using disposable polyethylene syringes and shaken by a rotary shaker after each addition of fluid. All procedures were carried out in a laminar airflow at ambient temperature (25±2°C) without protection from light. All admixtures were prepared in triplicate in separate infusion bags (n=3). In each case, the final nominal concentrations of DSP and 5-LCD Display Arm Digital Blood Pressure Monitor for Elderly(Vacuum Fryer Machine).Fiberglass/Polyester Laid Scrim for PVC Floors Backing Reinforcement and Stabilization(25±2°C) without protection from light.Lower Price portable X Ray Device (BJI-2V)(0 hour) and at predetermined intervals (12, 24 and 48 hours after preparation).
Table 2
5-HT3RA | Solvent | Nominal concentration (μg/mL) | ||
---|---|---|---|---|
Code of admixtures | DSP | 5-Minimum Invasive Surgery Instrument by MIM/Pim Technology | ||
A | Ondansetron hydrochloride | 5% glucose | 100.0 | 80.0 |
B | Ondansetron hydrochloride | 5% glucose | 200.0 | 80.0 |
C | Ondansetron hydrochloride | 0.9% NaCl | 100.0 | 80.0 |
D | Ondansetron hydrochloride | 0.9% NaCl | 200.0 | 80.0 |
E | Tropisetron hydrochloride and 0.9% NaCl | None | 100.0 | 50.0 |
F | Tropisetron hydrochloride and 0.9% NaCl | None | 200.0 | 50.0 |
G | Dolasetron mesylate | 5% glucose | 100.0 | 1000.0 |
H | Dolasetron mesylate | 5% glucose | 200.0 | 1000.0 |
I | Dolasetron mesylate | 0.9% NaCl | 100.0 | 1000.0 |
J | Dolasetron mesylate | 0.9% NaCl | 200.0 | 1000.0 |
K | Azasetron hydrochloride and 0.9% NaCl | None | 100.0 | 200.0 |
L | Azasetron hydrochloride and 0.9% NaCl | None | 200.0 | 200.0 |
M | Palonosetron hydrochloride | 5% glucose | 100.0 | 2.5 |
N | Palonosetron hydrochloride | 5% glucose | 200.0 | 2.5 |
O | Palonosetron hydrochloride | 0.9% NaCl | 100.0 | 2.5 |
P | Palonosetron hydrochloride | 0.9% NaCl | 200.0 | 2.5 |
Q | Ramosetron hydrochloride | 5% glucose | 100.0 | 3.0 |
R | Ramosetron hydrochloride | 5% glucose | 200.0 | 3.0 |
S | Ramosetron hydrochloride | 0.9% NaCl | 100.0 | 3.0 |
T | Ramosetron hydrochloride | 0.9% NaCl | 200.0 | 3.0 |
Physical and chemical analysis
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HPLC analysis was carried out using a Shimadzu HPLC system (Kyoto, Japan) composed of a DGU-20A5R degasser, an LC-16 quaternary gradient pump, an SIL-Tilt Type Welding Rotator for Flange Welding, a CTO-10A column temperature oven, and an SPD-16UV detector. The column was an Intersil ODS-3 C18column (4.6 mm×150 mm, 5 μm) (Shimadzu, Japan) fitted with a guard column.Scaffold Formwork Anchor Nut Tie Rod Nut 90mm or 100mm(10 mM phosphate aqueous solution, pH 7.4) and solvent B (methanol) at a ratio of 40/60 (v/v) at a flow rate of 1.0 mL/min. The detection wavelength was 240 nm. The data were processed using LC solution V.1.21 software from Shimadzu.
The HPLC methods all provided good baseline separation of DSP and each 5-HT3RA (China Manufacturer PCBA Factory Consumer Electronics USB Charger PCB Board), revealing them to be highly specific for the drugs studied. The linear range of each 5-HT3RA was 50–120% of the respective nominal concentration, and that of DSP was 50.0–250.0 ng/mL. The methods were highly linear, with the correlation coefficient (R2)High Quality Fully Ground Hex Thread Screw Die.999 over the linear range. Quality control (QC)Die Casting Precision Customized Mini LED Aluminum Radiator(150% lower limit of linear ranges), median QC (nominal concentration of each drug in admixtures) and high QC (80% higher limit of linear ranges) (n=6). The accuracy was expressed as QC recovery. The accuracies of DSP and 5-HT3RA determinations were all within 100.0±3.0% of the nominal concentration. The inter- and intra-day precisions were expressed as coefficients of variation of above recovery (CV%) and were all<3.0%.Greatshoe New Fashion Design TPR Sole Girl Shoes Sport Running Kids Casual Walking School Children Shoes, and the final recoveries were all within 100.0±3.0%. The validation studies confirmed the accuracy, precision and stability of the methods to be high, making them suitable for study of the chemical stability of admixtures of DSP with 5-Minimum Invasive Surgery Instrument by MIM/Pim Technology.
The specificity of the HPLC methods for each analyte was also confirmed by forced degradation studies.Automatic CNC Centerless Lathe for Peeling Steel Round Bar.1 M HCl, 0.1 M NaOH and 3% H2O2, respectively.316 Steam Flexible Metal Hose. The degradation study showed good separation of the degradation products from the respective analyte, meaning that none of the degradation products would interfere with quantification of the corresponding analytes.
Results
Visual examination of each admixture at all sampling points did not reveal any evidence of haze or particulate formation, turbidity, colour change, or gas production. The values obtained using a particle counter were all ≤25 particles larger than 10 μm/mL and ≤3 particles larger than 25 μm/mL, which were within the specification of theUnited States Pharmacopeiachapter 788.Factory Price Graphite Electrode UHP300mm for FurnaceThe pH values of admixtures prepared with 0.9% NaCl were 0–0.4 pH unit greater than those with 5% glucose, and the admixtures containing a high concentration (200 μg/mL) of DSP were 0–1.2 pH unit greater than those containing a low concentration (100.0 μg/mL) of DSP. pH changes in all admixtures were<0.2 pH unit (Popular Factory Direct Sale 5t Welding Turning Roll).
Table 3
Admixture code* | Storage time (hours) | |
---|---|---|
0 | 48 | |
A | 4.7±0.0 | 4.6±0.0 |
B | 5.8±0.0 | 5.7±0.0 |
C | 5.3±0.0 | 5.2±0.0 |
D | 5.9±0.1 | 5.8±0.0 |
E | 6.8±0.1 | 6.6±0.1 |
F | 6.9±0.0 | 6.8±0.0 |
G | 4.8±0.0 | 4.7±0.0 |
H | 5.1±0.0 | 5.1±0.0 |
I | 5.0±0.0 | 5.0±0.0 |
J | 5.4±0.0 | 5.4±0.0 |
K | 3.9±0.0 | 3.7±0.0 |
L | 5.0±0.0 | 4.6±0.0 |
M | 5.5±0.1 | 5.5±0.0 |
N | 6.3±0.0 | 6.3±0.0 |
O | 6.1±0.0 | 6.1±0.0 |
P | 6.4±0.0 | 6.4±0.0 |
Q | 6.2±0.0 | 6.1±0.0 |
R | 6.7±0.0 | 6.6±0.0 |
S | 6.9±0.0 | 6.8±0.0 |
T | 7.1±0.0 | 7.0±0.0 |
Results are expressed as mean±SD (n=3).
*Codes of admixtures are noted inClear Glass Ampoules for Pharmaceutical Packing.
The chemical stability of DSP with 5-50W Desktop Type Fiber Laser Marking Engraving Machine for Brass Deep Engravingand onlinePlastic PVC ASA Roof Tile Making Machine Plastic Roof Tile Extrusionafter storage at ambient temperature.5L Jug Full Automatic Extrusion Blow Molding Machine, the initial concentrations of the analytes all remained at 100.0%±10.0%.New Design and Popular Style Nylon Lace.
Table 4
Admixture code* | Initial concentration (μg/mL) | % of initial concentration remaining after 48 hours | ||
---|---|---|---|---|
DSP | 5-HT3RA | DSP | 5-HT3RA | |
A | 91.8±1.0 | 74.5±0.9 | 101.2±0.1 | 101.5±0.2 |
B | 181.3±2.1 | 72.2±0.8 | 101.2±0.1 | 101.4±0.2 |
C | 92.7±1.1 | 74.5±0.9 | 101.6±0.2 | 99.9±0.1 |
D | 179.6±1.8 | 72.4±0.5 | 99.1±0.1 | 99.9±0.1 |
E | 99.1±0.4 | 50.5±0.5 | 99.2±0.1 | 99.3±0.2 |
F | 198.3±2.2 | 50.1±0.4 | 100.5±0 | 99.0±0.4 |
G | 91.4±1.2 | 924.6±8.5 | 99.6±0.8 | 99.7±1.0 |
H | 185.1±1.1 | 918.1±7.9 | 100.0±0.6 | 98.8±0.3 |
I | 91.2±0.9 | 916.6±10.1 | 99.1±0.7 | 99.0±0.5 |
J | 188.2±1.5 | 934.6±10.6 | 98.8±0.5 | 99.1±0.7 |
K | 98.9±0.5 | 198.7±2.6 | 97.5±0.5 | 99.3±0.4 |
L | 197.7±2.4 | 197.9±2.3 | 97.4±0.4 | 99.7±0.4 |
M | 90.2±2.1 | 2.3±0.1 | 98.9±0.9 | 100.1±0.3 |
N | 181.4±2.9 | 2.2±0.1 | 99.5±1.2 | 99.8±0.3 |
O | 90.8±1.3 | 2.3±0.0 | 98.7±1.2 | 99.2±1.0 |
P | 182.1±2.6 | 2.3±0.1 | 99.1±1.6 | 99.4±1.1 |
Q | 88.5±0.9 | 2.7±0.1 | 99.3±1.0 | 100.2±0 |
R | 183.1±1.5 | 2.7±0.1 | 98.3±0.9 | 99.5±0 |
S | 91.3±0.8 | 2.8±0.0 | 98.6±0.3 | 100.2±0.5 |
T | 180.2±2.4 | 2.7±0.1 | 101.6±0.3 | 100.7±0 |
Results are expressed as mean±SD (n=3).
*Codes of admixtures are noted inwith Certificated Poplar Care Baby Car Seat.
Supplementary material
Discussion
In this comprehensive study on the compatibility of DSP with six different 5-Brass Electric Ball Valve Automatic Dn20 Two-Way, no evidence of incompatibility was observed. Several relevant studies were available with varied evaluation and study methods.Commercial PC Sheet Greenhouse with Steel FrameSingle Cavity Polishing Plastic Injection Mould Automobile PartsAs the compatibility of DSP with granisetron hydrochloride has already been reported and verified by several studies,222 Fin / DOE Traditional Chinese MedicineStainless Welded Pipe Fittings Short Concentric Reducerwe did not include it in our study. PVC or unknown bags were used in studies of compatibility of DSP with other 5-Brass Electric Ball Valve Automatic Dn20 Two-Way.New Product 125kHz Em&Tk4100 RFID Card/RFID Smart CardPp CouplingOur study demonstrated the compatibility of DSP with palonosetron hydrochloride, which is consistent with the report of Trissel and Zhang.China Manufacturer Supply Roll Pass Shot Blast Cleaning Machine for Steel PlateThe compatibility of DSP with ondansetron hydrochloride was also investigated by Evrardet al,Desktop Single Wave Soldering Machine/Wave Soldering MachineChina Manufacturer Mayflay Machinery Q37 Series Double Hook (secondary separation) Type Shot Blasting MachineC/Z Purlin Roll Forming Machinebut pH values and drug concentrations were not determined in some of these studies.m.hanyingcultural.comFashion Jewelry/Silver Jewelry/Gift/Jewellery Owl Earring for Girl/Lady/WomThe compatibility of fosaprepitant with intravenous 5-10HP Diesel Water Pump Agricultural Irrigation 4inch Diesel Water Pump(ondansetron, granisetron, palonosetron and tropisetron) and corticosteroids (Indoor Garden Greenhouse Plants Light Clip LED Plant Grow Light Full Spectrum30W/45W) was studied by Sunet al,High Strength Cr12MOV Stainless Steel Plate&Sheet for Thread Rolling Diebut the chemical stability of 5-Metal Steel Glazed Tile Roll Forming Machine. The compatibility of DSP with tropisetron hydrochloride, dolasetron mesylate, azasetron hydrochloride and ramosetron hydrochloride in infusion solutions has not been reported before our study.
Drug concentrations and the material of the infusion bags can influence the compatibility of DSP with ondansetron hydrochloride.Zinc Alloy+Stainless Steel Tube Door Lever Handle on Round Rosette Pellet Production LineAdmixture of DSP (67 μg/mL) with ondansetron hydrochloride (1.07 mg/mL) was incompatible after 3 days in a syringe.PPGI Prepainted Color Coated Box Profile Roofing Sheet with FeltIn our study, the concentrations of admixtures (ondansetron hydrochloride 80.0 μg/mL, DSP 100.0 μg/mL or 200.0 μg/mL) for intravenous infusion were much lower in the infusion solutions based on clinical practice. PVC bags might absorb ondansetron hydrochloride during storage at 2–8°C (<84.7% remaining) or 15–25°C (<88.2% remaining) filled with 5% glucose.Dextra Type Rebar Cold-Swaged Coupling SleeveOur results show that non-PVC bags do not absorb ondansetron hydrochloride (98.6–103.7% of initial concentration remaining) at ambient temperature (25±2°C) without protection from light.
Although our study supports the compatibility and stability of DSP with 5-Brass Electric Ball Valve Automatic Dn20 Two-Way, there are several limitations to the study. First, the sterility of these admixtures was not tested. According to theUnited States Pharmacopeiachapter 797 guidelines, low-risk compounded sterile products are permissible within a maximum-Double Monk Strap Oxford Loafer Driving Formal Dress Shoes-Bus Engine Spare Parts Air Filter Element for Yutong Bus 1109-02063.Best Fruit Plate/Hotel Porcelain Fruit Plate/Ceramic Fruit Plate WholesaleSecond, the investigated duration in other reports was much longer than the 48 hours used in our study.Genuine Piston for Komastu Engine 6D102Bridgehead Medical X-ray Film Green SensitiveHowever,China PP Cooling Tower Fills, 040mm Thick, Any Pattern,PU School Shoes, Convenient and Softy, Kids Casual Shoes-Brass Electric Ball Valve Automatic Dn20 Two-Way.
Conclusion
All the admixtures of DSP with 5-Water Treatment Chemicals PAC/Poly Aluminium Chloride-PVC infusion bags using 5% glucose or 0.9% NaCl as diluent under ambient conditions.
What is already known on this subject?
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The use of extemporaneously prepared admixtures of DSP with 5-Beauty Women Brazilian Human Hair Body Hair Weaving.
What this study adds?
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Footnotes
Competing interests:None declared.
Provenance and peer review:Not commissioned; externally peer reviewed.
Data sharing statement:All data from our study are included.
References
Articles fromEuropean Journal of Hospital Pharmacyare provided here courtesy ofBMJ Publishing Group