Perioperative analgesic efficacy of lumbar erector spinae plane block in dogs undergoing hemilaminectomy: a randomized blinded clinical trial

OBJECTIVE

To evaluate the perioperative analgesic effect of the unilateral lumbar erector spinae plane block (ESPBL) in dogs undergoing hemilaminectomy.

STUDY DESIGN

Randomized, blinded clinical study.

ANIMALS

A total of 30 client-owned dogs undergoing thoracolumbar or lumbar hemilaminectomy for intervertebral disc extrusion (IVDE).

METHODS

Dogs were randomly assigned to receive a unilateral ESPBL, performed either with 0.4 mL kg-1 ropivacaine 0.5% [group ROPI (n = 15)] or with saline solution [CNT group (n = 15)]. Dogs were premedicated intravenously (IV) with acepromazine 5 μg kg-1 and methadone 0.2 mg kg-1, general anaesthesia was induced by administering IV midazolam 0.2 mg kg-1 and propofol to effect and maintained with isoflurane. Fentanyl was administered as rescue analgesia. Bradycardia [heart rate (HR) < 60 beats minute-1] with hypotension was treated with atropine IV. The Short-Form of the Glasgow Composite Pain Scale was used pre- and postoperatively at 1, 2, 4, 8, 12, 16, 20 and 24 hours after extubation, and methadone 0.2 mg kg-1 was administered IV when pain score was ≥ 5/20. HR and end-tidal concentration of isoflurane (Fe'Iso) were compared between groups with anova combined with a Dunnet's post hoc test. Time to the first rescue methadone and total dose of fentanyl (FENtot, μg kg-1 hour-1) and methadone (METtot, mg kg-1) in the first 24 postoperative hours were compared using unpaired Student's t test. Postoperative pain scores were compared with the Mann-Whitney test and atropine administration with a Fisher's exact test; p < 0.05.

RESULTS

HR, Fe'Iso, FENtot, METtot and atropine administration were significantly lower in group ROPI compared to CNT. Postoperative analgesic effect was significantly longer, and pain scores were significantly lower in group ROPI for all time points.

CONCLUSIONS AND CLINICAL RELEVANCE

Unilateral ESPBL with ropivacaine reduced perioperative opioid consumption and the occurrence of bradycardia in dogs undergoing hemilaminectomy.

VNS improves VSMC metabolism and arteriogenesis in infarcted hearts through m/n-AChR-Akt-SDF-1α in adult male rats

Vagal nerve stimulation (VNS) provides a novel therapeutic strategy for injured hearts by activating cholinergic anti-inflammatory pathways. However, little information is available on the metabolic pattern and arteriogenesis of VSMCs after MI. VNS has been shown to stimulate the expression of CPT1α, CPT1β, Glut1, Glut4 and SDF-1α in coronary VSMCs, decreasing the number of CD68-positive macrophages while increasing CD206-positive macrophages in the infarcted hearts, leading to a decrease in TNF-α and IL-1β accompanied by a reduced ratio of CD68- and CD206-positive cells, which were dramatically abolished by atropine and mecamylamine in vivo. Knockdown of SDF-1α substantially abrogated the effect of VNS on macrophagecell alteration and inflammatory factors in infarcted hearts. Mechanistically, ACh induced SDF-1α expression in VSMCs in a dose-dependent manner. Conversely, atropine, mecamylamine, and a PI3K/Akt inhibitor completely eliminated the effect of ACh on SDF-1α expression. Functionally, VNS promoted arteriogenesis and improved left ventricular performance, which could be abolished by Ad-shSDF-1α. Thus, VNS altered the VSMC metabolism pattern and arteriogenesis to repair the infarcted heart by inducing SDF-1α expression, which was associated with the m/nAChR-Akt signaling pathway.

Cholinergic signaling of muscarinic receptors directly involves in the neuroprotection of muscone by inducing Ca2+ antagonism and maintaining mitochondrial function

ETHNOPHARMACOLOGICAL RELEVANCE

Musk, a traditional Chinese medicine, is broadly used in inducing resuscitation and refreshing the mind, activating blood and alleviating pain. It is commonly used for the treatment of ischemic stroke, and muscone is its core medicinal component.

AIM OF THE STUDY

The aim of this study was to explore whether muscone ameliorates neuronal damage through cholinergic signaling of muscarinic receptors.

MATERIALS AND METHODS

The effects of muscone were tested in a rat model of middle cerebral artery occlusion (MCAO) as well as injured neurons induced by oxygen-glucose deprivation (OGD) in PC12 cells. Cell counting kit 8 (CCK8) assay was used to measure the cell viability, and the production of lactate dehydrogenase (LDH) and adenosine-triphosphate (ATP) were examined by kit. 2',7'-Dichlorodihydrofluorescein diacetate (DCFH-DA), tetramethylrhodamine ethyl ester (TMRE) and Fluo-4 acetoxymethyl ester (Fluo-4 AM) staining were used to demonstrate effect of muscone on the reactive oxygen species (ROS) level, mitochondria membrane potential (MMP) and intracellular Ca2+ measurement in cells respectively, in which all of those staining was visualized by laser confocal microscope. For in vivo experiments, rats' cerebral blood flow was measured using laser Doppler blood flowmetry to evaluate the MCAO model, and a modified neurological severity score (mNSS) was used to assess the recovery of neurological function. Calculate infarct rate was measured by 2,3,5-Triphenyl Tetrazolium Chloride (TTC) staining. Except DCFH-DA and Fluo-4 AM staining, 5,5',6,6'-tetrachloro-1,1',3,3'-tetraethyl benzimidazolylcarbocyanine iodide (JC-1) staining was used to observe intracellular Ca2+ measurement in brain cells. Protein levels in cells and tissues were detected by Western blot.

RESULTS

Pretreatment with muscone significantly improved the cell viability, lactic acid production, mitochondrial membrane potential collapse and function, Ca2+ overload, ROS generation, and cell apoptosis in OGD PC12 cells. Muscone also regulated PI3K, ERK and AKT signal pathways by activating cholinergic signaling of muscarinic receptors in PC12 cells induced with OGD. More importantly, the blocking of cholinergic signaling of muscarinic receptors by atropine significantly reduces the neuroprotective effects of muscone, including the cell viability, Ca2+ efflux, and mitochondrial repair. Furthermore, muscone was found to effectively alleviate mitochondrial dysfunction and elevated levels of ROS induced by the MCAO in the brain tissue. Notably, this beneficial effect of muscone was attenuated by atropine but not by (+)-Sparteine.

CONCLUSIONS

Our study indicates that muscone exerts its neuroprotective effects by activating muscarinic receptors of cholinergic signaling, thus providing a promising therapeutic target for the treatment of OGD-induced nerve injury in stroke. The findings suggest that these treatments may hold potential benefits for stroke patients.

Meglumine cyclic adenylate improves cardiovascular hemodynamics and motor-function in a rat model of acute T4 thoracic spinal cord injury

STUDY DESIGN

Animal experimental study.

OBJECTIVES

Spinal cord injury (SCI) at or above the T6 level causes cardiovascular dysfunction. Maintaining cAMP levels with cAMP analogs can facilitate neurological recovery. In the present study, the effects of meglumine cyclic adenylate (MCA), a cAMP analog and approved cardiovascular drug, on cardiovascular and neurological recovery in acute T4-SCI in rats were investigated.

SETTING

Hospital in Kunming, China.

METHODS

Eighty rats were randomly allocated to five groups, and groups A-D received SCI: (A) a group administered MCA at 2 mg/kg/d iv qd, (B) a group administered dopamine at 2.5 to 5 μg/kg/min iv to maintain mean arterial pressure above 85 mm Hg, (C) a group administered atropine at 1 mg/kg iv bid, (D) a group receiving an equal volume of saline iv qd for 3 weeks after SCI and (E) a group undergoing laminectomy only. The cardiovascular and behavioral parameters of the rats were examined, and spinal cord tissues were processed for hematoxylin and eosin staining, Nissl staining, electron microscopy, and analysis of cAMP levels.

RESULTS

Compared with dopamine or atropine, MCA significantly reversed the decrease in cAMP levels in both myocardial cells and the injured spinal cord; improved hypotension, bradycardia and behavioral parameters at 6 weeks; and improved spinal cord blood flow and histological structure at 7 days post-SCI. The regression analysis suggested spinal cord motor-function improved as decreased heart rate and mean arterial pressure were stopped post-SCI.

CONCLUSIONS

MCA may be an effective treatment for acute SCI by sustaining cAMP-dependent reparative processes and improving post-SCI cardiovascular dysfunction.

SPONSORSHIP

N/A.

Real-world safety and supportive care use of second-line 5-fluorouracil-based regimens among patients with metastatic pancreatic ductal adenocarcinoma

OBJECTIVE

Chemotherapy-related adverse events (AEs) can negatively impact the care of patients. The prevention and management of AEs often require additional medications. This study evaluated the percentages of patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) undergoing second-line therapy with 5-fluorouracil (5-FU)-based regimens that experienced AEs during treatment and received medication to manage those AEs.

METHODS

We conducted a retrospective observational analysis utilizing the Flatiron Health database of adult patients with mPDAC who started second-line therapy between January 2016 and August 2020. The occurrence of diarrhea, fatigue, nausea and vomiting, neuropathy, and hematologic AEs including G3/G4 anemia, neutropenia, and thrombocytopenia was assessed. The use of concomitant medications including atropine and granulocyte colony stimulating factor (G-CSF) was assessed.

RESULTS

Of the 825 eligible patients, 29.0% (n = 239) received FOLFIRINOX, 24.0% (n = 198) received FOLFOX, 6.8% (n = 56) received FOLFIRI, and 40.2% (n = 332) received liposomal irinotecan-based regimens. FOLFIRI and FOLFIRINOX regimens were associated with the highest rates of anemia (16.1% and 15.5%), neutropenia (19.6% and 22.6%), and thrombocytopenia (14.3% and 9.6%). The liposomal irinotecan and FOLFOX regimens were associated with lower rates of anemia (11.8% and 12.1%), neutropenia (12.4% and 14.7%), and thrombocytopenia (2.4% and 8.1%). G-CSF use was observed among 63.6%, 34.9%, 33.9%, and 44.9% of patients treated with FOLFIRINOX, FOLFOX, FOLFIRI, and liposomal irinotecan-based regimens, respectively. Diarrhea was observed among 12.5%, 4.5%, 12.5%, and 10.2% of patients who were treated with FOLFIRINOX, FOLFOX, FOLFIRI, and liposomal irinotecan-based regimens, respectively. Nausea and vomiting occurred in 14.9%, 12.6%, 10.5%, and 13.1% of patients treated with FOLFIRINOX, FOLFOX, FOLFIRI, and liposomal irinotecan-based regimens, respectively. Atropine use was higher in patients treated with FOLFIRINOX and FOLFIRI (90.8% and 94.6%, respectively) than in patients treated with liposomal irinotecan-based regimens (75.6%).

CONCLUSIONS

In patients with mPDAC who received second-line therapy, those who received liposomal irinotecan-based regimens had the lowest rates of anemia, neutropenia, and thrombocytopenia compared to FOLFIRI, FOLFIRINOX, and FOLFOX, while requiring a similar or lower level of medication to treat and manage those adverse events. Patients treated with FOLFIRI received the highest dose of pegfilgrastim to manage neutropenia. The results of this real-world analysis are consistent with prior evaluations of patients with mPDAC and highlight the importance of managing adverse events and associated cost implications.

Antihypertensive Activity in High Salt-Induced Hypertensive Rats and LC-MS/MS-Based Phytochemical Profiling of Melia azedarach L. (Meliaceae) Leaves

Melia azedarach L. leaves have been traditionally used but not scientifically evaluated for antihypertensive activity. The focus of the present work was to carry out the detailed phytochemical profiling and antihypertensive potential of methanolic extract and subsequent fractions of this plant. The tandem mass spectrometry-based phytochemical profiling of M. azedarach extract (Ma.Cr) and fractions was determined in negative ionization mode while molecular networking was executed using the Global Natural Product Social (GNPS) molecular networking platform. This study resulted in the identification of 29 compounds including flavonoid O-glycosides, simple flavonoids, triterpenoidal saponins, and cardenolides as the major constituents. Ma.Cr at the concentration of 300 mg/kg resulted in a fall in blood pressure (BP), i.e., 81.44 ± 2.1 mmHg in high salt-induced hypertensive rats in vivo, in comparison to normotensive group, i.e., 65.36 ± 1.8 mmHg at the same dose. A decrease in blood pressure was observed in anaesthetized normotensive and hypertensive rats treated with extract and various fractions of M. azedarach. A reasonable activity was observed for all fractions except the aqueous fraction. The highest efficacy was shown by the ethyl acetate fraction, i.e., 77.06 ± 3.77 mmHg in normotensive and 88.96 ± 1.3 mmHg in hypertensive anaesthetized rats. Ma.Cr and fractions showed comparatively better efficacy towards hypertensive rats as compared to rats with normal blood pressure. Blood pressure-lowering effects did not change upon prior incubation with atropine. In vitro testing of Ma.Cr and polarity-based fractions resulted in L-NAME sensitive, endothelium-dependent vasodilator effects on aortic tissues. Pretreatment of aorta preparations with Ma.Cr and its fractions also blocked K+-induced precontractions indicating Ca2+ channel blocking activity comparable to verapamil. The extract and polarity-based fractions did not reveal a vasoconstrictor response in spontaneously beating isolated rat aorta. Ma.Cr and fractions when used in atrial preparations resulted in negative inotropic and chronotropic effects. These effects in atrial preparations did not change in the presence of atropine. These effects of extract and fractions explained the antihypertensive potential of M. azedarach and thus provided a scientific basis for its ethnopharmacological use in the treatment of hypertension. Among the constituents observed, flavonoids and flavonoid O-glycosides were previously reported for antihypertensive potential.

Sonography and color Doppler sonography for monitoring conservatively treated infantile hypertrophic pyloric stenosis

OBJECTIVE

To evaluate the role of sonography in infants with hypertrophic pyloric stenosis undergoing conservative medical treatment.

METHODS

Twenty-two infants (17 male and 5 female; age range, 1-12 weeks) were clinically and sonographically considered suitable for conservative treatment and underwent follow-up during the course of the disease. Sonography was performed under a standardized protocol and included color Doppler sonography.

RESULTS

Fifteen infants (mean age, 9 weeks) needed surgery. They initially had a mean pyloric length of 18 mm, a diameter of 10.5 mm, and a wall thickness of 4 mm, with visible passage of food into the duodenum. These values deteriorated during follow-up (mean preoperative values: length, 20 mm; diameter, 12 mm; and wall thickness, 4.5 mm); furthermore, passage of food through the pyloric canal ceased. Seven infants (mean age, 3 weeks) were successfully treated conservatively Their initial mean pyloric measurements were slightly smaller (length, 15 mm; diameter, 10 mm; and wall thickness, 3.8 mm) and did not deteriorate during follow-up. In all of them, sonography showed improvement of passage through the pyloric canal within several days, as shown and documented by color Doppler sonography; morphologic changes persisted longer despite clinical improvement.

CONCLUSIONS

Sonography, including color Doppler sonography, is a valuable tool for monitoring infants with hypertrophic pyloric stenosis undergoing conservative treatment; however, initial sonograms cannot predict the further course of the disease.

Effects of administration of phentonium bromide on opioid withdrawal syndrome in rats

This study has tested whether phentonium bromide, a quaternary ammonium anti-muscarinic agent, could reverse the signs of precipitated opioid withdrawal. Rats were treated with either saline or morphine for 4 days, after which half the rats received naloxone and half saline. Each animal also received one of four doses of phentonium bromide (0, 1, 3 and 9 mg kg(-1), i.p.). Administration of phentonium bromide in rats receiving naloxone after chronic morphine treatment reduced the intensity of withdrawal signs such as increased defecation or micturition, salivation and wet-dog shakes, and elevated the nociceptive threshold values. The effects of administration of phentonium bromide might result from its anti-muscarinic activity interfering peripherally with the mechanisms involved in the regulation of the withdrawal symptoms. The use of this drug is thus suggested as a possible means of controlling some of the signs observed during the acute phase of opioid withdrawal in heroin addicts.

[Flutropium bromide was effective in relieving symptoms of lymphangioleiomyomatosis--a case report]

A 32-year-old woman was admitted with persistent dyspnea. Chest roentgenogram showed hyperinflation of the lungs, and diffuse reticular shadows in both lung fields. Chest CT showed diffuse cystic lesions and thickened vasculature. Examinations revealed severe hypoxemia, restrictive and obstructive ventilatory impairments, increased residual volume, and decreased carbon monoxide diffusing capacity. Lymphagioleiomyomatosis was strongly suspected, and a diagnosis confirmed histopathologically by lung biopsies. Inhalation of flutropium bromide was remarkably effective in relieving dyspnea and impaired pulmonary functions. It is suggested that flutropium bromide is beneficial for symptomatic improvement in patients with lymphangioleiomyomatosis.

The effect of mannitol and anisodamin on the prevention of free radical injury to post-ischaemia flaps: an experimental study

Rat abdominal skin flaps were subjected to total venous occlusion for 8 h. Five minutes before release of the vascular occlusion, mannitol, mannitol plus anisodamin, anisodamin or placebo (0.9% normal saline) was administered intravenously. Drug treated flaps showed a statistically significant increase in the proportion of area surviving (P < 0.001). The combination of mannitol and anisodamin was not more effective than either agent alone in increasing the proportion of area surviving. The results of biochemical analyses indicated that neither mannitol nor anisodamin affected xanthine oxidase activity (p > 0.05) but that both agents significantly reduced the increase of malondialdehyde (MDA) concentration caused by ischaemia-reperfusion (p < 0.01). Treatment with mannitol or anisodamin also prevented the increase of lactate and water content and the decrease in glucose content in the island skin flap tissue which occurred on reperfusion. The data indicate that mannitol and/or anisodamin have the potential to salvage anticipated flap necrosis. It is possible that the mechanism of action is inhibition of damage caused by toxic oxygen species and improvement in capillary reperfusion.

Anticonvulsant actions of anticholinergic drugs in soman poisoning

The acute effects of the organophosphorus cholinesterase inhibitor soman include hypersecretions, convulsions, and death. The purpose of this study was to evaluate the anticholinergic compounds aprophen, atropine sulfate, azaprophen, benactyzine, benztropine, biperiden, scopolamine HBr, and trihexyphenidyl for their efficacy in preventing soman-induced hypersecretions and convulsions. Male rats were injected with the oxime HI-6 (125 mg/kg, i.p.), to increase survival time, along with various intramuscular doses of the anticholinergics 30 min prior to a dose of soman (180 micrograms/kg, s.c.; equivalent to 1.6 x the median lethal dose) that produced 100% convulsions. Signs of intoxication as well as the time-to-onset of convulsions were observed. The calculated anticonvulsant median effective dose values were 0.18, 0.33, 0.36, 0.55, 2.17, 2.30, 2.45, and 31.09 mumol/kg for scopolamine HBr, biperiden, trihexyphenidyl, benactyzine, benztropine, azaprophen, aprophen, and atropine sulfate, respectively. The same rank order of potency for inhibition of hypersecretions among these compounds was observed. Parallel studies with quaternary analogs of atropine sulfate and scopolamine HBr demonstrated, however, that these charged compounds afford no protection against soman-induced hypersecretions and convulsions. The results indicate that tertiary anticholinergic compounds afford protection against soman-induced convulsions and hypersecretions and that the beneficial anticonvulsant effects are mediated through the central cholinergic system. Excitatory amino acid neurotransmitter systems may be involved in the effectiveness of these compounds.

[The possible role of presynaptic effects in realizing the protective action of M-cholinolytics in dimethyl dichlorovinyl phosphate poisoning]

Under the conditions of the constancy of the postsynaptic effect of two M-cholinolytics atropine and amizil the relationship between the presynaptic and protective effects of the drugs in DDVF intoxication was studied. The indication of the level of the postsynaptic activity was the suppression by the cholinolytics of tremor reaction in rats induced by the action of arecoline. The presynaptic effect of the drugs was judged by the charge of the "bound" acetylcholine content in the brains of the animals. It was found that when administered in the equieffective by the choline-blocking activity doses, atropine to a greater extent reduced the content of the "bound" acetylcholine which was increased due to the action of DDVF and at the same time it possessed the less pronounced protective activity in intoxication with DDVF than amizil. It is supposed that the removal of the presynaptic suppression of acetylcholine release due to the anticholinesterase substance action deteriorates the prognosis of the course of DDVF intoxication.

Participation of the parasympathetic nervous system in the development of activity-stress ulcers

The present study investigates the effects of truncal vagotomy and drug treatment, comprising atropine methylbromide and chlorisondamine, on the development of activity-stress ulcers in rats. To induce gastric lesions, female rats were housed individually in activity-wheel cages and subjected to a food-restricted schedule of only 1 hr food availability per day. Bilateral truncal vagotomy significantly prevented gastric ulceration, while those rats with vagotomy showed more running activity than sham-operated rats. Daily treatment with either methylatropine (3 and 6 mg/kg, s.c.) or chlorisondamine (2 and 4 mg/kg, i.p.) also significantly decreased the severity of lesions without a significant reduction in running activity. This evidence suggests that the development of activity-stress ulcers is mainly due to the hyperactivity of the peripheral parasympathetic nervous system.

A random double-blind trial of the combination of nebulized atropine methylnitrate and albuterol in nocturnal asthma

The combination of nebulized atropine methylnitrate (AMN) and a beta-agonist has been shown to produce greater and longer lasting bronchodilation than either drug alone. We examined the efficacy of the combination in diminishing the "morning dipping" in PEFR in eight hospitalized but stable asthmatics. The patients received nebulized albuterol along with either AMN (AMN + ALB) or placebo (ALB) in a random double-blind cross-over fashion at 10 PM on four nights. PEFR and FEV1 were recorded at 6 PM, 10 PM, and 6 AM before the administration of bronchodilators. There was no statistically significant difference between ALB and AMN + ALB in reducing the morning dipping in these patients.

Efficacy of atropine methylnitrate alone and in combination with albuterol in children with asthma

The bronchodilator effect of nebulized AMN, albuterol and their combination was evaluated in 16 steroid-dependent asthmatic children. In phase 1, maximal bronchodilation was determined by dose-response studies on separate days. Maximal bronchodilator dose of each drug was administered either alone or in combination during phase 2. In phase 1, 0.11 +/- 0.01 mg/kg of albuterol and 0.03 mg/kg of AMN produced maximum bronchodilation. In phase 2, the peak response to albuterol occurred within 30 min and to AMN, at 60 min. Maximal FEV1 achieved after AMN was 90 percent of the maximal achieved after albuterol. AMN FEV1 response was better than for placebo for 3 h; that for albuterol was better for 4 h. Combination therapy produced a peak response similar to that of albuterol but was better than albuterol by 6 h. Thus, the maximum bronchodilator effect of AMN is less than that of albuterol in asthmatic children, but the combination may extend the period of bronchodilatation.

Influence of antihistamine (astemizole) and anticholinergic drugs (ipratropium bromide) on bronchoconstriction induced by substance P

Several studies have demonstrated that neuropeptides are present in bronchial tissue. The aim of this study was to evaluate in vivo the influence of antihistamine in comparison to an anticholinergic drug on bronchospasm induced by inhalation of substance P (SP). Seven moderate asthmatic patients (mean age = 34.4 +/- 8.9), five being female, were studied. The acetate salt of SP was prepared in 0.9% saline to produce a dose range of 23 to 184 x 10(-6) mol. Patients were studied on three separate days with an interval of 3 weeks between challenges. On the first day the dose of SP producing a 20% change in FEV1 was calculated from the individual semilogarithmic dose-response curve. On subsequent days, in a randomized double-blind manner, the patients were treated either with astemizole (20 mg BID for three days) and placebo ipratropium bromide or with placebo of astemizole (twice a day for three days) and with pressurized aerosol of ipratropium bromide (IB) (40 micrograms 20 minutes before the challenge). Two way analysis of variance was used for statistical analysis. Our results demonstrated that inhaled SP is able to produce a dose-response curve of bronchoconstriction with a geometric mean of PD20 of 50.51 x 10(-6) moles (37.38 to 68.19 x 10(-6) mol). Treatment with astemizole induced a geometric mean PD20 of 65.51 x 10(-6) mol (33.02 to 130.21 x 10(-6) mol) and the premedication with the IB induced a significant (P less than .05) shift of dose-response curve to SP (geometric mean PD20 = 109.1 x 10(-6) mol; 58.67 to 204.05 x 10(-6) mol). Our results demonstrated that bronchoconstriction induced by SP could be attributed to a weak cholinergic activation and not to histamine release.

Severe exacerbations of COPD and asthma. Incremental benefit of adding ipratropium to usual therapy

Single dose studies have assessed the utility of ipratropium bromide alone or with beta agonists in the short- and long-term management of chronic obstructive lung disease and asthma. We performed a randomized, double-blind trial to assess the incremental benefit over 24 hours of adding ipratropium vs placebo to a standardized regimen of medications commonly used in the acute and subsequent hospital management of COPD and asthma. Sixty-eight subjects received nebulized salbutamol, intravenous methylprednisolone, intravenous aminophylline, and antibiotics and were randomized to receive either 80 micrograms of ipratropium or placebo via metered dose inhaler and spacing device with each salbutamol treatment (6 to 8 times per day). Among the 50 patients who completed the study, there were no significant differences between ipratropium and placebo groups with respect to baseline FEV1, FVC, and PaCO2. The improvement of FEV1 from baseline to 24 hours was 294 (SD = 568) ml in the ipratropium group vs 393 (SD = 622) ml in placebo group. Adjusting FEV1 by age, gender, and smoking did not significantly alter the findings. Those with an admission diagnosis of asthma showed larger 24 hour FEV1 responses (487 ml in ipratropium vs 801 ml in placebo) than those with COPD (149 ml ipratropium vs 102 ml in placebo). However, within these two strata, there were no significant differences in FEV1 improvement between ipratropium and placebo groups. This study suggests that if ipratropium is used in the initial emergency treatment of COPD or asthma, it could safely be discontinued by 24 hours in order to reduce the cost and complexity of therapy.

Treatment of non-allergic nasal hypersecretion with ipratropium and beclomethasone

The effect of ipratropium and beclomethasone administered as nasal aerosols was compared in a double-blind, double-dummy, randomized, cross-over designed study. Twenty-four patients with non-allergic, watery hypersecretion participated in the trial. According to the patients' daily registration of nasal symptoms, no significant difference could be found between the two drugs. It was not possible to characterize patients who would benefit from treatment with either ipratropium or beclomethasone.

Comparison of inhaled terbutaline and inhaled terbutaline plus ipratropium bromide in acute asthmatic children

Twenty asthmatic children, aged 4 to 15 years, consisting of 14 boys and 6 girls, were studied during acute episodes of asthmatic attacks. A group of 10 children each received either inhaled terbutaline 0.5 mg or inhaled terbutaline 0.5 mg followed by ipratropium bromide 0.04 mg 15 minutes later through a 750-ml volumetric spacer. Significant increases in FEV1 over the baseline were observed from 2 minutes to 2 hours and from 2 minutes to 6 hours following the first and second regimen respectively. A slightly greater increase and longer duration in FEV1 were observed in the combined drug treatment and very slight decreases in systolic and diastolic blood pressure below the base-line were observed. Neither regimen showed any serious adverse effect on the heart rate and respiratory rate.

[Inhalation bronchodilators in infancy--comparative study between salbutamol and ipratropium bromide]

The effectiveness of bronchodilators in infancy still remains uncertain. The objective of the present study was, on the basis of clinical scores, to determine the effect of salbutamol and ipratropium bromide in the treatment of acute airways obstruction in infants. For this purpose, we investigated a total of 22 infants whose ages ranged between 1 and 12 months and who were randomized to three different treatment groups. Infants in group 1 were given 0.9% NaCl to inhale, those in group 2 received ipratropium bromide, and those in group 3 salbutamol. The response to treatment was assessed on the basis of a decrease in the clinical score. A statistically significant decrease in the score was found only for those infants given ipratropium to inhale. None of the infants in this group failed to respond to treatment. Ipratropium bromide proved to be more effective than salbutamol in the treatment of infants with acute airways obstruction.

[The bronchospasmolytic test with anticholinergic drugs and sympathomimetics: differences between body plethysmography and spirometry measuring procedures]

The different bronchodilator effects after inhalation of anticholinergic and beta-adrenergic drugs due to the different methods of measurement (i.a. body plethysmography vs. spirometry) were studied in 43 patients with COLD and in 20 healthy subjects. The greatest changes occur when the body plethysmographic value Rt was chosen. The spirometric values FEV1 and PEF show the greatest bronchodilator effect. The patients with COLD have the best bronchodilation after inhalation of the beta-adrenergic drug, whereas the healthy subjects show the greatest effect after anticholinergic drugs.

Nebulized ipratropium in the treatment of acute asthma

The efficacy of ipratropium and salbutamol was determined in 117 patients with acute asthma who presented to an emergency department to determine whether the order of administration of the two agents affects the improvement in peak flow rates. Patients were given two nebulized treatments at an interval of one hour in a randomized, double-blind design. They received either 5 mg nebulized salbutamol followed by 0.5 mg ipratropium, ipratropium followed by salbutamol, or both drugs administered together followed by nebulized saline. Ipratropium was an effective bronchodilator when given as the first agent. Simultaneous administration with salbutamol was as effective as sequential administration. At one hour after treatment, there was no difference in peak flow between the combination of drugs and either drug given alone. Ipratropium given after salbutamol was not superior to saline solution given after the combination of drugs. Our data do not suggest a substantial therapeutic effect from addition of ipratropium to salbutamol in the immediate treatment of acute asthma.

Changes in maximum expiratory flow-volume curve configuration after treatment with inhaled corticosteroids

The present study reports the changes in configuration of maximal flow-volume curves after eight weeks' treatment with inhaled corticosteroids in 14 asthmatic patients. The configuration was compared with that seen after bronchodilatation following inhalation of a single dose of ipratropium bromide. After inhaled corticosteroids the shape of the flow-volume curves was less bowed toward the volume axis, whereas the shape of the flow-volume curves after inhalation of ipratropium bromide showed no significant change. A significant correlation was observed between the decrease in blood eosinophil cell count and the straightening of the flow-volume curves, quantitatively expressed as shape factor and slope ratio. It is concluded that these changes in flow-volume curve configuration reflect a decrease in inhomogeneously distributed inflammatory airway narrowing.

Long-term effect of ipratropium bromide and fenoterol on the bronchial hyperresponsiveness to histamine in children with asthma

We studied the effects of the anticholinergic ipratropium bromide (40 micrograms three times daily) and the beta-agonist, fenoterol (0.2 mg three times daily), both administered by powder inhaler, on bronchial hyperresponsiveness (BHR) to histamine in children, aged 7 to 15 years with mild stable asthma and limited bronchoconstriction who had a highly increased BHR. The double-blind, randomized, parallel study was conducted and performed in spring and early summer. BHR and FEV1 were measured on two occasions, before the start of treatment and monthly thereafter for 4 months. Symptoms, peak expiratory flow, and concomitant medication were registered daily. Nine of the 12 patients receiving ipratropium bromide and all eight patients receiving fenoterol completed the study. Patients completing treatment had few symptoms and were in a stable condition throughout the treatment period. Neither the administration of ipratropium bromide nor fenoterol resulted in a significant change of BHR. We concluded that long-term treatment with ipratropium bromide or fenoterol had no effect on BHR in children with mild stable asthma.

The effect of anticholinergic and beta-agonist pretreatment on bronchoconstriction induced by N-formyl-methionyl-leucyl-phenylalanine

N-Formyl-methionyl-leucyl-phenylalanine (FMLP), an acylated tripeptide bacterial neutrophil chemotactic factor, has been shown to be a bronchoconstrictor by inhalation in man in vivo. It thus has a putative role in the generation of bronchoconstriction associated with bacterial bronchial infection. We have investigated the effect of pretreatment with the anticholinergic agent, ipratropium bromide (IB), and the beta 2-agonist, fenoterol (F), on FMLP-induced bronchoconstriction. Ten non-asthmatic subjects aged 21-28 yrs performed dose-response curves to nebulized FMLP on 3 study days after pretreatment with saline, F or IB. Amongst the 8 subjects who bronchoconstricted by 20% to FMLP there was a significant increase in the provocative concentration causing a 20% fall in forced expiratory volume in one second (FEV1) (PC20FMLP) after both IB and F. F was significantly better than IB. When comparison was made using absolute fall in FEV1 and including all 10 subjects the same results were found. Partial inhibition of FMLP-induced bronchoconstriction by IB suggests that part of the effect of FMLP is vagally mediated. We suggest that F is acting via modulation of FMLP-induced rises in intracellular free calcium.

Effect of salbutamol, ipratropium bromide and cromolyn sodium on prostaglandin F2 alpha-induced bronchospasm

We studied the effects of salbutamol, ipratropium bromide and cromolyn sodium on PGF2 alpha-induced bronchospasm in ten patients with asthma. Initially, the bronchial reactivity to IC-PGF2 alpha and the DP20-PGF2 alpha were determined. Recalculations were made two days later and again 1 h after administration of various drugs given on different days. Salbutamol and ipratropium bromide induced significant bronchodilation and of similar magnitude 1 h after administration. On the day salbutamol was given, surface area under the dose-response curve to PGF2 alpha was significantly higher and the final drop of FEV1 significantly lower than those observed on days when placebo, ipratropium bromide and cromolyn sodium were given. No differences among these values were found for placebo, ipratropium bromide and cromolyn sodium. Thus, beta 2 stimulants attenuate significantly PGF2 alpha-induced bronchospasm, while ipratropium bromide and cromolyn sodium do not have protective effect.

Short-term effects of paraoxon and atropine on schedule-controlled behavior in rats

The effects of lethal (2.0 mg/kg) and high sublethal (1.3 mg/kg) dosages of the organophosphate acetylcholinesterase (AChE) inhibitor paraoxon on FR10 performance rate was determined 1 and 2 days after intoxication. The lethal doses were antidoted with either centrally acting atropine sulfate (AS), or atropine methyl bromide (AMB) or atropine methyl nitrate (AMN), both quaternary salts and not expected to act centrally. AChE inhibition in the brain was about 35-60% on the second day after treatment. AS yielded a small transient depression in performance, while AMB and AMN yielded severe deficits, with incomplete recovery. Performance was depressed by 1.3 mg/kg paraoxon by 52% and 34% on days 1 and 2, respectively, while performance was more greatly depressed by the lethal dose, especially with the noncentrally acting antidotes: AS, 67 and 48%; AMB, 81 and 55%; AMN, 91 and 78%. However, a low dose of AS with 2 mg/kg paraoxon resulted in very severe, nonrecovering deficits. A lethal dose of the nonpersistent anti-AChE eserine sulfate, antidoted with a low dose of AS, yielded no deficits. Thus, a high level, acute intoxication with paraoxon yields behavioral deficits which are attenuated by high levels of a centrally acting muscarinic receptor antagonist. The paraoxon-induced performance deficits or their recovery do not correlate directly with AChE inhibition.

[Effect of fenoterol, ipratropium bromide and their combination--Berodual--on pulmonary ventilation in patients with asthma]

The study aimed at evaluating FVC, FEV1, and FMF25-75% following and inhalation of fenoterol, ipratropium bromide and Berodual in 10 patients with the bronchial asthma. Berodual may be inhaled directly from the metered dose inhaler or with added tube spacer. Spirometry was performed after a single deep inspiration of each drug in the consecutive days, and after 5, 15, 30 and 60 minutes as well as 2, 3, 4, and 5 hours following the inhalation. The differences at each time point were compared with baseline values and expressed as percentage of the increase. The obtained results were analysed statistically. It was shown that bronchodilatory action of Berodual, being both beta 2-agonist and anticholinergic agent, is the most pronounced. The highest values of the measured spirometric parameters followed Berodual inhalation with the aid of tube spacer but the differences compared with Berodual applied with the metered dose inhaler were not statistically significant.

Comparative efficacy of salbutamol, ipratropium, and cromoglycate in the prevention of bronchospasm induced by exercise and hyperosmolar challenges

We compared the inhibitory effects of inhaled salbutamol (S), ipratropium (I), and cromoglycate (C) on bronchospasm induced by exercise (EX) or hyperosmolar (HY) saline aerosol in a group of 11 subjects with stable asthma. Each subject had eight tests in a randomized order, four EX and four HY challenges, each preceded by the double-blind inhalation of either a placebo, 200 micrograms of S, 80 micrograms of I, or 4 mg of C. This study demonstrated that the three drugs protected against the two types of challenges in almost all subjects. Although we observed a large interindividual variability in the airway response to the challenges, there was no statistically significant difference in the mean percent protection after HY or EX challenges when these challenges were preceded by S, I, or C (p greater than 0.05). Moreover, for EX- and HY-induced bronchospasm, the mean percent protection afforded by the three medications was in the same order (S greater than I greater than C), although the protective effect against EX-induced was weaker than against HY-induced bronchospasm. This suggests that hyperosmolarity, although it may not be the sole factor involved, plays a role in EX-induced bronchospasm.

The inhaled bronchodilators ipratropium bromide and metaproterenol in adults with CF

Ten patients with CF who were more than 18 years old, participated in a double-blind, placebo-controlled study evaluating the efficacy of inhaled ipratropium bromide and metaproterenol as bronchodilators. The mean FEV1 of the group improved 17.1 percent after treatment with ipratropium bromide, 12.5 percent after metaproterenol treatment, and 16.6 percent after treatment with both of these medications together. There was no significant difference between these responses and patients who responded to one treatment tended to respond to the others. The side effects with these medications were minimal. When compared with patients in previous studies, our patients, who were much older as a group, demonstrated a greater degree of bronchodilation with ipratropium bromide and metaproterenol, as well as a greater degree of bronchoconstriction with placebo.

Comparison of preservative-free and preservative-containing ipratropium bromide

A double-blind crossover study was performed on 33 children with asthma to compare the effectiveness of nebulized solutions of preservative-containing and preservative-free ipratropium bromide. Both solutions produced bronchodilation. No significant differences were found between the two solutions at any time after nebulization in minimum and maximum changes from baseline value or in the areas under the lung function time curves. The presently formulated preservative-containing ipratropium bromide solution was not shown to be inferior to a preservative-free compound.

Pulmonary effects of sulfur dioxide exposure and ipratropium bromide pretreatment in adults with nonallergic asthma

In this study we examined the potential short-term effect of sulfur dioxide (SO2) on total respiratory resistance and forced expiratory volume in patients with nonallergic asthma. A group of nine adult subjects with nonallergic asthma, 55 years of age or older, were exposed to SO2 at 0, 0.5, and 1.0 ppm for 20 minutes at rest followed by 10 minutes during light-moderate exercise. The measures of pulmonary function assessed were FEV1, specific total respiratory resistance (SRT), and maximal expiratory flow rates at 50% (Vmax50) and 75% (Vmax75) of expired vital capacity. Measurements were made before exposure to SO2 (baseline), postresting exposure, postexercising exposure, and at 30 minutes thereafter (recovery). Repeat measure analysis of variance revealed a statistically significant dose-response effect of SO2 inhalation on FEV1 (p = 0.008), SRT (p = 0.033), Vmax50 (p = 0.017), and Vmax75 (p = 0.048). Eight subjects had repeat exposure to SO2 at 1.0 ppm after treatment with either placebo or ipratropium bromide, 60 micrograms by metered-dose inhaler. Inpratropium bromide treatment, compared to placebo treatment, resulted in a statistically significant improvement in all baseline measures of pulmonary function: FEV1 (p = 0.017), SRT (p = 0.027), Vmax50 (p = 0.018), and Vmax75 (p = 0.035). However, this drug did not significantly alter the proportionate change in pulmonary function caused by SO2 inhalation in these subjects. These findings indicate that adults with nonallergic asthma are sensitive to short-term low-level SO2 exposure and that treatment with 60 micrograms of ipratropium bromide causes significant bronchodilation but does not protect, completely, these patients from the effect of SO2 inhalation.

A comparison of the effect of ipratropium and albuterol in the treatment of chronic obstructive airway disease

Twenty-five subjects with moderate to severe chronic obstructive airway disease were studied to compare the effect of ipratropium bromide, albuterol, and placebo on the forced expiratory volume in 1 s, (FEV1), forced vital capacity, heart rate, and blood pressure during six hours. Ipratropium produced a significantly greater improvement than albuterol in the FEV1 at 30 minutes and at 3, 4, and 5 hours and in the forced vital capacity at one through six hours. Fifteen subjects did not demonstrate a 15% improvement and at least a 200-mL increase in the FEV1, 15 minutes after metaproterenol sulfate aerosol. All 15 did improve after ipratropium therapy during the study. Ipratropium was effective significantly longer than albuterol. Subjects with better peak responses to ipratropium had a lower FEV1 percent predicted and a greater pack-year smoking history. In patients with chronic obstructive airway disease, ipratropium produces a longer duration of action than albuterol. It is more effective than albuterol in treating severely obstructed individuals and those not responding to metaproterenol. It is equally effective in treating others.

Localization of bronchial response to ipratropium bromide by respiratory impedance measurement in asthmatics

In 10 asthmatic subjects, the influence of 0.040 mg ipratropium bromide on impedance (Z) of the respiratory system (rs) was determined after cold air challenge. Cold air inhalation caused a significant increase of respiratory resistance (Rrs) at frequencies between 8 and 32 Hz. This increase of Rrs was more pronounced at lower frequencies and, therefore, Rrs became frequency dependent. Respiratory reactance (Xrs) decreased at all frequencies, resulting in an increase of resonant frequency. These changes were compatible with a peripheral airway obstruction and a decrease of airway compliance, according to Mead's analog of the respiratory system. Five min after inhalation of ipratropium bromide, a significant decrease of Rrs between 8 and 28 Hz and a significant increase of Xrs at all frequencies were observed, resulting in a decrease of resonant frequency. Ipratropium bromide significantly reversed the peripheral broncho-constriction induced by cold air challenge.

Effect of inhaled ipratropium bromide on methacholine and exercise provocation in asthmatic children

To determine whether doses of ipratropium bromide (IB) greater than those usually administered by aerosol (75-250 micrograms) give a greater degree of protection from exercise-induced asthma (EIA) in children, 12 patients with chronic asthma, ages 7-13 yr, were challenged with methacholine and exercise after inhalation of saline or 125, 250, 500, and 750 micrograms of IB on different days. A small and similar bronchodilation (mean increase over baseline: 5.26%) was observed 60 min after the administration of each dose of IB. IB prevented the bronchoconstriction caused by methacholine in all doses we used without statistically significant differences between them. All doses gave an all-or-none protection from EIA. Mean percent fall in FEV1 after exercise was 36.8, 18.3, 23.7, 27.1, and 23.2 following inhalation of saline or 125, 250, 500, or 750 micrograms of IB, respectively. The degree of protection from EIA was not correlated with the bronchodilation caused by IB. We suggest that muscarinic mechanisms are only partly responsible for the pathogenesis of EIA in children. Their importance varies among subjects and also may be variable in the same subject. Alternative mechanisms may be responsible for bronchoconstriction.

Cardiac response to upper gastrointestinal endoscopy

In 54 subjects, cardiac function was investigated during upper gastrointestinal endoscopy with a Holter electrocardiorecorder. The heart rate of patients who were premedicated with an anticholinergic agent increased more than did that of patients who received no premedication. In the group who received no anticholinergic premedication, sinus tachycardia was evident during endoscopy, but the only clinically important change was in one patient who converted to atrial flutter from atrial fibrillation. The heart rate increased during endoscopy among patients undergoing the procedure for the first time, but it did not increase in the patients who had previously undergone endoscopy. These results show that endoscopy is a relatively safe examination from the view point of cardiac risk when performed without the administration of an anticholinergic agent, but that cardiac patients should be monitored carefully. The endoscopist should also take into consideration the psychological state of the examinees.

Ipratropium bromide treatment of experimental rhinovirus infection

The importance of parasympathetic-cholinergic mechanisms in the production of common cold symptoms is not clear. The quaternary ammonium anticholinergic antagonist ipratropium bromide was intranasally administered under double-blind, randomized, placebo-controlled conditions to assess its tolerance and efficacy in reducing nasal hypersecretion in adult volunteers with experimental rhinovirus colds. Ipratropium was sprayed intranasally three times daily (80 micrograms per treatment) for 5 days beginning 24 h after intranasal inoculation of rhinovirus type 39. Clinical colds occurred in 50% of 30 infected ipratropium recipients and in 76% of 33 infected placebo recipients (P = 0.04). The nasal mucus weights tended to be lower for ipratropium-treated persons (mean +/- standard deviation, 14.7 +/- 15.1 g/5 days) than for placebo-treated recipients (24.7 +/- 28.0 g/5 days; P = 0.076). Whereas total nasal symptom scores were similar between the two groups, the rhinorrhea score analyzed for each day of treatment showed nonsignificant trends favoring the ipratropium group over the last 4 days of treatment. Ipratropium was generally well tolerated. The results suggest that cholinergic mechanisms are at least partially responsible for nasal mucus production in rhinovirus colds but that the effect of anticholinergic compounds alone is insufficient to be of practical use in treatment, although they may have value as components of multi-ingredient preparations.

The development of subsensitivity to atropine methylnitrate. A double-blind, placebo-controlled crossover study

This is a double-blind, placebo-controlled crossover study designed to assess the effectiveness of nebulized atropine methylnitrate (AMN) with chronic use. We studied 22 patients with asthma, 10 receiving theophylline and inhaled beta-agonists and 12 who were receiving corticosteroids as well. All had demonstrated at least a 15% change in FEV1 either spontaneously or after bronchodilator. Bronchodilator effect was measured serially for 4 h after inhalation of the initial dose and again after 2 wk of four-times-daily use. Significant bronchodilator effect was seen initially with AMN when compared to placebo (p less than 0.01). After 2 wk of use, the bronchodilator effect of AMN was significantly diminished as compared to the initial effect (p less than 0.01) but was still better than placebo (p less than 0.05). Subsensitivity did develop to varying degrees in the patients, but we were unable to identify any clinical parameters that would allow prediction of subsequent subsensitivity. We conclude that the development of subsensitivity to AMN occurs in certain patients with chronic administration but does not reflect a total loss of bronchodilator effect.

[Relationship between the choline-blocking and protective actions of m-cholinolytics in chlorophos poisoning]

It was established in experiments on mice that the protective effect of metacine and atropine iodomethylate during chlorophos and acetylcholine intoxication is directly proportional to the peripheral m-cholinolytic activity of the drugs. The protective effect of the doses of metacine and atropine iodomethylate equieffective by the choline-blocking effect was equal during acetylcholine intoxication but differed during chlorophos intoxication. Atropine iodomethylate exhibited a stronger selective peripheral m-cholinolytic action than metacine.

Lack of correlation between the grade of methacholine-induced bronchial hyperreactivity and ipratropium bronchodilation in asthmatics

In 46 never-smoking randomly chosen patients with non-allergic asthma, 40 to 60 years old, a methacholine hyperreactivity test and lung function tests were performed after inhalation of different doses of ipratropium bromide (IB). The grade of hyperreactivity was measured as the cumulative dose of methacholine necessary to produce a decrease in the forced expiratory volume in one second of 20% of the lowest post-NaCl value (PD20). The following lung function tests were carried out: Lung volumes, ventilatory capacity including flow-volume curves, airway resistance and nitrogen single-breath wash-out test. The bronchodilator effect, measured as a change in the different lung function tests for different doses of IB given (0.08 mg, 0.15 mg and 0.25 mg), was correlated to the grade of hyperreactivity (PD20 dose). No or only a slight correlation was found between the grade of methacholine-induced hyperreactivity and the bronchodilator effects of the different doses of IB. These results indicate a lack of correlation between an anticholinergic bronchodilator effect and the grade of methacholine-induced bronchial hyperreactivity, or possibly an insensitivity of the above-mentioned methacholine test.