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Zein-Elabdeen SMM, Hassan NA, El-Ebiary AA, Hafez ASAF, Hodeib AA. Albuterol as an adjuvant in acute anticholinesterase pesticide poisoning: a randomized, placebo-controlled clinical trial. Toxicol Res (Camb) 2024; 13:tfae048. [PMID: 38559756 PMCID: PMC10980788 DOI: 10.1093/toxres/tfae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
Acute anticholinesterase pesticide poisoning is a serious clinical problem, particularly in developing countries. Atropine is the most acceptable treatment for acute anticholinesterase poisoning. However, it only stops fluid production. Albuterol is a beta-2 receptor agonist that can increase fluid removal and speed the return of effective oxygen exchange. This study aims to evaluate the safety and efficacy of nebulized albuterol as an adjuvant therapy in patients with acute anticholinesterase poisoning. This stratified block randomized, single-blinded, placebo-controlled, parallel-group clinical trial was conducted between November 2020 and October 2021. It enrolled 80 patients with acute anticholinesterase pesticide poisoning who were admitted to Tanta University Poison Control Center. Patients were allocated into two groups (40 patients each). The strata were based on the severity of poisoning (moderate and severe). Patients in group I received 10 mg of nebulized albuterol. Group II received an equivalent volume of nebulized normal saline. Additionally, standard treatment was provided to both groups. Outcomes included oxygenation, mortality, need for endotracheal intubation and mechanical ventilation, hospital stay duration, time to atropinization, and total doses of atropine and oxime. We found insignificant differences in sociodemographics, exposure characteristics, clinical manifestations, or routine laboratory tests between the studied groups. The median values of oxygen saturation by pulse oximetry were 99% in the albuterol moderate toxicity group and 98% in the control moderate toxicity group. Albuterol significantly improved oxygen saturation in moderate intoxicated patients (P = 0.039). Therefore, nebulized albuterol is a safe drug. Moreover, it may improve oxygenation in acute anticholinesterase pesticide poisoning.
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Affiliation(s)
- Samar M M Zein-Elabdeen
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Neven A Hassan
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Ahmad A El-Ebiary
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Amal S A F Hafez
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Aliaa A Hodeib
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
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Carbajal-García A, Reyes-García J, Casas-Hernández MF, Flores-Soto E, Díaz-Hernández V, Solís-Chagoyán H, Sommer B, Montaño LM. Testosterone augments β 2 adrenergic receptor genomic transcription increasing salbutamol relaxation in airway smooth muscle. Mol Cell Endocrinol 2020; 510:110801. [PMID: 32278021 DOI: 10.1016/j.mce.2020.110801] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/12/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
Androgens in asthmatic men may be linked to asthma severity, acting via nongenomic and genomic effects. This ailment affects boys more than girls during infancy, and this proportion reverses in puberty. Plasmatic androgen concentration in young men increases at this age and might be related to lower asthma symptoms. Nongenomic actions occur in a brief period and are independent of the androgen receptor (AR), while genomic effects depend on AR, take hours-days and are modified by transcription or protein synthesis inhibitors. Guinea pig tracheas chronic incubation with testosterone (TES, 40 nM, 48 h) potentiates salbutamol-induced relaxation, an effect that was reversed by flutamide, not observed when tissues were pre-incubated with TES-bovine serum albumin (TES-BSA) nor when tissues were preincubated with TES for 15-60 min. In tracheal myocytes, TES chronic incubation increases salbutamol-induced K+ currents (IK+), an effect that was also reversed by flutamide, actinomycin D and cycloheximide and not seen with TES-BSA. The increment in IK+ was blocked by 4-aminopyridine and iberiotoxin, indicating that delayed rectifier K+ and high-conductance Ca2+ activated K+ channels were involved in the TES potentiation effect. Immunofluorescence studies showed that chronic TES augmented the β2 adrenergic receptor (β2-AR) expression in ASM and this finding was corroborated by q-PCR and Western blot assays. β2-AR affinity for salbutamol after TES incubation was increased. In conclusion, chronic exposure to physiological TES concentration of the guinea pig ASM promotes β2-AR upregulation favoring β2 adrenergic responses and probably limiting the severity of the asthmatic exacerbations in teenage boys and men.
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Affiliation(s)
- Abril Carbajal-García
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, México
| | - Jorge Reyes-García
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, México
| | - María F Casas-Hernández
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, México
| | - Edgar Flores-Soto
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, México
| | - Verónica Díaz-Hernández
- Departamento de Embriología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, México
| | - Héctor Solís-Chagoyán
- Laboratorio de Neurofarmacología, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, CDMX, México
| | - Bettina Sommer
- Departamento de Investigación en Hiperreactividad Bronquial, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, CDMX, México
| | - Luis M Montaño
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, México.
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Herbert J, Thiermann H, Worek F, Wille T. COPD and asthma therapeutics for supportive treatment in organophosphate poisoning. Clin Toxicol (Phila) 2019; 57:644-651. [PMID: 30696282 DOI: 10.1080/15563650.2018.1540785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Nerve agents like sarin or VX have repeatedly been used in military conflicts or homicidal attacks, as seen in Syria or Malaysia 2017. Together with pesticides, nerve agents assort as organophosphorus compounds (OP), which inhibit the enzyme acetylcholinesterase. To counteract subsequent fatal symptoms due to acetylcholine (ACh) accumulation, oximes plus atropine are administered, a regimen that lacks efficacy in several cases of OP poisoning. New therapeutics are in development, but still need evaluation before clinical employment. Supportive treatment with already approved drugs presents an alternative, whereby compounds from COPD and asthma therapy are likely options. A recent pilot study by Chowdhury et al. included β2-agonist salbutamol in the treatment of OP-pesticide poisoned patients, yielding ambiguous results concerning the addition. Here, we provide experimental data for further investigations regarding the value of these drugs in OP poisoning. Methods: By video-microscopy, changes in airway area were analyzed in VX-poisoned rat precision cut lung slices (PCLS) after ACh-induced airway contraction and subsequent application of selected anticholinergics/β2-agonists. Results: Glycopyrrolate and ipratropium efficiently antagonized an ACh-induced airway contraction in VX-poisoned PCLS (EC50 glycopyrrolate 15.8 nmol/L, EC50 ipratropium 2.3 nmol/L). β2-agonists formoterol and salbutamol had only negligible effects when solely applied in the same setting. However, combination of formoterol or salbutamol with low dosed glycopyrrolate or atropine led to an additive effect compared to the sole application [50.6 ± 8.8% airway area increase after 10 nmol/L formoterol +1 nmol/L atropine versus 11.7 ± 9.2% (10 nmol/L formoterol) or 8.6 ± 5.9% (1 nmol/L atropine)]. Discussion: We showed antagonizing effects of anticholinergics and β2-agonists on ACh-induced airway contractions in VX-poisoned PCLS, thus providing experimental data to support a prospective comprehensive clinical study. Conclusions: Our results indicate that COPD and asthma therapeutics could be a valuable addition to the treatment of OP poisoning.
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Affiliation(s)
- Julia Herbert
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
| | - Horst Thiermann
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
| | - Franz Worek
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
| | - Timo Wille
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
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Chowdhury FR, Rahman MM, Ullah P, Ruhan AM, Bari MS, Alam MMJ, Uddin MM, Maruf S, Patwary MI, Eddleston M. Salbutamol in acute organophosphorus insecticide poisoning – a pilotdose-response phase II study. Clin Toxicol (Phila) 2018; 56:820-827. [DOI: 10.1080/15563650.2018.1440587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Fazle Rabbi Chowdhury
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
- Centre for Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Md. Mustafezur Rahman
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
- Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Parash Ullah
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
- Department of Medicine, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh
| | - Abdul Mumith Ruhan
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Md. Shafiqul Bari
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - M. M. Jahangir Alam
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Md. Moyeen Uddin
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Shomik Maruf
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md. Ismail Patwary
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
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Nassenstein C, Wiegand S, Lips KS, Li G, Klein J, Kummer W. Cholinergic activation of the murine trachealis muscle via non-vesicular acetylcholine release involving low-affinity choline transporters. Int Immunopharmacol 2015; 29:173-80. [PMID: 26278668 DOI: 10.1016/j.intimp.2015.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 11/15/2022]
Abstract
In addition to quantal, vesicular release of acetylcholine (ACh), there is also non-quantal release at the motor endplate which is insufficient to evoke postsynaptic responses unless acetylcholinesterase (AChE) is inhibited. We here addressed potential non-quantal release in the mouse trachea by organ bath experiments and (immuno)histochemical methods. Electrical field stimulation (EFS) of nerve terminals elicited tracheal constriction that is largely due to ACh release. Classical enzyme histochemistry demonstrated acetylcholinesterase (AChE) activity in nerve fibers in the muscle and butyrylcholinesterase (BChE) activity in the smooth muscle cells. Acute inhibition of both esterases by eserine significantly raised tracheal tone which was fully sensitive to atropine. This effect was reduced, but not abolished, in AChE, but not in BChE gene-deficient mice. The eserine-induced increase in tracheal tone was unaffected by vesamicol (10(-5)M), an inhibitor of the vesicular acetylcholine transporter, and by corticosterone (10(-4)M), an inhibitor of organic cation transporters. Hemicholinium-3, in low concentrations an inhibitor of the high-affinity choline transporter-1 (CHT1), completely abrogated the eserine effects when applied in high concentrations (10(-4)M) pointing towards an involvement of low-affinity choline transporters. To evaluate the cellular sources of non-quantal ACh release in the trachea, expression of low-affinity choline transporter-like family (CTL1-5) was evaluated by RT-PCR analysis. Even though these transporters were largely abundant in the epithelium, denudation of airway epithelial cells had no effect on eserine-induced tracheal contraction, indicating a non-quantal release of ACh from non-epithelial sources in the airways. These data provide evidence for an epithelium-independent non-vesicular, non-quantal ACh release in the mouse trachea involving low-affinity choline transporters.
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Affiliation(s)
- Christina Nassenstein
- Institute for Anatomy and Cell Biology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC) and German Center for Lung Research (DZL), Excellence Cluster Cardio-Pulmonary System, 35385 Giessen, Germany.
| | - Silke Wiegand
- Institute for Anatomy and Cell Biology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC) and German Center for Lung Research (DZL), Excellence Cluster Cardio-Pulmonary System, 35385 Giessen, Germany
| | - Katrin S Lips
- Laboratory for Experimental Trauma Surgery, Justus-Liebig University Giessen, 35392 Giessen, Germany
| | - Guanfeng Li
- Department of Pharmacology, School of Pharmacy, Goethe University Frankfurt, 60438 Frankfurt am Main, Germany
| | - Jochen Klein
- Department of Pharmacology, School of Pharmacy, Goethe University Frankfurt, 60438 Frankfurt am Main, Germany
| | - Wolfgang Kummer
- Institute for Anatomy and Cell Biology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC) and German Center for Lung Research (DZL), Excellence Cluster Cardio-Pulmonary System, 35385 Giessen, Germany
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Somekawa-Kondo T, Yamaguchi K, Ishitsuka Y, Ito S, Tanaka K, Irikura M, Moriuchi H, Takahama K, Ando Y, Yamazaki T, Irie T. Aminophylline, administered at usual doses for rodents in pharmacological studies, induces hippocampal neuronal cell injury under low tidal volume hypoxic conditions in guinea-pigs. J Pharm Pharmacol 2012; 65:102-14. [PMID: 23215693 DOI: 10.1111/j.2042-7158.2012.01566.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To establish whether aminophylline, administered at usual doses for rodents in pharmacological studies, induces brain injury in systemic hypoxaemia in guinea-pigs. METHODS A hypoxaemia (partial oxygen tension of arterial blood (PaO₂) = 40-60 mmHg) model was developed by low tidal volume mechanical ventilation in guinea-pigs. KEY FINDINGS Under hypoxic conditions, aminophylline significantly increased the concentration of brain-specific creatine kinase in the serum in a dose- and time-dependent manner. A reduced number of hippocampal neuronal cells in the CA1 region, an increase in the concentration of neuron-specific enolase (NSE) in cerebrospinal fluid (CSF), an increase in lipid hydroperoxides and a decrease in the ratio of glutathione to glutathione disulfide in the brain tissues were also observed. These effects were not observed when aminophylline at the same doses was administered under normoxic conditions (PaO₂ = 80-100 mmHg). There was no difference in either serum or CSF concentrations of theophylline between normoxic and hypoxic conditions. Another methylxanthine, caffeine, did not increase the concentration of NSE in CSF. CONCLUSIONS Aminophylline potentially induces brain damage under hypoxic conditions. We suggest that aminophylline treatment has adverse effects in patients with hypoxaemia subsequent to respiratory disorders such as asthma.
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Affiliation(s)
- Tomoko Somekawa-Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
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Aworet-Samseny RRR, Souza A, Kpahé F, Konaté K, Datté JY. Dichrostachys cinerea (L.) Wight et Arn (Mimosaceae) hydro-alcoholic extract action on the contractility of tracheal smooth muscle isolated from guinea-pig. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2011; 11:23. [PMID: 21414220 PMCID: PMC3068131 DOI: 10.1186/1472-6882-11-23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 03/17/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Dichrostachys cinerea (L.) Wight et Arn. (Mimosaceae) is largely used in ethno-medically across Africa, and mainly employed for the treatment of asthma in Ivory Coast and Gabon. The paper analyses the relaxation induced by the methanolic extract of D. cinerea (Edici) in the guinea-pig trachea preparations (GPTPs). PURPOSE This study aimed to bring out the scientific basis to the use of this plant leading to the validation of this phytomedicine. METHOD The aorta obtained from guinea-pigs was immediately placed in a Mac Ewen solution. Experiments were performed in preparations suspended between two L-shaped stainless steel hooks in a 10 ml organ bath containing Mac Ewen solution. The isometric contractile force of the aorta strips of guinea-pig were recorded by using a strain gauge. The different drugs were directly administered into the organ bath and the magnitude of GPTPs was evaluated. RESULTS Phytochemical analysis of the methanolic extract of Dichrostachys cinerea (Edici) using chemical methods revealed the presence of flavenoids, tannins, sterols, triterpenes and polyphenols. Pharmacological studies performed in GPTPs show that of Dichrostachys cinerea (0.1 mg/ml - 2 mg/ml) evoked a broncho-constriction in GPTPs. Whereas, at concentration up to 2 mg/ml, Edici induced a significant dose-dependent relaxation in the GPTPs. KCl-, ACh- or histamine-evoked contractions of isolated trachea was significantly inhibited by increasing concentrations of Edici (3.5-10 mg/ml). Edici (10 mg/ml) as well as promethazine (0.25 mg/ml) significantly inhibited contractions induced by increasing concentrations of histamine (1×10-7-1×10-4mg/ml). In the presence of atropine at a concentration of 10-6mg/ml, contractile response curve (CRC) evoked by ACh (1×10-5-1×10-2 mg/ml) was significantly abolished in concentration-dependent manner. Edici did not significantly reduced ACh evoked contraction (10-5-10-2mg/ml). CONCLUSION These observations suggest that Edici could act through two mechanisms: firstly by activation of β-adrenergic or histaminergic receptors; and secondly muscarinic receptors may not be greatly involved, that justifying the use of the extract in traditional Medicine in Africa.
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Affiliation(s)
- Raissa RR Aworet-Samseny
- Institut de Pharmacopée et de Médecine Traditionnelle, Centre National de la Recherche Scientifique et Technologique (Cenarest) BP: 1156 Route de Sibang 3 Libreville Gabon
| | - Alain Souza
- Institut de Pharmacopée et de Médecine Traditionnelle, Centre National de la Recherche Scientifique et Technologique (Cenarest) BP: 1156 Route de Sibang 3 Libreville Gabon
| | - Fidele Kpahé
- Laboratoire de Nutrition et de Pharmacologie, UFR BioSciences, Université de Cocody, Abidjan 22 BP: 582 Abidjan -Côte d'Ivoire
| | - Kiessoun Konaté
- Laboratoire de Biochimie et de chimie Appliquées, UFR Science de la Vie et de la Terre, Université de Ouagadougou, 09 BP 848 Ouagadougou 09 Burkina Faso
| | - Jacques Y Datté
- Laboratoire de Nutrition et de Pharmacologie, UFR BioSciences, Université de Cocody, Abidjan 22 BP: 582 Abidjan -Côte d'Ivoire
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Chávez J, Vargas MH, Cruz-Valderrama JE, Montaño LM. Non-quantal release of acetylcholine in guinea-pig airways: role of choline transporter. Exp Physiol 2011; 96:460-7. [DOI: 10.1113/expphysiol.2010.056440] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Paraoxon attenuates vascular smooth muscle contraction through inhibiting Ca2+ influx in the rabbit thoracic aorta. J Biomed Biotechnol 2010; 2010:829190. [PMID: 20445738 PMCID: PMC2859412 DOI: 10.1155/2010/829190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Revised: 01/31/2010] [Accepted: 02/03/2010] [Indexed: 12/04/2022] Open
Abstract
We investigated the effect of paraoxon on vascular contractility using organ baths in thoracic aortic rings of rabbits and examined the effect of paraoxon on calcium homeostasis using a whole-cell patch-clamp technique in isolated aortic smooth muscle cells of rabbits. The findings show that administration of paraoxon (30 μM) attenuated thoracic aorta contraction induced by phenylephrine (1 μM) and/or a high K+
environment (80 mM) in both the presence and absence of thoracic aortic endothelium. This inhibitory effect of paraoxon on vasoconstrictor-induced contraction was abolished in the absence of extracellular Ca2+, or in the presence of the Ca2+ channel inhibitor, verapamil. But atropine had little effect on the inhibitory effect of paraoxon on phenylephrine-induced contraction. Paraoxon also attenuated vascular smooth muscle contraction induced by the cumulative addition of CaCl2
and attenuated an increase of intracellular Ca2+ concentration induced by K+
in vascular smooth muscle cells. Moreover, paraoxon (30 μM) inhibited significantly L-type calcium current in isolated aortic smooth muscle cells of rabbits. In conclusion, our results demonstrate that paraoxon attenuates vasoconstrictor-induced contraction through inhibiting Ca2+ influx in the rabbits thoracic aorta.
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Ventilatory effects of low-dose paraoxon result from central muscarinic effects. Toxicol Appl Pharmacol 2008; 233:186-92. [DOI: 10.1016/j.taap.2008.08.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 07/30/2008] [Accepted: 08/05/2008] [Indexed: 11/15/2022]
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