Effect of Vegetable Waste on Growth Performance and Hematology of Broiler Chicks

Vegetable waste (spinach, potato, and cauliflower) is a rich and natural source of nutrients, potentially good for supplying minerals, essential amino acids, and antioxidants to the birds. Relatively, its cost very low, easily to accessible, easily process & pose little risk of illness. The aim of present study was to evaluate the effect of vegetable waste (VW) as feed supplement on growth performance and hematology of broiler chicks. For this purpose, a total of 200 (4 days old) vaccinated chicks were acquired from a commercial hatchery Multan which was acclimated for three weeks (21 days) on basal starter feed after that 25-day-old chicks with uniform body weight were allocated according to a CRD (completely randomized design) into four dietary treatments with three replicates of each contained 15 chicks in 12 pens. In dietary treatments, chicks were feed with basal feed (BF) and supplemented feed with vegetable waste (VW) of spinach, potato, and cauliflower. For this purpose, the dietary treatments included control treatment (T 1) (100% BF+0% VW) and other dietary treatments (T 2) (75% BF+25% VW), (T 3) (50% BF+50% VW), and (T 4) (25% BF+75% VW). The body weight, feed intake, food conversion ratio (FCR), and mortality were checked on weekly and daily basis. For hematology analysis, after the 1st experimental week (25-day-old chicks) and the last 5th experimental week (56-day-old chicks), the samples of blood were gathered from the wing's veins of two birds from each treatment in random way. At the end of five weeks (35 days), birds with uniform average body weight were selected per treatment with three replicates (2 bird/replicate) and then were manually slaughtered according to the Halal method to analyze the weight of internal body organs of broilers by physical and statistical analysis (ANOVA). There was no significant effect (P > 0.05) on feed intake and FCR among all the dietary treatments. But in average, body weight and BWG were higher in treatment (T 2) (P < 0.01) than all other dietary treatments (T 3) and (T 4) and control treatment (T 1). The blood constituents in this study showed that broilers in control treatment (T 1) and other dietary treatments (T 2), (T 3), and (T 4) fed on different doses were significantly (P < 0.01) different from each other. The week 5 (W 5) shows higher values of blood constituents (P < 0.01) than week 1 (W 1). The carcass yield of the chicks fed on different doses showed that they were significantly different (P < 0.01) among the dietary treatments. The VW inclusion 0%, 25%, 50%, and 75% had positive effect on blood constituents and carcass yield of the broiler chicks; they were significantly (P < 0.01) different among the treatments.

Diet and irritable bowel syndrome: an update from a UK consensus meeting

There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.

Molecular markers-based DNA fingerprinting coupled with morphological diversity analysis for prediction of heterotic grouping in sunflower (Helianthus annuus L.)

Cultivated sunflower holds a very narrow genetic base and the efficient utilization of available genetic diversity is very important for a successful breeding program. In the present study, 109 sunflower genotypes were assessed for diversity paneling through a combined approach of morphological and molecular markers analysis. Morphological parameters including days to flower initiation, days to flower completion, plant height, stem curvature, number of leaves per plant, leaf area, head diameter, hundred seed weight, and seed yield per plant were studied. Simple sequence repeats (40 DNA markers) were deployed for diversity profiling. Data were analyzed by both univariate and multivariate statistics. SD and coefficient of variation confirm the presence of significant amounts of genetic variation for all the morphological parameters. Cluster Analysis and Principal Component Analysis further confirm the presence of distinct grouping patterns in the studied material. Cluster analysis of both morphological and molecular analysis revealed that restorer lines tend to group separately from A, B, and open-pollinated lines. Further grouping, at the sub-cluster level, revealed six distinct sub-clusters in each of the two major clusters. In total, 12 genotypes, 6 CMS lines (CMS-HAP-12, CMS-HAP-54, CMS-HAP-56, CMS-HAP-99, CMS-HAP-111, and CMS-HAP-112) and 6 restorer lines (RHP-38, RHP-41, RHP-53, RHP-68, RHP-69, and RHP-71) could be used as potential parents for hybrid development. As genotypes of similar genetic backgrounds tend to group closer, it is deduced that one genotype with the highest seed yield per plant could be used for further hybrid breeding programs in sunflowers.

Impact of different levels of zinc and nitrogen on growth, productivity, and quality of aromatic rice cultivated under various irrigation regimes in two districts of Pakistan

Rice is a staple food for more than 50% of the global population and it is one of the most valuable cereal crops. To fulfill the dietary requirement of the ever-growing world population, an increase in per-unit production of rice is direly required. In Pakistan, it stands as the 2nd in consumption after wheat, which is a staple food. A huge gap is observed between yield potential and actual yield of the aromatic rice cultivars at a farmer-field level. The significant limitations responsible for this gap are shortage of irrigation water, inappropriate application of fertilizers, less plant population, deficiency of micronutrients, and improper and poor plant protection measures. A field study was planned to assess the yield response and quality attributes of aromatic rice to three levels of zinc (Zn) and nitrogen (N) under three irrigation regimes (8-, 12-, and 16-acre inches) in the Sheikhupura and Sargodha districts of Pakistan. Irrigation treatments significantly influenced the growth, yield, and quality attributes; however, maximum improvement was observed by the application of irrigation at 12-acre inches. Among the Zn treatments, application of Zn at 10 kg ha^-1 was observed to be more responsive to improving the growth and quality parameters of aromatic rice crops. In the case of N treatments, application of N at 140 kg ha^-1 produced the maximum total tillers, as well as productive tillers per hill, spikelets per panicle, leaf area index, leaf area duration, crop growth rate, total dry matter, harvest index, kernel length, kernel width, and 1,000-kernel weight. Application of N at 140 kg ha^-1 not only improved the growth attributes but also increased the net assimilation rate, photosynthetically active radiation, and radiation use efficiency, with respect to total dry matter and kernel yield. The maximum percentage of normal kernels and minimum percentage of opaque, abortive, and chalky kernels were also recorded by application of N at 140 kg ha^-1. The outcomes of current experiments depicted that application of irrigational water, zinc, and nitrogen at 12-acre inches, 10, and 140 kg ha^-1, respectively, are responsible to achieve maximum resource utilization efficiency, along with increased yield and quality of rice.

Coeliac disease and noncoeliac wheat or gluten sensitivity

Coeliac disease (CD) and noncoeliac wheat or gluten sensitivity (NCWS/NCGS) are common gluten-related disorders. Both conditions can present with gastrointestinal and extraintestinal manifestations, which can be a challenge for physicians to discern between. Whilst coeliac serology and histological assessment are required for the diagnosis of CD, there are no clear biomarkers for the diagnosis of NCGS. The management of both conditions is with a gluten-free diet (GFD), although the duration, as well as strictness of adherence to a GFD in NCGS, is unclear. Adherence to a GFD in CD can also be challenging, with recent developments of noninvasive assessments, although histological assessment via duodenal biopsies remains the gold standard. The management of refractory coeliac disease remains particularly challenging, often requiring specialist input. Whilst wheat is noted to be a trigger for symptom generation in NCGS, it is unclear which components of wheat are responsible for symptom generation in this group, with further research required to elucidate the pathophysiology.

The role of diet in irritable bowel syndrome: implications for dietary advice

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects approximately 10% of the population. Diet triggers symptoms in the vast majority of individuals with IBS. In view of this, there has been a focus on the role of diet in IBS. The diets currently being headlined for IBS include (i) traditional dietary advice, (ii) the low fermentable oligo-, di-, mono- saccharides and polyols (FODMAPs) diet and (iii) the gluten-free diet (GFD). Although traditional dietary advice is considered as the first-line dietary therapy, its evidence base is variable, with a few randomized controlled trials (RCTs) exploring the efficacy of this approach, other than for fibre. There are now a growing number of RCTs demonstrating the efficacy of the low FODMAP diet in the short-term, with some emerging data on the long-term 'adapted' low FODMAP diet. There are also several RCTs showing the benefits of a GFD in IBS; however, this concept is hampered with uncertainty as to the mechanism of action. Nevertheless, all of these dietary therapies are viable options for individuals with IBS, with the dietitian and patient engagement at the forefront of achieving success. However, future pragmatic studies are needed to clarify the comparative efficacy and convenience of implementing these various diets into routine life. Moreover, it is imperative to better delineate the concern that restrictive diets - such as the low FODMAP and GFD - may promote nutritional inadequacies, disordered eating behaviours, and lead to detrimental alterations to the gut microbiota.

Comparative efficiency of wheat straw and sugarcane bagasse biochar reduces the cadmium bioavailability to spinach and enhances the microbial activity in contaminated soil

Biochar is considered a novel soil amendment for cadmium (Cd) stabilization in contaminated soils. A pot experiment was conducted to examine the efficiency of wheat straw and sugarcane bagasse induced biochar on Cd mobility in soil and its bioavailability to spinach in contaminated soil. Soil pH, Cd contents in plant tissues and microbial biomass were examined. Results showed that Cd was significantly decreased by 30.95% and 20.83% with wheat straw and sugarcane bagasse biochar at 2% application rate respectively, relative to the control. Similarly, Cd contents were decreased in plants shoots by 15.41 and 14.33%, while in roots by 48.3 and 35.54%, when wheat straw and sugarcane biochar were added at 2% application rate respectively. Moreover, soil microbial biomass was significantly increased with the application of all biochar types and their applications rates. Finally, wheat straw biochar at 2% application rate can be considered as an effective approach for Cd stabilization in contaminated soils.

Current insecticide susceptibility status of Malaysian Anopheles maculatus Theobald to malathion, permethrin, DDT and deltamethrin

Chemical insecticides are still considered as important control agents for malaria vector control. However, prolonged use of these chemicals may select mosquito vectors for resistance. In this study, susceptibility status of adult Anopheles maculatus collected from 9 localities in peninsular Malaysia, viz., Jeli, Temerloh, Pos Banun, Senderut, Jeram Kedah, Segamat, Kota Tinggi, Kluang and Pos Lenjang were determined using the standard WHO bioassay method in which the adult mosquitoes were exposed to standard insecticide impregnated papers malathion, permethrin, DDT and deltamethrin--at pre-determined diagnostic dosage. Deltamethrin was most effective insecticide among the four insecticides tested, with the LT50 of 29.53 min, compared to malathion (31.67 min), DDT (47.76 min) and permethrin (48.01 min). The effect of all insecticides on the laboratory strain was greater (with all insecticides demonstrated LT50 < 1 hour) than the field strains (deltamethrin 32.7, malathion 53.0, permethrin 62.0, DDT 67.4 min). An. maculatus exhibited low degree of resistance to all test insecticides, indicating that these chemical insecticides are still effective in the control of malaria vector.

Non-celiac gluten sensitivity: clinical relevance and recommendations for future research

BACKGROUND

There has been increasing interest in the entity of Non-Celiac Gluten Sensitivity (NCGS) in recent years; however, it still remains a controversial topic and its pathogenesis is not well understood. Celiac Disease, in contrast, is a well-studied condition that has become increasingly recognized as a prevalent condition arising from a heightened immunological response to gluten. Wheat allergy is an IgE-mediated condition capable of causing a variety of gastrointestinal symptoms. However, the number of patients who have neither celiac disease nor wheat allergy, but appear to derive benefit from a gluten-free diet, is also increasing substantially. The use of the term NCGS as a way of describing this condition has become increasingly prevalent in recent years.

PURPOSE

In this review, we will focus on gastrointestinal manifestations of NCGS and discuss the evidence for the condition and its putative pathogenesis. We will discuss areas of controversy and areas for potential future research.

Quality not quantity for transglutaminase antibody 2: the performance of an endomysial and tissue transglutaminase test in screening coeliac disease remains stable over time

National Institute of Clinical Excellence (NICE) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidance for the diagnosis of coeliac disease has been published. However, there is some controversy regarding the advice on the use of stratifying levels of immunoglobulin (IgA) tissue transglutaminase antibody (TG2) test positivity in the absence of test standardization and the vagueness of the indication to test equivocal samples. Using repeat service audit, we demonstrate that a combination of TG2 followed by IgA endomysial antibodies (EMA) is the best strategy for all degrees of mucosal abnormality using our test combination. Reliance upon immunoassay titre is not as effective, and cannot be applied consistently across populations in the absence of assay standardization. Guidelines advocating the use of tests should involve experts in laboratory diagnostics and external quality assurance to ensure that errors of generalization do not occur and that test performance is achievable in routine diagnostic use.

A prospective study into the aetiology of lymphocytic duodenosis

BACKGROUND

Lymphocytic duodenosis is defined by normal villous architecture and intraepithelial lymphocytes (IELs) >25 per 100 enterocytes. Such patients should not be diagnosed with coeliac disease, solely by histology, as previous retrospective studies have suggested other associations with lymphocytic duodenosis.

AIM

To study prospectively the aetiology of lymphocytic duodenosis.

METHODS

One hundred patients with lymphocytic duodenosis were investigated rigorously for coeliac disease and other known associations for lymphocytic duodenosis by initial investigations of coeliac serology, and exclusion of infection. Of 34 with no explanation for lymphocytic duodenosis, 29 underwent repeat duodenal biopsies following a gluten challenge.

RESULTS

Coeliac disease was present in 16% of patients with lymphocytic duodenosis. In the absence of a positive coeliac diagnosis, lymphocytic duodenosis was most commonly associated with drugs (21%), infection (19%), immune dysregulation (4%), inflammatory bowel disease (2%), microscopic colitis (2%), sarcoidosis (1%) and IgA deficiency (1%). Of 34 with no known associations, 18 had symptoms of irritable bowel syndrome (IBS), and in 29 patients investigated with repeat duodenal biopsies, the IEL count returned to normal in 22.

CONCLUSIONS

In 66% of cases of lymphocytic duodenosis, a known association can be found by further investigations; importantly, 16% will have coeliac disease. In those with no apparent cause, there may be an association with IBS and the IEL count becomes normal on repeat biopsy in 76%.

Investigation and management of chronic cough using a probability-based algorithm

Chronic cough is a common and distressing symptom. A novel algorithm has been developed for the management of chronic cough, in which an assessment of clinical probability of disease determines the need to proceed to investigation. In this study, the performance of this algorithm in clinical practice was prospectively evaluated. A total of 131 consecutively referred patients (86 females) whose principal presenting symptom was a cough of duration >8 weeks were studied. Their age (median (range)) was 60 (16-88) yrs and cough duration 5.9 (0.2-65) yrs. A cause of cough was established in 93% of cases. The most frequent diagnoses were asthma (24% of cases), gastro-oesophageal disease (22%), post-viral cough (8%), bronchiectasis (8%) and interstitial lung disease (8%). Primary pulmonary disease was significantly more likely in patients with a productive cough and in patients with an abnormal chest radiograph. Only a small proportion (<8%) of patients had multiple causes of cough. The probability of treatment started on the basis of a high clinical suspicion of either asthma, gastro-oesophageal disease or rhinitis being successful was 74%. Overall, 26% of the patients were managed successfully without the need for any form of investigation other than chest radiography and spirometry. Use of the algorithm resulted in identification of the cause of cough and successful treatment in the large majority of cases. It is concluded that this protocol has the potential to improve management by providing a structured approach, reducing the number of investigations performed, and minimising unnecessary delays in treatment.

Abnormal oesophageal motility in patients with chronic cough

BACKGROUND

Although gastro-oesophageal reflux is a recognised cause of chronic cough, the role of oesophageal dysmotility is unknown. The aim of this study was to determine the prevalence of abnormal oesophageal motility in a selected group of patients with chronic cough.

METHODS

Oesophageal manometry and 24 hour pH monitoring were performed in 43 patients with chronic cough, 34 of whom had symptoms suggestive of gastro-oesophageal reflux. Comparative manometric measurements were made in 21 healthy subjects.

RESULTS

Nine patients with chronic cough had normal manometry and 24 hour pH. Of the remaining 34 patients, 11 (32%) had abnormal manometry alone, five (15%) had abnormal 24 hour pH monitoring alone, and in 18 (53%) both tests were abnormal. Only one patient in the control group had manometric abnormalities.

CONCLUSIONS

These results point to a previously unrecognised high prevalence of abnormal oesophageal manometry in patients presenting with chronic cough. Oesophageal dysmotility may therefore be important in the pathogenesis of cough in these patients.

Cardiac morbidity and mortality following carotid endarterectomy: the importance of diabetes and multiple Eagle risk factors

The objectives of this study were to (1) determine cardiac morbidity and mortality in patients undergoing carotid endarterectomy (CEA) and (2) to determine whether any Eagle risk factors and/or the indication for CEA are associated with a higher risk of an adverse cardiac event. The records of 123 male patients who underwent CEA were retrospectively reviewed. The Eagle risk factors for adverse cardiac events, indications for CEA, and adverse cardiac events were recorded and analyzed. In males undergoing CEA, the presence of diabetes or multiple Eagle risk factors significantly increases the risk of an adverse postoperative cardiac event. There is no difference in cardiac event rate between symptomatic and asymptomatic CEA. Thus, asymptomatic CEA should be approached with caution in these higher cardiac risk patients.

Effects of once-daily formoterol and budesonide given alone or in combination on surrogate inflammatory markers in asthmatic adults

OBJECTIVES

We wished to evaluate the effects of once-daily combination therapy on surrogate inflammatory markers.

METHODS

Fifteen patients with atopic persistent asthma were evaluated (mean age, 32.4 years; FEV(1), 75.2% predicted) in a randomized, double-blind, double-dummy, placebo-controlled crossover study with a 1-week placebo washout period, comparing the following once-daily nighttime treatments: (1) formoterol (FM), 12 microg, for 2 weeks and FM, 24 microg, for 2 weeks; or (2) budesonide (BUD), 400 microg, for 2 weeks and BUD, 800 microg, for 2 weeks; or (3) FM, 12 microg, plus BUD, 400 microg, for 2 weeks and FM, 24 microg, plus BUD, 800 microg, for 2 weeks. Adenosine monophosphate (AMP) bronchial challenge, exhaled nitric oxide (NO), and serum eosinophilic cationic protein (ECP) were evaluated at 12 h postdosing after administration of each placebo and after 2 and 4 weeks of each treatment.

RESULTS

The results of AMP challenge (provocative concentration causing a 20% fall in FEV(1)) at 4 weeks showed significant (p<0.05) improvements after patients had received all active treatments compared to placebo (20 mg/mL), with FM plus BUD, 261 mg/mL, being superior (p<0.05) to FM alone, 82 mg/mL, but not to BUD, 201 mg/mL. NO and ECP showed significant (p<0.05) reductions compared to placebo with FM plus BUD or BUD alone but not with FM alone. Combination therapy was associated with optimal patient preference (rank order, FM plus BUD > FM > BUD; p<0.0005), highest domiciliary peak expiratory flow, and lowest rescue inhaler usage. All three treatments produced equivalent improvements in spirometry.

CONCLUSIONS

Patients preferred once-daily combination therapy, but this had no greater effect on inflammatory markers than therapy with BUD alone. FM alone had no anti-inflammatory activity but exhibited bronchoprotection. This emphasizes the importance of first optimizing anti-inflammatory control with inhaled corticosteroids before considering adding a regular long-acting beta(2)-agonist.

Effects of adding a leukotriene antagonist or a long-acting beta(2)-agonist in asthmatic patients with the glycine-16 beta(2)-adrenoceptor genotype

PURPOSE

In the United Kingdom, about 40% of patients with asthma are homozygous for the glycine-16 beta(2)-adrenoceptor polymorphism, which predisposes them to agonist-induced down-regulation and desensitization of the beta(2)-adrenoceptor. We assessed the effects of adding treatment with either a long-acting beta(2)-agonist (inhaled formoterol, 12 microg twice daily) or a leukotriene receptor antagonist (oral zafirlukast, 20 mg twice daily) to inhaled corticosteroid therapy in patients with this genotype.

SUBJECTS AND METHODS

We enrolled 24 patients with mild to moderate asthma who were being treated with inhaled corticosteroids. Patients were randomly assigned to receive one of three treatments (placebo, zafirlukast, or formoterol in addition to inhaled corticosteroids) for 1 week each in a crossover fashion, separated by a 1-week placebo run-in and washout period. Measurements of bronchoprotection (measured as the provocative dose of methacholine that produced a 20% decline in forced expiratory volume in 1 second [FEV(1)]), exhaled nitric oxide (a surrogate marker of airway inflammation), and symptoms were made before each treatment and 12 hours after the last dose of each treatment.

RESULTS

Both formoterol and zafirlukast were equally effective in maintaining asthma control compared with placebo: the geometric mean-fold difference in the methacholine provocative dose was 1.5-fold (95% confidence interval [CI]: 1.1- to 2.2-fold) for zafirlukast and 1.9-fold (95% CI: 1.2- to 2.9-fold) for formoterol. As compared with placebo, zafirlukast caused a significant suppression in exhaled nitric oxide (1.7-fold difference in geometric mean values, 95% CI: 1.1- to 2.6-fold) but formoterol did not (1.2-fold difference, 95% CI: 0.8- to 1.9-fold). Diary cards showed significant (P <0.05) improvements in the peak flow with formoterol (morning and evening) and zafirlukast (evening) as compared with placebo.

CONCLUSIONS

Formoterol and zafirlukast maintained asthma control in patients who might be genetically predisposed to fare worse with long-acting beta(2)-agonists. The reduction in exhaled nitric oxide with zafirlukast suggests that it may have anti-inflammatory effects in addition to those seen with inhaled corticosteroids.

Functional antagonism with formoterol and salmeterol in asthmatic patients expressing the homozygous glycine-16 beta(2)-adrenoceptor polymorphism

BACKGROUND

Formoterol and salmeterol differ in their relative intrinsic activity at airway beta(2)-adrenoceptors, with formoterol being a full agonist. The homozygous glycine-16 polymorphism of the beta(2)-adrenoceptor occurs in approximately 40% of patients and is known to predispose to agonist-induced downregulation and desensitization.

OBJECTIVES

To evaluate possible differences in intrinsic beta(2)-adrenoceptor agonist activity between salmeterol and formoterol in terms of their functional antagonism against methacholine-induced bronchoconstriction (the primary end point) in genetically susceptible patients who exhibited the homozygous glycine-16 polymorphism.

METHODS

Eighteen patients with mild-to-moderate persistent asthma receiving inhaled corticosteroid who expressed the homozygous glycine-16 genotype were randomized to completion (mean [SEM] age, 35.8 [3.2] years; mean FEV(1), 76.9 [2. 5]% predicted). Patients received three different treatments for 1 week in randomized, double-blind, crossover fashion, with a 1-week washout period between treatments: formoterol, 12 microg bid; salmeterol, 50 microg bid; and placebo. For each of the randomized treatment periods, there were three separate methacholine challenges: baseline after washout, 12 h after the first dose, and 12 h after the last dose.

RESULTS

Both salmeterol and formoterol exhibited significantly (p < 0.05) greater bronchoprotection than placebo for their effects after single or repeated dosing, although there was no significant difference between the two drugs. The geometric mean fold protection vs placebo (95% confidence interval [CI]) for the first dose was 1.6-fold (95% CI, 1.1 to 2.2) for salmeterol and 1.9-fold (95% CI, 1.1 to 3.2) for formoterol, and for last dose was 1.6-fold (95% CI, 1.2 to 2.3) for salmeterol and 1. 9-fold (95% CI, 1.2 to 2.8) for formoterol. Salmeterol and formoterol produced significant (p < 0.05) increases in FEV(1) and forced expiratory flow after 25 to 75% of vital capacity has been expelled, after the first but not the last dose compared to placebo, while there were significant (p < 0.05) improvements in domiciliary peak flows during treatment with both drugs.

CONCLUSION

Our results showed no difference between formoterol and salmeterol in the degree of functional antagonism against methacholine-induced bronchoconstriction at the end of a 12-h dosing interval in patients who expressed the homozygous glycine-16 genotype. There was a significant residual degree of bronchoprotection after 1 week of treatment, which was not significantly different compared to the first-dose effect.

Bronchodilator response to albuterol after regular formoterol and effects of acute corticosteroid administration

BACKGROUND

There is controversy about the development of bronchodilator subsensitivity after regular administration of long-acting beta(2)-agonists.

OBJECTIVES

The purpose of the study was to evaluate whether regular treatment with formoterol affects the bronchodilator response to repeated puffs of albuterol, and also to assess the effects of acute administration of a bolus dose of IV or inhaled corticosteroid.

MATERIALS AND METHODS

Twelve patients (mean [SD] age, 43 [15] years; FEV(1), 57 [17] % predicted) with stable, moderate to severe persistent asthma who were all taking inhaled corticosteroids were evaluated in a randomized, placebo-controlled, double-blind, double-dummy, crossover study. Patients received treatments each for 2 weeks followed by a bolus (IV/inhaled) of corticosteroid or placebo: (1) placebo inhaler bid + bolus placebo; (2) formoterol Turbuhaler 24 microg metered dosage bid (delivered dosage 18 microg bid) + placebo; (3) formoterol 24 microg bid + bolus IV hydrocortisone, 200 mg; or (4) formoterol 24 microg bid + bolus inhaled budesonide, 1,600 microg. Bronchodilator response to repeated puffs of albuterol (200 to 1,600 microg) for > 80 min was measured at 2 h after bolus administration of placebo or corticosteroid. The study was powered at the 80% level to detect a 20% difference in area under curve between 20 and 80 min (AUC) for FEV(1) response to albuterol as change from baseline (primary end point).

RESULTS

There was significant subsensitivity (p = 0.01) of the mean albuterol FEV(1) response (as AUC, L x s) after formoterol alone (737) as compared to placebo (1,453) along with partial reversal by steroid administration: formoterol + hydrocortisone (1, 050), and formoterol + budesonide (942). There was a similar pattern of subsensitivity (p = 0.03) for the mean albuterol forced expiratory flow between 25% and 75% of vital capacity response (as AUC, L): placebo (2,149), formoterol alone (1,002), formoterol + hydrocortisone (1,402), and formoterol + budesonide (1,271).

CONCLUSION

Regular treatment with formoterol produced significant bronchodilator subsensitivity to repeated puffs of albuterol, which was partially reversed by a bolus dose of systemic or inhaled corticosteroid.

Determinants of survival after inferior vena cava trauma

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Comparative trough effects of formoterol and salmeterol on lymphocyte beta2-adrenoceptor--regulation and bronchodilatation

OBJECTIVES

The primary aim of the present study was to evaluate comparative trough effects of formoterol and salmeterol on beta2-adrenoceptor regulation and bronchodilator response after regular twice-daily treatment, with a secondary aim to evaluate any possible association with beta2-adrenoceptor polymorphism.

METHODS

Sixteen asthmatic subjects, with mean (SD) age 33(9) years, all taking inhaled corticosteroids and with a forced expiratory volume in 1 s (FEV1) of 81(12)% predicted were recruited to take part in a randomised single-blind, three-way cross-over study. The subjects received three treatments each for 1 week, with 1-week washout periods in between: (1) formoterol dry powder, 12 microg twice daily, (2) salmeterol dry powder, 50 microg twice daily, or (3) placebo, twice daily. Spirometry and lymphocyte beta2-adrenoceptor parameters were measured before the first dose and 12 h after the last dose of each treatment, as well as domiciliary peak flow during each treatment.

RESULTS

There were no differences in beta2-adrenoceptor density (Bmax) between the three treatments prior to the first dose; whereas, after the last dose, Bmax was lower with both active treatments than with placebo, but was significant for salmeterol only--a 1.2-fold geometric mean fold difference (95% CI 1- to 1.4-fold), P = 0.04. Compared with placebo, there were n = 9 of 16 subjects with salmeterol and n = 6 of 16 with formoterol who had a greater than 15% fall in Bmax. Post-hoc trend analysis of polymorphism showed that the propensity for downregulation appeared to be related to the occurrence of an allelic substitution of glycine at codon 16-8 of 13 for salmeterol versus 5 of 13 for formoterol with a greater than 15% fall compared with placebo. There were no significant differences between salmeterol and formoterol in terms of mean or individual values for downregulation. There was evidence of persistent bronchodilator activity with both active treatments compared with placebo; this was significant for forced expiratory flow rate between 25% and 75% of vital capacity (FEF25-75)--the mean difference versus salmeterol was 0.39 1/s (95% CI 0.06-0.70), P = 0.02, and versus formoterol was 0.35 1/s (95% CI 0.16-0.53), P = 0.001. These effects were mirrored by significant improvements in morning peak flow rate compared with placebo--mean difference versus salmeterol was 24 1/min (95% CI 7-42), P = 0.01, and versus formoterol was 36 1/min (95% CI 25-48), P < 0.0001.

CONCLUSION

There were no differences between regular treatment with formoterol and salmeterol in their effects on lymphocyte beta2-adrenoceptor regulation at the end of a 12-h dosing interval, with both drugs exhibiting a residual degree of bronchodilator activity at the same time point. Further studies to evaluate receptor regulation and bronchodilator response are required in susceptible patients who have the homozygous glycine-16 polymorphism.

In vivo effect of albuterol on methacholine-contracted bronchi in conjunction with salmeterol and formoterol

BACKGROUND

It has been shown in vitro that prior treatment with salmeterol and formoterol antagonizes the relaxant effect of albuterol in carbachol-contracted human bronchi.

OBJECTIVES

The primary aim of this study was to evaluate whether there is a potential in vivo interaction between long- and short-acting beta2-agonists in the presence of increased airway tone induced by methacholine. In addition, a post hoc analysis was made to evaluate the effects of beta2-adrenoceptor polymorphisms.

METHODS

Sixteen asthmatic subjects (mean age [+/-SD], 39 [13] years; FEV1, 81% [17%] of predicted value), all taking inhaled corticosteroids and having methacholine PD20 values of less than 500 micrograms, were randomized in double-blind, double-dummy, cross-over fashion to receive single doses of inhaled placebo, inhaled formoterol 12 micrograms, or inhaled salmeterol 50 micrograms followed 12 hours later by a single dose of inhaled albuterol 400 micrograms (low dose) or 1600 micrograms (high dose). Methacholine challenges were performed on each of 6 separate occasions 1 hour after albuterol.

RESULTS

There was a greater numerical difference in geometric mean PD20 values between low- and high-dose albuterol after placebo dosing (671 micrograms vs 1080 micrograms, a 1.61-fold difference; P <.05) compared with low- and high-dose albuterol after formoterol dosing (660 micrograms vs 799 micrograms, a 1. 21-fold difference; P =.4), or after salmeterol dosing (568 micrograms vs 847 micrograms, a 1.49-fold difference; P =.055). PD20 values with high-dose albuterol in combination with formoterol or salmeterol were numerically lower than those found with high-dose albuterol in combination with placebo, but they were not significantly different. There was a significant difference between PD20 values with low-dose albuterol after dosing with formoterol (PD20 = 660 micrograms, a 1. 6-fold difference; P <.05) or with salmeterol (PD20 = 568 micrograms, a 1.9-fold difference; P <.05) compared with PD20 with high-dose albuterol after placebo dosing (PD20 = 1080 micrograms). Post hoc polymorphism analysis for pooled pretreatment with formoterol and salmeterol (excluding placebo pretreatment) showed significantly (P <.05) lower PD20 values with homozygous glycine-16 compared with heterozygous glycine/arginine-16 and significantly (P <.05) lower PD20 values with homozygous glutamate-27 compared with either heterozygous glutamate/glutamine-27 or homozygous glutamine-27.

CONCLUSION

Compared with placebo, both salmeterol and formoterol caused a significant degree of antagonism of albuterol-induced bronchorelaxation in methacholine-contracted bronchi in vivo. This interaction could be caused by prolonged occupancy of airway beta2-adrenoceptors by long-acting beta2-agonists or by early tachyphylaxis 12 hours after a single-dose exposure. The degree of albuterol protection was also related to beta2-adrenoceptor polymorphism.

Beta2-adrenoceptor polymorphism and bronchoprotective sensitivity with regular short- and long-acting beta2-agonist therapy

The aim of the present study was to investigate bronchoprotective sensitivity in patients receiving regular treatment with short- and long-acting beta2-agonists and to evaluate any possible association with genetic polymorphism. Thirty-eight patients with stable mild to moderate asthma and receiving inhaled corticosteroids were randomized in a parallel group, double-blind, double-dummy fashion to receive 2 weeks of treatment with either formoterol (12 microg once daily, 6 microg twice daily or 24 microg twice daily) or terbutaline (500 microg four times daily). Bronchoprotection against methacholine challenge (as a provocative dose to produce a 20% fall in forced expiratory volume in 1.0 s: PD20) was measured at baseline (unprotected) after an initial 1 week run-in without beta2-agonist, and at 1 h after the first and last doses of each treatment. The PD20 values were log-transformed and calculated as change from baseline. Percentage desensitization of log PD20 for first- versus last-dose bronchoprotection was calculated and analysed according to effects of treatment and beta2-adrenoceptor polymorphism at codon 16 or 27. The mean degree of desensitization for bronchoprotection was comparable with all four treatments and there were no significant differences in absolute PD20 values after 2 weeks of chronic dosing. The PD20 values were (as microg of methacholine, geometric means+/-S. E.M.): formoterol, 12 microg once daily, 99+/-42 microg; formoterol, 6 microg twice daily, 107+/-44 microg; formoterol, 24 microg twice daily, 108+/-45 microg; terbutaline, 500 microg four times daily, 88+/-37 microg. All patients receiving formoterol, 24 microg twice daily, exhibited a loss of protection greater than 30% which was unrelated to polymorphism at codon 16 or 27. For codon 16, the use of lower doses of formoterol (12 microg once daily or 6 microg twice daily) showed wider variability in the propensity for protection loss in patients who were heterozygous, in contrast to a more uniform protection loss seen with homozygous glycine patients. The amount of protection loss was not significantly related to polymorphism at codon 16 or 27, expressed as values (mean+/-S.E.M.) for percentage desensitization according to each genotype (pooled treatments): Gly-16, 66+/-11%; Het-16, 53+/-8%; Arg-16, 69+/-18%; Glu-27, 68+/-12%; Het-27, 58+/-8%; Gln-27, 52+/-12%. The results of this preliminary study showed that bronchoprotective desensitization occurred readily in response to short- or long-acting beta2-agonist exposure irrespective of beta2-adrenoceptor polymorphism at codon 16 or 27. Further studies with larger patient numbers are required to further evaluate the effects of polymorphisms with lower doses of regular formoterol.

A bolus of inhaled budesonide rapidly reverses airway subsensitivity and beta2-adrenoceptor down-regulation after regular inhaled formoterol

BACKGROUND

Subsensitivity of airway beta2-adrenoceptors develops readily in asthmatics receiving regular long-acting beta2-agonists. This subsensitivity may be rapidly reversed by using systemic corticosteroids. The purpose of the present study was to investigate whether the same acute facilitatory effects occur when using a bolus dose of inhaled corticosteroid.

METHODS

Ten subjects with stable mild-to-moderate asthma, with a mean age of 27 years, mean (+/- SD) FEV1 of 2.95 L (0.94 L), 81% (15%) of predicted, all receiving inhaled corticosteroids, reactive to adenosine monophosphate (AMP) with a provocative concentration producing a 20% fall in FEV1 (PC20) < 200 mg/mL, were recruited into a randomized double-blind crossover study. The subjects received two separate 1-week treatment periods with formoterol dry powder, 24 microg bid, with an initial 1-week run-in and a 1-week washout period between the treatments. A single dose of placebo or budesonide turbuhaler, 1,600 microg, was taken in conjunction with the last dose of both treatment periods. AMP challenge was performed 2 h after the first and last dose of formoterol. Blood for lymphocyte beta2-adrenoceptor density (Bmax) was also measured before and after treatment with formoterol.

RESULTS

There was no significant difference in the geometric mean PC20 after the first dose of formoterol comparing the two treatment periods: 362 mg/mL vs 391 mg/mL. The PC20 after the last dose of formoterol was significantly higher (p < 0.05) in conjunction with budesonide than with placebo: 427 mg/mL vs 99 mg/mL, amounting to a 4.3-fold difference (95% confidence interval [CI], 1.1 to 16.6). For comparison within each treatment period, there was significant subsensitivity (p < 0.05) between the first and last dose of formoterol when the latter was given with placebo: 391 mg/mL vs 99 mg/mL, a 3.9-fold fall (95% CI, 1.0 to 15.2), but not when the latter was given with budesonide: 362 mg/mL vs 427 mg/mL, a 1.2-fold rise (95% CI, 0.5 to 2.8). Lymphocyte 02-adrenoceptor density (geometric mean Bmax: fmol/10(6) cells) also showed significant down-regulation (p < 0.05) by formoterol given with placebo: preformoterol 2.53 vs postformoterol 1.91, but not by formoterol given with budesonide: preformoterol 2.43 vs postformoterol 2.67. The Bmax was significantly higher (p < 0.05) with formoterol + budesonide as compared to formoterol + placebo, amounting to a 1.40-fold difference (95% CI, 1.09 to 1.80).

CONCLUSION

We have shown that a bolus dose of inhaled budesonide rapidly reverses subsensitivity to AMP bronchoprotection and associated beta2-adrenoceptor down-regulation in asthmatics taking regular formoterol. Further studies are indicated to assess whether high-dose inhaled corticosteroids should be administered as soon as possible along with beta2-agonists during an acute episode of bronchoconstriction.

Effects of genetic polymorphism on ex vivo and in vivo function of beta2-adrenoceptors in asthmatic patients

BACKGROUND

Genetic polymorphism determines agonist-induced down-regulation and desensitization of beta2-adrenoceptors.

OBJECTIVES

The aim of the present study was to investigate the effects of genetic polymorphism on ex vivo (lymphocytes) and in vivo (bronchoprotection) function of beta2-adrenoceptors in asthmatic patients, having been washed out of previous beta2-agonist exposure.

METHODS

Sixty patients with stable mild-to-moderate asthma were evaluated, with a post hoc analysis of genotype performed at end of study. Having withheld treatment with long-acting beta2-agonists for > or = 48 h and short-acting beta2-agonists for > or = 12 h, measurements of lymphocyte beta2-adrenoceptors were made for binding density, binding affinity, basal cyclic adenosine monophosphate (cAMP), and maximal cAMP response to isoproterenol (Emax). In addition, in 48 of these patients who were methacholine responsive (PD20 < 1,000 microg), the acute protective effect of formoterol as a 24-microg single dose (at 1 h) was also evaluated. Comparisons were made according to homozygous and heterozygous (Het) polymorphisms at codon 16 and codon 27.

RESULTS

There were no significant differences in age, FEV1 percent predicted, or inhaled corticosteroid dose, when comparing mean values for polymorphisms at either codon-16 or codon 27. There were also no significant differences between polymorphisms for any of the measured lymphocyte beta2-adrenoceptor parameters apart from basal cAMP between Glu-27 and Het-27. Mean values for Emax (after-before isoproterenol as pmol/10(6) cells) were as follows: Gly-16 (3.4), Arg-16 (3.5), Het-16 (4.0), Glu-27 (3.9), Gln-27 (3.5), and Het-27 (3.7). Polylorphism had no significant effect on formoterol protection as doubling dose shift in methacholine PD20 (geometric mean): Gly-16 (5.3), Arg-16 (5.4), Het-16 (4.6), Glu-27 (5.3), Gln-27 (5.3), Het-27 (4.5).

CONCLUSIONS

Our results show that genetic polymorphism at codon 16 or 27 does not influence stimulated coupling of lymphocyte beta2-adrenoceptors and similarly did not influence the degree of functional antagonism exhibited by formoterol. Thus, a single dose of beta2-agonist when used on demand affords equal protection against bronchoprotection regardless of genetic polymorphism.

A high dose of albuterol does not overcome bronchoprotective subsensitivity in asthmatic subjects receiving regular salmeterol or formoterol

BACKGROUND

Regular treatment with inhaled, long-acting beta2 -agonists is associated with subsensitivity for bronchoprotective effects. It is not known whether a high dose of short-acting beta2 -agonist could overcome this subsensitivity.

OBJECTIVES

The objective of this study was to investigate the acute effects of a high dose of inhaled albuterol on methacholine-induced bronchoconstriction in patients receiving regular treatment with salmeterol or formoterol.

METHODS

Ten stable asthmatic subjects (mean age, 34 years; FEV1, 77% of predicted value), all taking inhaled corticosteroids (methacholine PD20 < 500 microg), were recruited into a randomized, single-blind, crossover study. After an initial 1-week run-in period, subjects underwent 3 separate treatment periods each of 9 days (separated by a washout of at least 5 days) comprising inhaled placebo twice daily, inhaled salmeterol dry powder 50 microg twice daily, or inhaled formoterol dry powder 12 microg twice daily. Methacholine challenge was performed 1 hour after the first dose and after 7 days of treatment. After 9 days of treatment, a third methacholine challenge was performed 1 hour after inhalation of a single 1600 microg dose of albuterol dry powder.

RESULTS

There was significant (P <.001) improvement in geometric mean PD20 after the first dose of active treatment as compared with placebo (78 microg) versus salmeterol (266 microg, a 3.4-fold difference [95% CI 1.9 to 6.1]) and versus formoterol (318 microg, a 4.1-fold difference [95% CI 2.3 to 7.3]). This bronchoprotection diminished with regular treatment, although it remained significant (P <.01) compared with placebo (68 microg) versus salmeterol (144 microg, a 2.1-fold difference [95% CI 1.2 to 3.8]) and versus formoterol (230 microg, 3.4-fold difference [95% CI 1.9 to 6.2]). After 9 days, the protection afforded by a single dose of albuterol after placebo pretreatment (889 microg) was significantly (P =.005) higher in comparison with albuterol protection after salmeterol pretreatment (338 microg, a 2.7-fold difference [95% CI 1.1 to 6.8]) and after formoterol pretreatment (247 microg, a 3.6-fold difference [95% 1.4 to 9.1]).

CONCLUSIONS

Thus in stable asthmatic subjects receiving regular salmeterol or formoterol, bronchoprotective subsensitivity was not overcome by administering a high dose of albuterol. Further studies are required to evaluate the clinical relevance of this pharmacologic phenomenon when albuterol is used in acute asthma.

Subsensitivity to bronchoprotection against adenosine monophosphate challenge following regular once-daily formoterol

Regular treatment with inhaled long-acting beta2-agonists leads to subsensitivity to their bronchoprotective effects, although the effect of dosing frequency on this subsensitivity is not known. The aim of this study was to assess whether a once-daily dosing regimen with formoterol might be associated with a lesser degree of subsensitivity. In a randomized placebo-controlled double-blind, double-dummy crossover study 10 asthmatics treated with inhaled steroids (mean age 31 yrs, forced expiratory volume in one second (FEV1) 82% predicted) received 1 week of treatment with: formoterol dry powder 24 microg twice daily (08:00 and 20:00 h); formoterol 24 microg once daily (20:00 h); or identical placebo. Adenosine monophosphate (AMP) bronchial challenge was performed 12 h after the first and the last dose of each treatment. There was significant loss of protection with formoterol twice daily between the first and last dose (geometric mean provocative concentration causing a 20% fall in FEV1 (PC20)): 475 versus 129 mg x mL(-1) (a 3.7-fold loss, p=0.006) and with formoterol once daily: 367 versus 127 mg x mL(-1) (a 2.9-fold loss, p=0.005), compared with placebo: 71 versus 75 mg x ml(-1) (nonsignificant). There was no significant difference in the degree of loss of protection between formoterol once and twice daily. For first-dose protection there was a significant difference between active treatments and placebo, but after the last dose the residual protection between active treatments and placebo was not significant. Thus, in patients taking inhaled corticosteroids, regular formoterol 24 micreog once daily induces a similar degree of subsensitivity to adenosine monophosphate bronchial challenge as with formoterol 24 microg twice daily. This in turn suggests that even with a 24-h dosing interval there is the development of tolerance to formoterol by prolonged occupancy of airway beta2-adrenoceptors.