The endocrine effects of bitter tastant administration in the gastrointestinal system: intragastric versus intraduodenal administration

Bitter tastants are recently introduced as potential hunger-suppressive compounds, the so-called "Bitter pill." However, the literature about bitter administration lacks consistency in methods and findings. We want to test whether hunger ratings and hormone plasma levels are affected by: 1) the site of administration: intragastrically (IG) or intraduodenally (ID), 2) the bitter tastant itself, quinine hydrochloride (QHCl) or denatonium benzoate (DB), and 3) the timing of infusion. Therefore, 14 healthy, female volunteers participated in a randomized, placebo-controlled six-visit crossover study. After an overnight fast, DB (1 µmol/kg), QHCl (10 µmol/kg), or placebo were given IG or ID via a nasogastric feeding tube. Blood samples were taken 10 min before administration and every 10 min after administration for a period of 2 h. Hunger was rated at the same time points on a visual analogue scale. ID bitter administration did not affect hunger sensations, motilin, or acyl-ghrelin release compared with its placebo infusion. IG QHCl infusion tended to suppress hunger increase, especially between 50 and 70 min after infusion, simultaneously with reduced motilin values. Here, acyl-ghrelin was not affected. IG DB did not affect hunger or motilin, however acyl-ghrelin levels were reduced 50-70 minutes after infusion. Plasma values of glucagon-like peptide 1 and cholecystokinin were too low to be properly detected or to have any physiological relevance. In conclusion, bitter tastants should be infused into the stomach to reduce hunger sensations and orexigenic gut peptides. QHCl has the best potential to reduce hunger sensations, and it should be infused 60 min before food intake.NEW & NOTEWORTHY Bitter tastants are a potential new weight-loss treatment. This is a noninvasive, easy approach, which should be received with considerable enthusiasm by the public. However, literature about bitter administration lacks consistency in methods and findings. We summarize how the compound should be given based on: the site of administration, the best bitter compound to use, and at what timing in respect to the meal. This paper is therefore a fundamental step to continue research toward the further development of the "bitter pill."

Genetic recombination in disgust-associated bitter taste-responsive neurons of the central nucleus of amygdala in male mice

A bitter substance induces specific orofacial and somatic behavioral reactions such as gapes in mice as well as monkeys and humans. These reactions have been proposed to represent affective disgust, and therefore, understanding the neuronal basis of the reactions would pave the way to understand affective disgust. It is crucial to identify and access the specific neuronal ensembles that are activated by bitter substances, such as quinine, the intake of which induces disgust reactions. However, the method to access the quinine-activated neurons has not been fully established yet. Here, we show evidence that a targeted recombination in active populations (TRAP) method, induces genetic recombination in the quinine-activated neurons in the central nucleus of the amygdala (CeA). CeA is one of the well-known emotional centers of the brain. We found that the intraoral quinine infusion, that resulted in disgust reactions, increased both cFos-positive cells and Arc-positive cells in the CeA. By using Arc-CreER;Ai3 TRAP mice, we induced genetic recombination in the quinine-activated neurons and labelled them with fluorescent protein. We confirmed that the quinine-TRAPed fluorescently-labelled cells preferentially coexpressed Arc after quinine infusion. Our results suggest that the TRAP method can be used to access specific functional neurons in the CeA.

Intragastric administration of the bitter tastant quinine lowers the glycemic response to a nutrient drink without slowing gastric emptying in healthy men

The rate of gastric emptying and the release of gastrointestinal (GI) hormones are major determinants of postprandial blood-glucose concentrations and energy intake. Preclinical studies suggest that activation of GI bitter-taste receptors potently stimulates GI hormones, including glucagon-like peptide-1 (GLP-1), and thus may reduce postprandial glucose and energy intake. We evaluated the effects of intragastric quinine on the glycemic response to, and the gastric emptying of, a mixed-nutrient drink and the effects on subsequent energy intake in healthy men. The study consisted of 2 parts: part A included 15 lean men, and part B included 12 lean men (aged 26 ± 2 yr). In each part, participants received, on 3 separate occasions, in double-blind, randomized fashion, intragastric quinine (275 or 600 mg) or control, 30 min before a mixed-nutrient drink (part A) or before a buffet meal (part B). In part A, plasma glucose, insulin, glucagon, and GLP-1 concentrations were measured at baseline, after quinine alone, and for 2 h following the drink. Gastric emptying of the drink was also measured. In part B, energy intake at the buffet meal was quantified. Quinine in 600 mg (Q600) and 275 mg (Q275) doses alone stimulated insulin modestly (P < 0.05). After the drink, Q600 and Q275 reduced plasma glucose and stimulated insulin (P < 0.05), Q275 stimulated GLP-1 (P < 0.05), and Q600 tended to stimulate GLP-1 (P = 0.066) and glucagon (P = 0.073) compared with control. Quinine did not affect gastric emptying of the drink or energy intake. In conclusion, in healthy men, intragastric quinine reduces postprandial blood glucose and stimulates insulin and GLP-1 but does not slow gastric emptying or reduce energy intake under our experimental conditions.

Intravenous artesunate plus oral dihydroartemisinin-piperaquine or intravenous quinine plus oral quinine for optimum treatment of severe malaria: lesson learnt from a field hospital in Timika, Papua, Indonesia

BACKGROUND

Intravenous artesunate and its follow on full course dihydroartemisinin-piperaquine are the standard treatment for severe malaria in Indonesia. The current policy suggests that intravenous and oral quinine could be used when standard therapy is not available. Its pragmatic use of both treatment combinations in a field hospital is evaluated.

METHODS

A retrospective study among hospitalized malaria patients receiving intravenous anti-malarial treatments at Mitra Masyarakat Hospital, Timika from April 2004 to December 2013 was conducted. The length of hospital stay (LoS) and the risk of malaria recurrence within 28 days after hospital admission were compared between patients receiving intravenous artesunate and oral dihydroartemisinin-piperaquine (Iv Art + DHP) and those receiving intravenous and oral quinine (Iv + Oral Qu).

RESULTS

Of 10,514 patients requiring intravenous therapy, 2759 received Iv + Oral Qu and 7755 received Iv Art + DHP. Plasmodium falciparum infection accounted for 65.8% (6915), while Plasmodium vivax, Mixed infections, Plasmodium malariae and Plasmodium ovale were accounted for 17.0% (1789), 16.4% (1729), 0.8% (79) and 0.01% (2) of the infections, respectively. The majority of severe malaria hospital admissions were highland Papuans (78.0%, 8201/10,501). In total 49% (5158) of patients were older than 15 years and 3463 (32.9%) were children under 5 years old. The median LoS was shorter in patients receiving intravenous artesunate compared to those treated with intravenous quinine (median = 2 [IQR 1-3] versus 3 days [IQR 2-4], p < 0.0001). Patients treated with intravenous quinine had higher risk of being hospitalized longer than 2 days (aOR of 1.70 [95% CI 1.54-1.88], p < 0.0001). The risk of recurrences within 28 days after hospital admission was 1.94 times higher (95% CI aHR 1.57-2.39, p < 0.0001) in patients receiving intravenous quinine with follow on oral quinine treatment than in patients treated with DHP after intravenous artesunate therapy.

CONCLUSIONS

Intravenous artesunate reduced the LoS of malaria patients and in combination with DHP reduced the risk of malaria recurrence within 28 days after hospital admission compared to those with Iv + Oral Qu treatment. Thus, ensuring continuous supply of intravenous artesunate and artemisinin-based combination therapy (ACT) should be a priority.

Absence of compulsive drinking phenotype in adult male rats exposed to ethanol in a binge-like pattern during adolescence

The abuse of alcohol during adolescence is widespread and represents a particular concern, given that earlier age of drinking onset is associated with increased risk for the development of alcohol use disorders (AUDs). Despite this risk, it remains unclear whether binge-like adolescent alcohol exposure facilitates drinking despite aversive consequences, a characteristic common among individuals with AUDs. The present study examined voluntary alcohol consumption and aversion-resistant drinking in adult male Long-Evans rats that had undergone adolescent intermittent ethanol (AIE) exposure by vapor inhalation between postnatal days (PD) 28-44. Ethanol consumption during adulthood was examined using a two-bottle choice (2BC) intermittent access procedure. Rats were tested for aversion-resistant drinking using ethanol adulterated with quinine (10, 30, 100 mg/L) after two 7-week periods of 2BC drinking. After completion of the second test of aversion-resistant drinking, rats were trained to operantly self-administer ethanol. The results revealed that both air control (AIR) and AIE-exposed rats exhibited similar ethanol intake and preference in the 2BC paradigm. After 7 weeks of 2BC drinking, quinine adulteration significantly suppressed ethanol intake, but only at the highest concentration examined (100 mg/L). However, upon retesting after a total of 17 weeks of 2BC drinking, 30-mg/L quinine suppressed ethanol intake. Notably, AIR- and AIE-exposed rats were equally sensitive to quinine-adulterated ethanol at both time points. In addition, AIR- and AIE-exposed rats responded similarly during operant ethanol self-administration on both fixed and progressive ratio schedules of reinforcement. Finally, both AIR- and AIE-exposed rats exhibited similar preference for sucrose. The results of this study show that binge-like ethanol vapor exposure during adolescence does not alter voluntary ethanol consumption, motivation to operantly respond for ethanol, or promote aversion-resistant ethanol consumption in adulthood. These data, together with previous work reporting conflicting results across various rodent models of adolescent alcohol exposure, underscore the need to further explore the role that exposure to alcohol during adolescence has on the development of heavy and compulsive drinking phenotypes in adulthood.

Artemether for severe malaria

BACKGROUND

In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This Cochrane Review evaluates intramuscular artemether compared with both quinine and artesunate.

OBJECTIVES

To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in the treatment of severe malaria in adults and children.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, and LILACS, ISI Web of Science, conference proceedings, and reference lists of articles. We also searched the WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 7 September 2018. We checked the reference lists of all studies identified by the search. We examined references listed in review articles and previously compiled bibliographies to look for eligible studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous/intramuscular quinine or artesunate for treating severe malaria.

DATA COLLECTION AND ANALYSIS

The primary outcome was all-cause death. Two review authors independently screened each article by title and abstract, and examined potentially relevant studies for inclusion using an eligibility form. Two review authors independently extracted data and assessed risk of bias of included studies. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and have presented both measures with 95% confidence intervals (CIs). Where appropriate, we combined data in meta-analyses and used the GRADE approach to summarize the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs, enrolling 2874 adults and children with severe malaria, carried out in Africa (12 trials) and in Asia (7 trials).Artemether versus quinineFor children, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.97, 95% CI 0.77 to 1.21; 13 trials, 1659 participants, moderate-certainty evidence). Coma resolution time may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low-certainty evidence). Artemether may make little difference to neurological sequelae (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low-certainty evidence). Compared to quinine, artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate-certainty evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low-certainty evidence).For adults, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate-certainty evidence).Artemether versus artesunateArtemether and artesunate have not been directly compared in randomized trials in children.For adults, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97; two trials, 494 participants, moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Artemether appears to be more effective than quinine in children and adults. Artemether compared to artesunate has not been extensively studied, but in adults it appears inferior. These findings are consistent with the WHO recommendations that artesunate is the drug of choice, but artemether is acceptable when artesunate is not available.

A Neuronal Ensemble in the Rostral Agranular Insula Tracks Cocaine-Induced Devaluation of Natural Reward and Predicts Cocaine Seeking

In substance use disorders, negative affect associated with drug withdrawal can elicit strong drug craving and promote relapse. One brain region implicated in those processes is the rostral agranular insular cortex (RAIC), although precisely how this region encodes negative affect associated with drug seeking is unknown. Here, a preclinical model was used where RAIC activity was examined in male Sprague Dawley rats during intraoral infusions of a sweet (saccharin) paired with impending but delayed access to cocaine self-administration, and for comparative purposes, during the sweet predicting saline self-administration or injection of lithium chloride (LiCl), or during intraoral infusions of a bitter taste (quinine). Consistent with previous work, cocaine-paired saccharin, LiCl-paired saccharin, and quinine all elicited aversive taste reactivity. However, the aversive taste reactivity elicited by the cocaine-paired tastant was qualitatively different from that evoked by the other two agents. Furthermore, differences in taste reactivity were reflected in RAIC cell firing, where distinct shifts in neural signaling were observed specifically after cocaine but not LiCl conditioning. Notably, low motivation for cocaine (indicated by low loading and slower latencies to lever press) was correlated with this shift in RAIC signaling, but aversive (gaping) responses were not. Collectively, these findings indicate that cocaine-paired tastants elicit unique aspects of aversive behaviors that differ from traditional conditioned taste aversion (LiCl) or quinine and that the RAIC plays a role in modulating drug-seeking behaviors driven by drug-induced dysphoria (craving), but not negative affect per se.SIGNIFICANCE STATEMENT In substance use disorders, negative affect associated with drug cues can elicit craving and promote relapse; however, the underlying neurocircuitry of this phenomenon is unknown. Here, we investigated the role of the rostral agranular insula cortex (RAIC) in these processes using a preclinical model wherein intraoral delivery of a sweet is paired with delayed access to cocaine self-administration. The taste comes to elicit negative affect that predicts heightened drug seeking. Here, we found that a population of RAIC neurons became inhibited during presentation of the cocaine-paired tastant (when negative affect is high) and that this inhibitory neural profile predicted lower drug seeking. These findings suggest that the RAIC may function to oppose cue-induced cocaine craving and help reduce motivation for the drug.

Distribution of Fos-immunoreactive neurons in the gustatory cortex elicited by intra-oral infusion of taste solutions in conscious rats

The location of neurons in the gustatory cortex (GC) activated by intra-oral infusion of solutions in conscious rats was mapped using Fos immunohistochemistry. Groups of adult male Wistar rats (N's = 5) received an infusion of one of the following: dH2O, 0.1 or 1.0 M NaCl, 0.1 or 1.0 M sucrose, 0.32 M MSG (with 100 µM amiloride and 2.5 M inosine 5'-monophosphate), 0.03 M HCl, or 0.003 M QHCl delivered via an intra-oral cannula (0.233 ml/min for 5 min). Unstimulated control rats received no infusion. Taste reactivity (TR) behaviors were videotaped and scored. The number of Fos-immunoreactive (Fos-IR) neurons was counted in eight sections throughout the anterior-posterior extent of the GC in the medial and lateral halves of the granular (GI), dysgranular (DI), and dorsal (AID) and ventral (AIV) agranular insular cortices. Intra-oral infusion of dH2O, NaCl, or sucrose altered the number of Fos-IR neurons in only specific subareas of the GC and the effects of these tastants were concentration-dependent. For example, 1.0 M NaCl increased Fos-IR neurons in the posterior lateral AID and DI and elicited more aversive TR responses than 0.1 M NaCl. Compared to dH2O, infusions of HCl or QHCl increased the total number of Fos-IR neurons in many subareas of the GC throughout its anterior-posterior extent and increased aversive TR behaviors. Linear regression analyses suggested that neurons in the medial AID of the posterior GC may influence aversive behavioral responses to HCl and QHCl while neurons in the posterior lateral AID and DI may play a role in aversive TR responses to 1.0 M NaCl.

Association Between Long-term Quinine Exposure and All-Cause Mortality

This cohort study uses UK primary care database data to explore the association between long-term quinine exposure and all-cause mortality.

Influence of Bitter Taste on Mastication Pattern

Mastication is a rhythmic activity that can be modified by peripheral information generated in the mouth. To study whether taste cognition could influence the way in which a food is broken down in the mouth, subjects masticated firm, sugar-based gelatine gels with differing concentrations of quinine, up to 1500 μmol/kg, while electromyography (EMG) of masticatory muscles was recorded. Taste intensity and composition of saliva were measured. With increasing quinine concentration, the average number of chews for nine subjects decreased from 30 to 22, and their average clearance time increased from 7 to 14 sec. Quinine concentration had no effect on chewing frequency (1.3 Hz) or on the rate of salivation (5.5 g/min). Bitterness increased, while acceptability and sweetness decreased, with increasing concentration of quinine in the gel and in saliva. Taste cognition could therefore modify food breakdown in the mouth.

Combinatorial approaches with selected phytochemicals to increase antibiotic efficacy against Staphylococcus aureus biofilms

Combinations of selected phytochemicals (reserpine, pyrrolidine, quinine, morin and quercetin) with antibiotics (ciprofloxacin, tetracycline and erythromycin) were tested on the prevention and control of Staphylococcus aureus biofilms. The phytochemicals were also studied for their ability to avoid antibiotic adaptation and to inhibit antibiotic efflux pumps. Morin, pyrrolidine and quercetin at subinhibitory concentrations had significant effects in biofilm prevention and/or control when applied alone and combined with antibiotics. Synergism between antibiotics and phytochemicals was found especially against biofilms of NorA overexpressing strain S. aureus SA1199B. This strain when growing with subinhibitory concentrations of ciprofloxacin developed increased tolerance to this antibiotic. However, this was successfully reversed by quinine and morin. In addition, reserpine and quercetin showed significant efflux pump inhibition. The overall results demonstrate the role of phytochemicals in co-therapies to promote more efficient treatments and decrease antimicrobial resistance to antibiotics, with substantial effects against S. aureus in both planktonic and biofilm states.

Consequences of constitutive deletion of melanin-concentrating hormone-1 receptors for feeding and foraging behaviors of mice

In order to decipher the functional involvement of melanin-concentrating hormone 1 (MCH1) receptors in the control of feeding and foraging behaviors, mice with constitutive deletion of MCH1 receptors MCH1R -/- or knockout (KO) were studied and compared to age-matched littermate control mice (MCH1R +/+ or wildtype (WT)). Several challenges to food-motivated behaviors of food-restricted WT and KO mice were implemented. There were no differences between genotypes in the acquisition of a nose-poke response that produced food or in a discrimination between a response that produced food and one that did not. There were also no genotype differences in the rate of extinction of a food-motivated response. However, during the first day of extinction, foraging behaviors were increased significantly more in KO than in WT mice. Likewise, when the response requirement to obtain food was progressively increased, KO mice made significantly more food-directed responses than WT mice. Although adulteration of food with quinine did not suppress food-directed behavior in either genotype when the mice were food-restricted, manipulation of the degree of food-deprivation resulted in suppression of behavior of WT mice without suppressing the behavior of KO mice. Although response-produced foot shock suppressed food-maintained responding of both WT and KO mice, equipotent levels of shock (based upon psychophysical thresholds) suppressed behavior of WT mice without suppressing behavior of the KO mice. Finally, under a Vogel conflict procedure, KO mice had significantly higher levels of both punished and non-punished food maintained responding. Thus, the data from challenges with both appetitive and noxious stimulus challenges support the conclusion that mice with constitutive deletion of MCH1Rs have increased food seeking motivation that is coincident with their higher metabolism. The data also highlight important differences in the biological impact of MCH1 receptor KO and MCH1 receptor antagonism.

A single alcohol drinking session is sufficient to enable subsequent aversion-resistant consumption in mice

Addiction is mediated in large part by pathological motivation for rewarding, addictive substances, and alcohol-use disorders (AUDs) continue to extract a very high physical and economic toll on society. Compulsive alcohol drinking, where intake continues despite negative consequences, is considered a particular obstacle during treatment of AUDs. Aversion-resistant drives for alcohol have been modeled in rodents, where animals continue to consume even when alcohol is adulterated with the bitter tastant quinine, or is paired with another aversive consequence. Here, we describe a two-bottle choice paradigm where C57BL/6 mice first had 24-h access to 15% alcohol or water. Afterward, they drank quinine-free alcohol (alcohol-only) or alcohol with quinine (100 μM), in a limited daily access (LDA) two-bottle-choice paradigm (2 h/day, 5 days/week, starting 3 h into the dark cycle), and achieved nearly binge-level blood alcohol concentrations. Interestingly, a single, initial 24-h experience with alcohol-only enhanced subsequent quinine-resistant drinking. In contrast, mice that drank alcohol-quinine in the 24-h session showed significantly reduced alcohol-quinine intake and preference during the subsequent LDA sessions, relative to mice that drank alcohol-only in the initial 24-h session and alcohol-quinine in LDA sessions. Thus, mice could find the concentration of quinine we used aversive, but were able to disregard the quinine after a single alcohol-only drinking session. Finally, mice had low intake and preference for quinine in water, both before and after weeks of alcohol-drinking sessions, suggesting that quinine resistance was not a consequence of increased quinine preference after weeks of drinking of alcohol-quinine. Together, we demonstrate that a single alcohol-only session was sufficient to enable subsequent aversion-resistant consumption in C57BL/6 mice, which did not reflect changes in quinine taste palatability. Given the rapid development of quinine-resistant alcohol drinking patterns, this model provides a simple, quick, and robust method for uncovering the mechanisms that promote aversion-resistant consumption.

Parsing the hedonic and motivational influences of nociceptin on feeding using licking microstructure analysis in mice

Opioid peptides are implicated in processes related to reward and aversion; however, how specific opioid peptides are involved remains unclear. We investigated the role of nociceptin (NOC) in voluntary licking for palatable and aversive tastants by studying the effect of intracerebroventricularly administered NOC on licking microstructure in wild-type and NOC receptor knockout (NOP KO) mice. Compared with the wild-type mice, NOP KO mice emitted fewer bouts of licking when training to lick for a 20% sucrose solution. Correspondingly, intracerebroventricular administration of NOC increased the number of licking bouts for sucrose and sucralose in wild-type, but not in NOP KO mice. The ability of NOC to initiate new bouts of licking for sweet solutions suggests that NOC may drive motivational aspects of feeding behavior. Conversely, adulterating a sucrose solution with the aversive tastant quinine reduced licking bout lengths in wild-type and NOP KOs, suggesting that NOC signaling is not involved in driving voluntary consumption of semiaversive tastants. Interestingly, when consuming sucrose following 20 h of food deprivation, NOP KO mice emitted longer bouts of licking than wild types, suggesting that under hungry conditions, NOC may also contribute toward hedonic aspects of feeding. Together, these results suggest differential roles for NOC in the motivational and hedonic aspects of feeding.

Alterations in taste perception as a result of hyperbaric oxygen therapy

The present study evaluates the effect of hyperbaric oxygen therapy on taste sensitivity, hedonic perception of taste, and food preferences. The studied groups included 197 people in total (79 in the study group; 118 in the control group). All patients from the study group were treated with hyperbaric oxygen therapy due to chronic non-healing wounds. The control group consisted of healthy people, who did not receive hyperbaric oxygen therapy. The taste intensity, recognition thresholds, and hedonic perception were examined using gustatory tests. The aqueous solutions of sucrose for sweet, sodium chloride for salty, citric acid for sour, quinine hydrochloride for bitter, and monosodium glutamate for umami taste were used. The participants fulfilled the questionnaire to examine pleasure derived from eating certain types of dishes. Gustatory tests and analyses of the pleasure derived from eating in the study group were carried out before the first exposure to hyperbaric oxygen and then at the end of therapy, after at least 25 sessions of treatment. In the control group, examination of perception of taste sensations was conducted only once. The results of comparing patients with non-healing wounds with healthy people are characterized by reduced taste sensitivity. After participation in hyperbaric oxygen therapy, the improvement in perception of taste sensations and changes in hedonic evaluation have occurred among patients with non-healing wounds. In terms of food preference, a decreased desire for eating sweet desserts, chocolate, and crisps was observed in those patients who received hyperbaric oxygen therapy.

The controversial experiments on the intravenous administration of drugs (and air!) during the cholera epidemic of 1867 in Italy

Cholera ravaged many American and European cities in the nineteenth century. Likewise, Italy was struck by six epidemics since the morbus first appeared in 1835-1837. After the International Sanitary Conferences held in Paris in 1851, there was a decrease of the cases due to consolidation of the city in terms of public and private health. Nevertheless, due to the lack of alternative and innovative remedies, the mortality remained unchanged, affecting more than 60 percent of patients. The city of Brescia in Northern Italy was severely hit by the epidemic of 1867. Not being able to implement effective therapeutic strategies, the administration of drugs like quinine and strychnine was proposed to be done intravenously. The results of intravenous injections were ominous, and all the patients died of "‘sudden death"’. Although the academic authorities forbade further experiments, some physicians carried on a long trial using test animals and mental patients as ‘"guinea pigs"’.

Mouth rinsing and ingestion of a bitter-tasting solution increases corticomotor excitability in male competitive cyclists

PURPOSE

Recently, we have shown that the combination of mouth rinsing and ingesting a bitter-tasting quinine solution immediately prior to the performance of a maximal 30-s cycling sprint significantly improves mean and peak power output. This ergogenic effect was proposed to be related to the activation of the corticomotor pathway by afferent taste signals originating from bitter taste receptors in the oral cavity. The aim of the present study was to use single-pulse transcranial magnetic stimulation to investigate whether mouth rinsing and ingestion of a bitter quinine solution increases corticomotor excitability.

METHODS

A series of 10 motor-evoked potentials (MEPs) were recorded from the relaxed first dorsal interosseus muscle in 16 male competitive cyclists immediately before and after they rinsed their mouth for 10 s and then ingested either a 2 mM bitter quinine solution or plain water.

RESULTS

Mean MEP amplitude was significantly increased in response to quinine administration by 16% (p < 0.05), with no evidence of a time-dependent effect over the 10 pulses. Mean MEP amplitude also increased by 10% in response to water administration (p < 0.05), though this increase was significantly smaller than the response to quinine (p < 0.05).

CONCLUSIONS

We conclude that the activation of bitter taste receptors in the oral cavity and upper gastrointestinal tract has the capacity to increase corticomotor excitability in male competitive cyclists.

Perinatal administration of a bitter tastant influences gene expression in chicken palate and duodenum

Bitter taste receptors (Tas2rs) and downstream effectors are responsible for mediating bitterness perception and regulation of food choice in mammals. Using RT-PCR, we demonstrated the expression of three Tas2rs and taste signal transduction molecules, α-gustducin, PLCβ2, and TRPM5, in the palate, tongue, and gastrointestinal tract sections in chicken. The bitter tastant quinine activates all three chicken Tas2rs in vitro as shown using calcium-imaging assays of transfected cells. Administration of quinine postnatally or perinatally (both pre- and posthatch) to chickens increased the expression of Tas2r genes in the palate by 6.45-fold (ggTas2r1 postnatal treatment), 4.86-fold (ggTas2r1 perinatal treatment), and 4.48-fold (ggTas2r7 postnatal treatment) compared to the genes' expression in the naı̈ve group respectively, and affected taste related gene expression in the duodenum. Whereas no-choice intake of quinine solution was not significantly lower than that of water in naı̈ve chicks, the treatment groups postnatal, prenatal, and perinatal showed significantly lower intake of quinine by 56.1, 47.7, and 50.2%, respectively, suggesting a possible trend toward sensitization. These results open new venues toward unraveling the formative stages shaping food intake and nutrition in chicken.

Artesunate. The standard intravenous treatment for severe attacks of malaria

Intravenous artesunate is more effective in reducing mortality than injectable quinine. It also has a better adverse effect profile and is more convenient to use.

Artemether for severe malaria

BACKGROUND

In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation, many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This review evaluates intramuscular artemether compared with both quinine and artesunate.

OBJECTIVES

To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in treating severe malaria in adults and children.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE and LILACS, ISI Web of Science, conference proceedings and reference lists of articles. We also searched the WHO clinical trial registry platform, ClinicalTrials.gov and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 9 April 2014.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous or intramuscular antimalarial for treating severe malaria.

DATA COLLECTION AND ANALYSIS

The primary outcome was all-cause death.Two authors independently assessed trial eligibility, risk of bias and extracted data. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD), and presented both measures with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 18 RCTs, enrolling 2662 adults and children with severe malaria, carried out in Africa (11) and in Asia (7). Artemether versus quinine For children in Africa, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.96, 95% CI 0.76 to 1.20; 12 trials, 1447 participants, moderate quality evidence). Coma recovery may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low quality evidence), and artemether may result in fewer neurological sequelae, but larger trials would be needed to confirm this (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low quality evidence). Artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate quality evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low quality evidence).For adults in Asia, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate quality evidence). Artemether versus artesunate Artemether and artesunate have not been directly compared in randomized trials in African children.For adults in Asia, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97, two trials,494 participants, moderate quality evidence).

AUTHORS' CONCLUSIONS

Although there is a lack of direct evidence comparing artemether with artesunate, artemether is probably less effective than artesunate at preventing deaths from severe malaria. In circumstances where artesunate is not available, artemether is an alternative to quinine.

Restoration of quinine-stimulated Fos-immunoreactive neurons in the central nucleus of the amygdala and gustatory cortex following reinnervation or cross-reinnervation of the lingual taste nerves in rats

Remarkably, when lingual gustatory nerves are surgically rerouted to inappropriate taste fields in the tongue, some taste functions recover. We previously demonstrated that quinine-stimulated oromotor rejection reflexes and neural activity (assessed by Fos immunoreactivity) in subregions of hindbrain gustatory nuclei were restored if the posterior tongue, which contains receptor cells that respond strongly to bitter compounds, was cross-reinnervated by the chorda tympani nerve. Such functional recovery was not seen if instead, the anterior tongue, where receptor cells are less responsive to bitter compounds, was cross-reinnervated by the glossopharyngeal nerve, even though this nerve typically responds robustly to bitter substances. Thus, recovery depended more on the taste field being reinnervated than on the nerve itself. Here, the distribution of quinine-stimulated Fos-immunoreactive neurons in two taste-associated forebrain areas was examined in these same rats. In the central nucleus of the amygdala (CeA), a rostrocaudal gradient characterized the normal quinine-stimulated Fos response, with the greatest number of labeled cells situated rostrally. Quinine-stimulated neurons were found throughout the gustatory cortex, but a "hot spot" was observed in its anterior-posterior center in subregions approximating the dysgranular/agranular layers. Fos neurons here and in the rostral CeA were highly correlated with quinine-elicited gapes. Denervation of the posterior tongue eliminated, and its reinnervation by either nerve restored, numbers of quinine-stimulated labeled cells in the rostralmost CeA and in the subregion approximating the dysgranular gustatory cortex. These results underscore the remarkable plasticity of the gustatory system and also help clarify the functional anatomy of neural circuits activated by bitter taste stimulation.

Taste hedonics influence the disposition of fat by modulating gastric emptying in rats

We investigated how preferred and nonpreferred tastes influence the disposition of fat. Adult male Sprague Dawley rats were infused with 5 ml of 20% intralipid through an intragastric catheter and with 0.3 ml of a taste solution through an intraoral catheter. At 120 min postinfusion, plasma concentrations of fat fuels (triglycerides and non-esterified fatty acids) were either unchanged or slightly higher after rats tasted a preferred sweet taste solution (0.125% saccharin +3% glucose) than after they tasted water. They were markedly lower after rats tasted a non-preferred solution–either a bitter solution (0.15% quinine hydrochloride) or a sweet solution that had previously been the conditioned stimulus for lithium-induced taste aversion. The distribution of ¹⁴C-triolein mixed with the gastric load was determined at 4 h postinfusion. Rats that received a non-preferred bitter taste had significantly more ¹⁴C remaining in the stomach than did those that received a preferred sweet taste. These results suggest that taste hedonics–either unconditioned or conditioned aversive tastes–influence fat disposition by altering gastric emptying.

[Malaria diagnosis and treatment: analysis of a cohort of hospitalised patients at a tertiary level hospital (1998-2010)]

INTRODUCTION

The increasing frequency of malaria infection in our area is due to the rise in international travel and immigration from endemic malaria areas. The aim of this study is to describe the chemoprophylaxis taken and treatment given as well as the clinical, epidemiological and microbiological characteristics for those patients admitted to our hospital with malaria.

METHODS

A retrospective study of patients with malaria admitted to the Hospital Virgen de la Arrixaca, between January 1998 and December 2010, was carried out.

RESULTS

During this period, fifty one cases of malaria were diagnosed. 78.3% of them were immigrants of whom 65% resided in Spain and had travelled to their country of origin for a short stay. Seventy four per cent acquired the infection in central and west Africa, and Plasmodium falciparum was responsible for the majority of the cases (88%). Only four patients had taken antimalarial chemoprophylaxis but none correctly. The most frequently treatment used was a combination of quinine and doxycicline (64.7%). Inappropriate anti-malarial treatment occurred in 9 patients (17.6%). At least one indicator of severe malaria was established in 23.5% of the cases; however, the clinical outcome was successful in every case and no patient died.

CONCLUSIONS

Imported malaria is observed mostly among immigrants who travel to their countries of origin for a short stay and do not take anti-malarial prophylaxis, increasing the risk of acquiring malaria. Inappropriate malarial treatment is relatively frequent in the case management of imported malaria.

Neurotoxic effects of administration of artemisinin combination therapy (artemether and quinine) and ascorbic acid on the cytoarchitecture of the cerebellum and trapezoid nuclei in adult rats

This study investigated the neurotoxic effects of the combined intramuscular administration of Artemether (0.5 mg/kg/b.w.), Quinine (5.14 mg/kg/b.w.) and Ascorbic acid (0.21 mg/kg/b.w) on the cerebellum, trapezoid nuclei and behavioural functions in male Wistar rats for a period of seven days. Statistical analyses showed no significant differences between the average weight of the brain and cerebellum of the experimental group compared with the control group. All experimental rats showed normal histology on completion of the experimental procedures in comparison with control rats. Histological assessment of the cerebellum and trapezoid nuclei in all groups showed normal cytoarchitecture. All rats displayed normal balance and co-ordination. This study observed that the combined therapy regime over a seven day period did not cause neurohistopathological effects on the cytoarchitecture of the cerebellum and trapezoid nuclei indicating that the current therapeutic doses of Artemether combined with Quinine used in the treatment of malaria are probably safe.

Behavioural analyses of quinine processing in choice, feeding and learning of larval Drosophila

Gustatory stimuli can support both immediate reflexive behaviour, such as choice and feeding, and can drive internal reinforcement in associative learning. For larval Drosophila, we here provide a first systematic behavioural analysis of these functions with respect to quinine as a study case of a substance which humans report as “tasting bitter”. We describe the dose-effect functions for these different kinds of behaviour and find that a half-maximal effect of quinine to suppress feeding needs substantially higher quinine concentrations (2.0 mM) than is the case for internal reinforcement (0.6 mM). Interestingly, in previous studies (Niewalda et al. 2008, Schipanski et al 2008) we had found the reverse for sodium chloride and fructose/sucrose, such that dose-effect functions for those tastants were shifted towards lower concentrations for feeding as compared to reinforcement, arguing that the differences in dose-effect function between these behaviours do not reflect artefacts of the types of assay used. The current results regarding quinine thus provide a starting point to investigate how the gustatory system is organized on the cellular and/or molecular level to result in different behavioural tuning curves towards a bitter tastant.

[A severe falciparum malaria case successfully treated by exchange transfusion as an adjunct therapy]

Plasmodium falciparum malaria is a type of malaria with high fatality rate despite optimal antimalarial treatment. Exchange transfusion (ET) is successfully used as a means of supportive therapy in severe P. falciparum malaria cases with hyperparasitemia. Herein, we present a case with hyperparasitemia, who received erythrocyte ET therapy due to lack of clinical response to antimalarial treatment. A 24-year-old male patient was admitted to our emergency clinic with the complaints of fever that persisted for 10 days, headache, nausea-vomiting, and impaired consciousness. Medical history revealed that he had been working in Sudan, Africa and returned back 12 days ago. On physical examination; he had fever, hypotension, tachycardia, subicterus and impaired cooperation. Laboratory examination revealed pancytopenia, elevated C-reactive protein, hyperbilirubinemia, hyponatremia, elevated creatinine level and hematuria. On thick blood smear and thin blood smear examinations, multiple (> 5%) trophozoites and gametocytes indicating P.falciparum species were observed. The case was diagnosed as P.falciparum malaria and parenteral fluid support, dopamine infusion, meropenem (IV), doxycycline (PO) and quinine sulphate (PO) were initiated in the intensive care unit. On reevaluation of the patient on the third day of hospitalization, it was observed that arterial hypotension and fever were persistent, anemia and trombocytopenia deteriorated and on thick blood smear parasitemiea was not decreased. It was decided to apply automated erythrocyte ET. After ET, patient's medical status was quickly improved and patient was discharged on the 7th day of hospitalization. In conclusion, it was noted that in addition to antimalarial treatment, erythrocyte ET may provide dramatic improvement in severe cases of P.falciparum malaria with hyperparasitemia.

Artesunate versus quinine for treating severe malaria

BACKGROUND

Severe malaria results in over a million deaths every year, most of them in children aged under five years and living in sub-Saharan Africa. This review examines whether treatment with artesunate, instead of the standard treatment quinine, would result in fewer deaths and better treatment outcomes.

OBJECTIVES

To compare artesunate with quinine for treating severe malaria.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, ISI Web of Science, the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles to November 2010.

SELECTION CRITERIA

Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility and risk of bias of trials, and extracted and analysed data. The primary outcome was all-cause death. Dichotomous outcomes were summarized using risk ratios (RR) and continuous outcomes by mean differences (MD). Where appropriate, we combined data in meta-analyses.

MAIN RESULTS

Eight trials enrolling 1664 adults and 5765 children are included in this review.Treatment with artesunate significantly reduced the risk of death both in adults (RR 0.61, 95% Confidence Interval (CI) 0.50 to 0.75; 1664 participants, five trials) and children (RR 0.76, 95% CI 0.65 to 0.90; 5765 participants, four trials)In children, treatment with artesunate increased the incidence of neurological sequelae at the time of hospital discharge. The majority of these sequelae were transient and no significant difference between treatments was seen at later follow up.

AUTHORS' CONCLUSIONS

The evidence clearly supports the superiority of parenteral artesunate over quinine for the treatment of severe malaria in both adults and children and in different regions of the world.

Effect of vitamin A adjunct therapy for cerebral malaria in children admitted to Mulago hospital: a randomized controlled trial

BACKGROUND

Malaria is a leading cause of mortality in Uganda accounting for 25% of deaths among children. Hitherto no adjunct therapy has been identified to improve outcome of cerebral malaria. Retinol suppresses growth of P.falciparum, scavenges free radicals, and exhibits synergistic action with quinine in parasite clearance.

OBJECTIVE

To determine the effect of vitamin A supplementation on treatment outcome of cerebral malaria

METHODS

In this randomised double-blind placebo controlled clinical trial we studied 142 children aged 6-59 months admitted with cerebral malaria in Mulago Hospital, Kampala. Children were randomised to either vitamin A or placebo and followed for 7 days. The main outcome measures were coma recovery time, time for convulsions to stop, and parasite and fever clearance. Secondary outcomes were overall mortality and time taken to start oral feeds.

RESULTS

There was no difference in the coma recovery time (p=0.44), resolution of convulsions (p=0.37), fever clearance (p=0.92), parasite clearance (p=0.12), and starting oral feeds between the two treatment groups. Mortality was higher (16.2%) in the placebo than in the vitamin A group (8.1%): RR 1.4; 95% CI 1.0-2.1.

CONCLUSIONS

Vitamin A as adjunct therapy did not significantly reduce coma duration but there were fewer deaths in the vitamin A arm.

Development and validation of a taste sensitivity test in a group of healthy children

AIM

This was to validate a taste test on healthy school children. A cross-sectional study was designed to perform a standardised clinical evaluation of the gustatory sensitivity.

MATERIALS AND METHODS

Forty (18 males and 22 females) children were selected. Inclusion criteria were age between 5 and 12 years, absence of systemic disease and no antibiotic treatment in the last six months. The taste assessment tests were performed following a standardised protocol, repeated at two different intervals: a) tested at time 0; b) tested after 20-30 days. Tests were performed using a pipette with the sample solution: sucrose, sodium chloride, citric acid and quinine hydrochloride at different concentrations. The examiner reported in a grid the flavour perceived by the subject. A placebo (tap water) was administered in between the flavours

RESULTS

The majority of the subjects detected the bitter taste at the lowest concentration (mean=1.83). The sour taste was detected with the second concentration (mean=2.56). The sweet solution was detected with the most diluted concentration (mean=1.56). The salty taste has a threshold of 2 (mean=2.04), which means that the majority of subjects detected the salty solution with the second concentration. Regarding the perceived intensity, it increases with the increasing concentrations and it reaches maximum values that are inversely proportional to the threshold, corresponding to the second concentration. Moreover, no statistically significant gender differences were detected regarding the threshold values or the perceived intensity.

CONCLUSION

The proposed test allows for a controlled, reliable and standardised evaluation of the gustatory modality.

Quercetin protects against testicular toxicity induced by chronic administration of therapeutic dose of quinine sulfate in rats

BACKGROUND

Quinine, a rapidly acting blood schizonticide with a long history of use for the treatment of malaria, is gradually been implicated in reproductive toxicity.

METHODS

In this study, testicular and spermatotoxic effects of quinine sulfate (QS) following treatment with an oral dose of 10 mg/kg/day (normal therapeutic dose) for 8 weeks was investigated in male albino rats. Toxicity was evaluated by assessing antioxidant defense capacity and markers of oxidative stress and testicular dysfunction in the testes and epididymal sperm. The possible ameliorative effect of quercetin (QC), when co-administered with QS, was also assessed.

RESULTS

Administration of QS induced oxidative stress in rats. The activities of superoxide dismutase, catalase, and malondialdehyde (a marker of lipid peroxidation) increased (p<0.05) both in the testes and epididymal sperm following QS treatment when compared with saline-treated (control) rats. Ascorbic acid levels were significantly reduced, with an insignificant decrease in glutathione and testosterone levels in the QS-treated rats, when compared with control. The spermiogram decreased with increase in total sperm abnormalities in QS-treated rats and was associated with histopathological changes. Our results revealed that QC significantly ameliorated QS-induced testicular toxicity and oxidative stress.

CONCLUSIONS

The testicular toxicity of QS is in part due to impairment of testicular antioxidant defense, spermatogenesis and enhancement of lipid peroxidation. Also, the ability of QC to reverse the deleterious effects of QS on the testes and epididymis qualifies it as a potent chemo-protective agent against QS-induced reproductive toxicity.

Neuroimmune regulation of alcohol consumption: behavioral validation of genes obtained from genomic studies

Analysis of mouse brain gene expression, using strains that differ in alcohol consumption, provided a number of novel candidate genes that potentially regulate alcohol consumption. We selected six genes [beta-2-microglobulin (B2m), cathepsin S (Ctss), cathepsin F (Ctsf), interleukin 1 receptor antagonist (Il1rn), CD14 molecule (Cd14) and interleukin 6 (Il6)] for behavioral validation using null mutant mice. These genes are known to be important for immune responses but were not specifically linked to alcohol consumption by previous research. Null mutant mice were tested for ethanol intake in three tests: 24-hour two-bottle choice, limited access two-bottle choice and limited access to one bottle of ethanol. Ethanol consumption and preference were reduced in all the null mutant mice in the 24-hour two-bottle choice test, the test that was the basis for selection of these genes. No major differences were observed in consumption of saccharin or quinine in the null mutant mice. Deletion of B2m, Ctss, Il1rn, Cd14 and Il6 also reduced ethanol consumption in the limited access two bottle choice test for ethanol intake; with the Il1rn and Ctss null mutants showing reduced intake in all three tests (with some variation between males and females). These results provide the most compelling evidence to date that global gene expression analysis can identify novel genetic determinants of complex behavioral traits. Specifically, they suggest a novel role for neuroimmune signaling in regulation of alcohol consumption.

[Functional MRI investigation of brain activity triggered by taste stimulation]

INTRODUCTION

Many factors contribute to the pathogenesis of morbid obesity, and the central nervous system - as one of those - also has an important role. Numerous studies focus on the central regulation of eating and metabolism, since associated problems like obesity, anorexia, diabetes or metabolic syndrome put an increasing burden on the health system of modern societies. Neither the pathophysiologic changes, nor the normal regulation of these systems are known adequately. Functional MR (fMRI) imaging, which has certainly gained popularity recently, aims to better understand these mechanisms. In this series we studied the brain fMRI activity changes of normal and obese persons, triggered by gustatory stimulation.

METHODS

10 obese and 10 normal weight healthy volunteers took part in the study, with comparable age and sex distribution. Gustatory stimulation was performed by 0.1 M sucrose (pleasant), 0.5 mM quinine HCl (unpleasant) and complex vanilla flavored (Nutridrink) solutions, which were administered through 0.5 mm PVC tubes, in 5-5 ml portions. For rinsing distilled water with neutral flavor was used. Imaging was performed in a 3T MRI, applying standard EPI sequences. Post processing of data was accomplished by FSL software package.

RESULTS

Brain activation for gustatory stimuli was characteristically different between the two groups. There were high intensity activations in more cortical and subcortical regions of the obese volunteers compared to the normal ones.

CONCLUSIONS

Our current fMRI investigations revealed different activations of numerous brain regions of normal and obese individuals, triggered by pleasant and unpleasant gustatory stimulation. Based on these results this method can help to recognize the role of the central nervous system in obesity, and may contribute to develop new therapies for weight loss.

Inhibition of phosphodiesterase-4 decreases ethanol intake in mice

RATIONALE

Cyclic AMP (cAMP)-protein kinase A signaling has been implicated in the regulation of ethanol consumption. Phosphodiesterase-4 (PDE4) specifically hydrolyzes cAMP and plays a critical role in controlling intracellular cAMP levels in the brain. However, the role of PDE4 in ethanol consumption remains unknown.

OBJECTIVE

The objective of this study is to examine whether PDE4 was involved in regulating ethanol intake.

METHODS

The two-bottle choice paradigm was used to assess intake of ethanol, sucrose, and quinine in C57BL/6J mice treated with the selective PDE4 inhibitor rolipram or Ro 20-1724; locomotor activity was also monitored using the open-field test in mice treated with rolipram.

RESULTS

Administration (i.p.) of either rolipram (0.25 and 0.5 mg/kg) or Ro 20-1724 (10 mg/kg) reduced ethanol intake and preference by 60-80%, but did not alter total fluid intake. In contrast, rolipram even at the higher dose of 0.5 mg/kg was not able to affect intake of sucrose or quinine, alcohol-induced sedation, or blood ethanol elimination. At 0.5 mg/kg, rolipram did decrease locomotor activity, but the effect only lasted for approximately 40 min, which did not likely affect behavior of ethanol drinking.

CONCLUSIONS

These results suggest that PDE4 is a novel target for drugs that reduce ethanol intake; PDE4 inhibitors may be used for treatment of alcohol dependence.

Efficacy of quinine against ichthyophthiriasis in common carp Cyprinus carpio

Ichthyophthiriasis, caused by Ichthyophthirius multifiliis, is an economically important worldwide parasitic disease that infects all freshwater fish. Since the banning of malachite green for use in food fish, there has been a great need for alternative therapeutants. The goal of this study was to investigate the efficacy of quinine against I. multifiliis. Parasite developmental stages from our laboratory-established life cycle in rainbow trout Oncorhynchus mykiss were exposed to quinine in vitro, and a dual fluorescent staining technique was used to allow a clear distinction between viable and damaged parasites. Furthermore, the effect of quinine was assessed in vivo by oral administration and intraperitoneal injections in common carp Cyprinus carpio. The results of the in vitro experiments proved quinine to be effective against the parasite. Quinine injected at a dosage of 60 mg kg(-1) body weight resulted in a significantly lower number of trophonts. In contrast, in-feed trials did not show a significant reduction of trophonts after treatment commencing 1 d after infection with concentrations of up to 20 g quinine kg(-1) feed for 3 d. After a 14-d treatment at concentrations of up to 10 g quinine kg(-1) feed prior to theront exposure, there was also no significant difference in parasite numbers between treated and control groups. The results of oral versus parenteral application of quinine indicate that the substance is not completely absorbed from the intestinal tract of common carp. However, medicated feed containing higher concentrations of quinine was less readily accepted by the fish, presumably due to the bitter taste.

Severe Plasmodium knowlesi malaria in a tertiary care hospital, Sabah, Malaysia

The simian parasite Plasmodium knowlesi causes severe human malaria; the optimal treatment remains unknown. We describe the clinical features, disease spectrum, and response to antimalarial chemotherapy, including artemether-lumefantrine and artesunate, in patients with P. knowlesi malaria diagnosed by PCR during December 2007-November 2009 at a tertiary care hospital in Sabah, Malaysia. Fifty-six patients had PCR-confirmed P. knowlesi monoinfection and clinical records available for review. Twenty-two (39%) had severe malaria; of these, 6 (27%) died. Thirteen (59%) had respiratory distress; 12 (55%), acute renal failure; and 12, shock. None experienced coma. Patients with uncomplicated disease received chloroquine, quinine, or artemether-lumefantrine, and those with severe disease received intravenous quinine or artesunate. Parasite clearance times were 1-2 days shorter with either artemether-lumefantrine or artesunate treatment. P. knowlesi is a major cause of severe and fatal malaria in Sabah. Artemisinin derivatives rapidly clear parasitemia and are efficacious in treating uncomplicated and severe knowlesi malaria.

A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomised trial

BACKGROUND

In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated.

METHODS AND FINDINGS

This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n  =  4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n  =  4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean  =  0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05-0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%-26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [-3.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%-48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/kg/day; 1.0% versus 7.5%; -6.5% [-12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; -6.8% [-11.9% to -1.6%]).

CONCLUSIONS

Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings.

Sensitivity to artemisinin, mefloquine and quinine of Plasmodium falciparum in northwestern Thailand

The increasing drug resistance of Plasmodium falciparum is a worldwide problem. The objective of the study was the assessment of the in vitro activity of artemisinin, mefloquine and quinine, in an area where P. falciparum is multi-drug resistant. The sensitivity tests were based on measuring the drug-dependent inhibition of schizont maturation. For the 43 successfully tested isolates the mean effective concentrations (IC(50) and IC(90)) for artemisinin were 0.0081 and 0.1372 μM, respectively. For mefloquine the IC(50) was 0.1260 μM and the IC(90) was 3.7345 μM. Quinine showed an IC(50) of 0.2155 μM and an IC(90) of 2.5040 μM. All tested drugs showed a significant reduction in the effectiveness, compared with the results of former years. This suggests a further rise of resistance of local P. falciparum, which is alarming especially for artemisinin and quinine.

Artesunate versus quinine for treating severe malaria

BACKGROUND

Severe malaria results in over a million deaths every year, most of them in children aged under five years and living in sub-Saharan Africa. This review examines whether treatment with artesunate, instead of the standard treatment quinine, would result in fewer deaths and better treatment outcomes.

OBJECTIVES

To compare artesunate with quinine for treating severe malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, ISI Web of Science, the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles to November 2010.

SELECTION CRITERIA

Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility and risk of bias of trials, and extracted and analysed data. The primary outcome was all-cause death. Dichotomous outcomes were summarized using risk ratios (RR) and continuous outcomes by mean differences (MD). Where appropriate, we combined data in meta-analyses.

MAIN RESULTS

Eight trials enrolling 1664 adults and 5765 children are included in this review.Treatment with artesunate significantly reduced the risk of death both in adults (RR 0.61, 95% Confidence Interval (CI) 0.50 to 0.75; 1664 participants, five trials) and children (RR 0.76, 95% CI 0.65 to 0.90; 5765 participants, four trials)In children, treatment with artesunate increased the incidence of neurological sequelae at the time of hospital discharge. The majority of these sequelae were transient and no significant difference between treatments was seen at later follow up.

AUTHORS' CONCLUSIONS

The evidence clearly supports the superiority of parenteral artesunate over quinine for the treatment of severe malaria in both adults and children and in different regions of the world.

Malaria: severe, life-threatening

INTRODUCTION

Severe malaria mainly affects children under 5 years old, non-immune travellers, migrants to malarial areas, and people living in areas with unstable or seasonal malaria. Cerebral malaria, causing encephalopathy and coma, is fatal in around 20% of children and adults, and neurological sequelae may occur in some survivors. Severe malarial anaemia may have a mortality rate of over 13%.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antimalarial treatments and adjunctive treatment for complicated falciparum malaria in non-pregnant people? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 33 systematic reviews, RCTs, or observational studies that met our inclusion criteria.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: dexamethasone, exchange blood transfusion, initial blood transfusion, intramuscular artemether, intravenous and intramuscular artesunate, intravenous and intramuscular dihydroartemisinin, quinine, and rectal/intravenous/intramuscular artemisinin and its derivatives.

Transferrin-conjugated solid lipid nanoparticles for enhanced delivery of quinine dihydrochloride to the brain

Transferrin (Tf)-conjugated solid lipid nanoparticles (SLNs) were investigated for their ability to deliver quinine dihydrochloride to the brain, for the management of cerebral malaria. SLNs were prepared by an ethanol injection method using hydrogenated soya phosphatidyl choline (HSPC), triolein, cholesterol and distearylphosphatidylethanolamine (DSPE). Coupling of SLNs with Tf was achieved by incubation of Tf with quinine-loaded SLNs in the presence of 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) hydrochloride in phosphate buffered saline (pH 7.4) as a cross-linker. SLNs were characterized for shape, particle size, polydispersity and percentage drug entrapment. The SLNs were 108–126 nm in size, and maximum drug entrapment was 38.4–42.7%. Average size increased on coupling with Tf but percentage drug entrapment was reduced. The in-vitro release profile was determined using a dialysis technique; non-conjugated SLNs released comparatively more drug than Tf-SLNs. Fluorescence studies revealed enhanced uptake of Tf-SLNs in brain tissue compared with unconjugated SLNs. In in-vivo performance studies, quinine plasma level and tissue distribution after intravenous administration of drug-loaded Tf-SLNs and unconjugated SLNs was compared with that of free drug. Intravenous administration of quinine dihydrochloride solution resulted in much higher concentrations of drug in the serum than with SLNs. Conjugation of SLNs with Tf significantly enhanced the brain uptake of quinine which was shown by the recovery of a higher percentage of the dose from the brain following administration of Tf-coupled SLNs compared with unconjugated SLNs or drug solution.