Validation of Fenoterol to Study β2-Adrenoceptor Function in the Rat Urinary Bladder

Fenoterol is a β2-adrenoceptor (AR)-selective agonist that is commonly used to investigate relaxation responses mediated by β2-AR in smooth muscle preparations. Some data have questioned this because fenoterol had low potency in the rat urinary bladder when a muscarinic agonist was used as a pre-contraction agent and because some investigators proposed that fenoterol may act in part via β3-AR. We designed the present study to investigate whether fenoterol is a proper pharmacological tool to study β2-AR-mediated relaxation responses in the rat urinary bladder. Firstly, we have compared the effect of pre-contraction agents on fenoterol potency and found that fenoterol potency was about 1.5 log units greater against KCl than carbachol (pEC50 7.19 ± 0.66 and 5.62 ± 1.09 of KCl and of carbachol, respectively). To test the selectivity of fenoterol, we have determined the effects of the β2-AR antagonist ICI 118,551 and the β3-AR antagonist L 748,337 on relaxation responses to fenoterol. While 300 nM L 748,337 had little effect on the potency of fenoterol (pEC50 6.56 ± 0.25 and 6.33 ± 0.61 in the absence and presence of L 748,337, respectively), the relaxation curve for fenoterol was right-shifted in the presence 300 nM ICI 118,551 (pEC50 5.03 ± 0.18). Thus, we conclude that fenoterol is a proper pharmacological tool to assess β2-AR-mediated responses in the rat urinary bladder and most likely in other smooth-muscle preparations containing multiple subtypes of the β-AR.

Acute tocolysis for uterine tachysystole or suspected fetal distress

BACKGROUND

Uterine tachysystole (more than 5 contractions per 10 minutes in 2 consecutive intervals) is common during labour, particularly with use of labour-stimulating agents. Tachysystole may reduce fetal oxygenation by interrupting maternal blood flow to the placenta during contractions. Reducing uterine contractions may improve placental blood flow, improving fetal oxygenation. This review aimed to evaluate the use of tocolytics to reduce or stop uterine contractions for improvement of the condition of the fetus in utero. This new review supersedes an earlier Cochrane Review on the same topic.

OBJECTIVES

To assess the effects of the use of acute tocolysis during labour for uterine tachysystole or suspected fetal distress, or both, on fetal, maternal and neonatal outcomes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (2 February 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating acute tocolysis for uterine tachysystole, intrapartum fetal distress, or both.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane.

MAIN RESULTS

We included eight studies (734 women), conducted in hospital settings, predominantly in high-income countries (USA, Austria, Uruguay). Two trials were conducted in upper and lower middle-income countries (South Africa, Sri Lanka). The hospital facilities all had the capacity to perform caesarean section. Overall, the studies had a low risk of bias, except for methods to maintain blinding. All of the trials used a selective beta₂ (ß₂)-adrenergic agonist in one arm, however the drug used varied, as did the comparator. Limited information was available on maternal outcomes.Selective ß₂-adrenergic agonist versus no tocolytic agent, whilst awaiting emergency deliveryThere were two stillbirths, both in the no tocolytic control group (risk ratio (RR) 0.23, 95% confidence interval (CI) 0.01 to 4.55; 2 studies, 57 women; low-quality evidence). One had gross hydrocephalus and the second occurred with vaginal delivery after waiting 55 minutes for caesarean section. The decision for caesarean section delivery was an inclusion criterion in both studies so we could not assess this as an outcome under this comparison. Abnormal fetal heart trace is probably lower with tocolytic treatment (RR 0.28, 95% CI 0.08 to 0.95; 2 studies, 43 women; moderate-quality evidence). The effects on the number of babies with Apgar score below seven were uncertain (low-quality evidence).Intravenous (IV) atosiban versus IV hexoprenaline (1 study, 26 women) One infant in the hexoprenaline group required > 24 hours in the neonatal intensive care unit (NICU) following a forceps delivery (RR 0.33, 95% CI 0.01 to 7.50; low-quality evidence). There were no fetal or neonatal mortalities and no Apgar scores below seven. There was one caesarean delivery in the IV hexoprenaline group (RR 0.33, 95% CI 0.01 to 7.50; low-quality evidence), and one case of abnormal fetal heart score in the atosiban group (RR 3.00, 95% CI 0.13 to 67.51; very low-quality evidence).IV fenoterol bromhydrate versus emergency delivery (1 study, 390 women) No data were reported for perinatal death, severe morbidity or fetal or neonatal mortality. IV fenoterol probably increases the risk of caesarean delivery (RR 1.12, 95% CI 1.04 to 1.22; moderate-quality evidence). Fenoterol may have little or no effect on the risk of Apgar scores below seven (RR 1.28, 95% CI 0.35 to 4.68; low-quality evidence).IV hexoprenaline versus no tocolytic agent, whilst awaiting emergency delivery (1 study, 37 women) No data were reported for perinatal death or severe morbidity. There were two fetal deaths in the no tocolytic control group (RR 0.23, 95% CI 0.01 to 4.55; low-quality evidence). The rate of caesarean delivery was not reported. There were two babies with Apgar scores below seven in the control group and none in the hexoprenaline group (RR 0.24, 95% CI 0.01 to 4.57; 35 women; low-quality evidence).Subcutaneous terbutaline versus IV magnesium sulphate (1 study, 46 women)No data were reported for perinatal death, severe morbidity or fetal or neonatal mortality. The decision for caesarean section was an inclusion criterion, so we could not assess this. The effects on abnormal fetal heart trace are uncertain (very low-quality evidence).Subcutaneous terbutaline with continuation of oxytocic infusion versus cessation of oxytocic infusion without tocolytic agent (1 study, 28 women) No data were reported for perinatal death, severe morbidity or fetal or neonatal mortality. There may be little or no difference in the rates of caesarean delivery in the subcutaneous terbutaline (8/15) and control groups (4/13) (RR 1.73, 95% CI 0.68 to 4.45; low-quality evidence). There were no cases of Apgar scores below seven or abnormal fetal heart trace.Subcutaneous terbutaline versus no tocolytic agent, whilst awaiting emergency delivery (1 study, 20 women) No data were reported for perinatal death or severe morbidity. There were no fetal or neonatal mortalities. The decision for caesarean section was an inclusion criterion, so we could not assess this. There were two babies with Apgar scores below seven in the control group and none in the terbutaline group (RR 0.17, 95% CI 0.01 to 3.08; low-quality evidence).IV terbutaline versus IV nitroglycerin (1 study, 110 women)No data were reported for perinatal death or severe morbidity or fetal or neonatal mortality. There may be little or no difference in the rates of caesarean delivery between the IV terbutaline (30/57) and control groups (29/53) (RR 0.96, 95% CI 0.68 to 1.36; low-quality evidence). There were no cases of Apgar scores below seven.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effects of tocolytics for uterine tachysystole or suspected fetal distress during labour. The clinical significance for some of the improvements in measures of fetal well-being with tocolytics is unclear. The sample sizes were too small to detect effects on neonatal morbidity, mortality or serious adverse effects. The majority of studies are from high-income countries in facilities with access to caesarean section, which may limit the generalisability of the results to lower-resource settings, or settings where caesarean section is not available.Further well-designed and adequately powered RCTs are required to evaluate clinically relevant indicators of maternal and neonatal morbidity and mortality.

Atosiban versus fenoterol as a uterine relaxant for external cephalic version: randomised controlled trial

OBJECTIVE

 To compare the effectiveness of the oxytocin receptor antagonist atosiban with the beta mimetic fenoterol as uterine relaxants in women undergoing external cephalic version (ECV) for breech presentation.

DESIGN

 Multicentre, open label, randomised controlled trial.

SETTING

 Eight hospitals in the Netherlands, August 2009 to May 2014.

PARTICIPANTS

 830 women with a singleton fetus in breech presentation and a gestational age of more than 34 weeks were randomly allocated in a 1:1 ratio to either 6.75 mg atosiban (n=416) or 40 μg fenoterol (n=414) intravenously for uterine relaxation before ECV.

MAIN OUTCOME MEASURES

 The primary outcome measures were a fetus in cephalic position 30 minutes after the procedure and cephalic presentation at delivery. Secondary outcome measures were mode of delivery, incidence of fetal and maternal complications, and drug related adverse events. All analyses were done on an intention-to-treat basis.

RESULTS

 Cephalic position 30 minutes after ECV occurred significantly less in the atosiban group than in the fenoterol group (34% v 40%, relative risk 0.73, 95% confidence interval 0.55 to 0.93). Presentation at birth was cephalic in 35% (n=139) of the atosiban group and 40% (n=166) of the fenoterol group (0.86, 0.72 to 1.03), and caesarean delivery was performed in 60% (n=240) of women in the atosiban group and 55% (n=218) in the fenoterol group (1.09, 0.96 to 1.20). No significant differences were found in neonatal outcomes or drug related adverse events.

CONCLUSIONS

 In women undergoing ECV for breech presentation, uterine relaxation with fenoterol increases the rate of cephalic presentation 30 minutes after the procedure. No statistically significant difference was found for cephalic presentation at delivery.

TRIAL REGISTRATION

 Dutch Trial Register, NTR 1877.

Betamimetics for inhibiting preterm labour

BACKGROUND

Preterm birth is a major contributor to perinatal mortality and morbidity worldwide. Tocolytic agents are drugs used to inhibit uterine contractions. Betamimetics are tocolytic agents that have been widely used, especially in resource-poor countries.

OBJECTIVES

To assess the effects of betamimetics given to women with preterm labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials of betamimetics, administered by any route or any dose, in the treatment of women in preterm labour where betamimetics were compared with other betamimetics, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors assessed risk of bias and extracted the data independently.

MAIN RESULTS

Twenty-eight trials were assessed as eligible for inclusion in the review, but eight did not report any outcome data relevant to the review. Results are based on the 20 trials that contributed data.Twelve trials, involving 1367 women, compared betamimetics with placebo. Betamimetics decreased the number of women in preterm labour giving birth within 48 hours (average risk ratio (RR) 0.68, 95% confidence interval (CI) 0.53 to 0.88, 10 trials, 1209 women). There was a decrease in the number of births within seven days (average RR 0.80; 95% CI 0.65 to 0.98, five trials, 911 women) but there was no evidence of a reduction in preterm birth (before 37 weeks' gestation) (RR 0.95; 95% CI 0.88 to 1.03, 10 trials, 1212 women). No benefit was demonstrated for betamimetics for perinatal death (RR 0.84; 95% CI 0.46 to 1.55, 11 trials, 1332 infants), or neonatal death (RR 0.90; 95% CI 0.27 to 3.00, six trials, 1174 infants). No significant effect was demonstrated for respiratory distress syndrome (RR 0.87; 95% CI 0.71 to 1.08, eight trials, 1239 infants). A few trials reported on cerebral palsy, infant death and necrotising enterocolitis; no significant differences between groups were identified for any of these outcomes. Betamimetics were significantly associated with the following outcomes: withdrawal from treatment due to adverse effects; maternal chest pain; dyspnoea; palpitation; tremor; headaches; hypokalaemia; hyperglycaemia; nausea or vomiting; nasal stuffiness; and fetal tachycardia.Nine trials compared different types of betamimetics. Other betamimetics were compared with ritodrine in five trials (n = 948). Other comparisons were examined in single trials: hexoprenaline compared with salbutamol (n = 140), slow versus moderate release salbutamol (n = 52) and salbutamol compared with terbutaline (n = 200). Trials were small, varied, and of insufficient quality to delineate any consistent patterns of effect.

AUTHORS' CONCLUSIONS

Betamimetics help to delay birth, which may give time to allow women to be transferred to tertiary care or to complete a course of antenatal corticosteroids. However, multiple adverse effects must be considered. The data are too few to support the use of any particular betamimetic.

Bronchodilator effect of Ipraterol on methacholine-induced bronchoconstriction in asthmatic patients

BACKGROUND

The addition of ipratropium, a synthetic cholinergic antagonist, to beta2-agonist therapy provides an additive improvement in adult with acute severe asthma and COPD because of increased vagal tone in the airways. We asked whether ipratropium in combination with fenoterol (Ipraterol) improved pulmonary function in comparison with original Berodual.

MATERIAL AND METHOD

In order to determine the effects of nebulized a single dose of Ipraterol, the study was conducted in a double-blind, randomized and crossover manner by comparing the effect of nebulized a single dose of Berodual on methacholine-induced bronchoconstriction. The study consisted of an 1-week run-in phase and two study visits separated by a washout period of 7 days.

PATIENTS

We studied 20 patients who ranged from 18 to 80 years of age and had mild to moderate persistent asthma.

RESULTS

Nebulized Ipraterol provided a rapid onset of bronchodilation effect similar to nebulized Berodual within 5 minutes by significantly increasing FEV, from 1.19 L to 1.73 L (p < 0.001) and from 1.19 to 1.69 L (p = 0.0001), respectively. This effect of Ipraterol lasted as long (up to 6 hours) and was similar to that of Berodual. The absolute FEV1 values at 360 min after Ipraterol treatment was still higher than the baseline values. We also found that there were no significant differences in the degree of improvement in FEV1 and hypokalemia following treatment with Ipraterol and Berodual.

CONCLUSION

Our data suggest that nebulized Ipraterol offers a statistically significant improvement in pulmonary function without significant systemic absorption causing hypokalemia, with the improvement being comparable to that achieved with nebulized Berodual.

The economic impact of severe asthma to low-income families

BACKGROUND

To estimate the direct and indirect costs of severe asthma and the economic impact of its management to low-income families in Salvador, Brazil.

METHODS

One hundred and ninety-seven patients with severe asthma and referred to a state-funded asthma center providing free treatment were evaluated. At registration, they were asked about family cost-events in the previous year and had a baseline assessment of lung function, symptoms and quality of life. During the subsequent year, they were reassessed prospectively.

RESULTS

One hundred-eighty patients concluded a 12-month follow-up. Eighty-four percent were female patients, and the median family income was US$ 2955/year. Forty-seven percent of family members had lost their jobs because of asthma. Total cost of asthma management took 29% of family income. After proper treatment, asthma control scores improved by 50% and quality of life by 74%. The income of the families increased by US$ 711/year, as their members went back to work. The total cost of asthma to the families was reduced by a median US$ 789/family/year. Consequently, an annual surplus of US$ 1500/family became available.

CONCLUSIONS

Family costs of severe asthma consumed over one-fourth of the family income of the underprivileged population in a middle-income country. Adequate management brings major economic benefit to individuals and families.

Magnesiumzusatztherapie zur Tokolyse: Klinisch-chemische Uberwachungsparameter

Pregnancy can result in magnesium deficiency, which may precipitate premature labour usually reversed by betamimetic therapy. Inclusion of magnesium in tocolytic therapy is useful for possible reduction of premature labour as well as for cardioprotection. 35 patients with premature labour received Fenoterol + 20 mmol/day magnesium aspartate hydrochloride (Mg-asp-HCl) orally or 30 or 40 mmol/day Mg-asp-HCl and magnesium sulphate (MgSO4) (1:1) i.v. Before and during this therapy, Mg, Ca, K, Na, Cl, creatinin and urea as well as human placental lactogen (HPL) and oestriol (E3) were determined. There were no significant changes in the level of these under oral magnesium therapy. Under intravenous administration, plasma levels of magnesium rose significantly. In the following weeks, the levels dropped in spite of continuing the therapy. The other parameters showed no important changes. Under i.v. administration of 40 mmol/day Mg-asp-HCl, the HPL increase was highly significant. If this could be taken as a hint of better placental function such a positive side effect of magnesium therapy could prove beneficial to "small-for-age" foetuses. Co-medication of 20 mmol/day Mg-asp-HCl (oral) or 40 mmol/day Mg-asp-HCl and MgSO4 (1:1, i.v.) is recommended.

Tokolyse mit β-Sympathikomimetika allein oder in Kombination mit dem Kalziumantagonisten Verapamil?

In a retrospective study covering 471 cases the influence of the calcium antagonist Verapamil on tocolytic therapy with beta-mimetics was examined. 308 patients received Fenoterol therapy (group A) and 163 were treated with a combination of Fenoterol and Verapamil in a dosage-relation 1/20 (group B). There was no significant difference between group A and B in respect of age, parity, week of gestational age at the beginning of therapy and at delivery, and mode of delivery. The cardiovascular parameters demonstrated alterations as described in literature. The heart frequencies increased significantly in all patients while the systolic and the diastolic blood pressures decreased significantly in hypertonic patients only. These alterations of the cardiovascular parameters were the same in both groups. The efficiency of the tocolytic therapy was tested by comparing the prolongation index (Richter) and the frequency of uterine contractions measured by external cardiotocography. There was no significant difference between groups A and B. Severe complications occurred in 6 patients so that the therapy had to be discontinued (3 women suffered from pulmonary oedemas). These complications were also seen under additional Verapamil application during tocolytic treatment. The side effects as far as reported by the patients were restricted to a significantly lower rate of obstipation in the Fenoterol/Verapamil treated group B. We conclude that administration of the calcium antagonist Verapamil is of no additional value in tocolytic treatment with beta-mimetics.

Tokolyse mit β-Sympathikomimetika allein oder in Kombination mit dem Kalziumantagonisten Verapamil?

In a retrospective study, patients who underwent tocolytic therapy by beta-mimetics were investigated. 308 received Fenoterol monotherapy (group A) and 163 a combination of Fenoterol with the calcium-antagonist Verapamil in a dosage-relation of 1/20 (group B). The review of 287 cardiotocograms showed a significant increase in the foetal heart rate in both groups by about 13% after 114 minutes (A) and 146 minutes (B). Although the diaplacental transfer of Fenoterol to the foetus is very small, a high percentage of foetuses showed an increase in heart rate (84.7% in A, 86% in B). There was a significantly longer duration of foetal tachycardia in group B. Both groups were not different in respect of perinatal mortality (5.4% in A, 5.2% in B), birth weight, APGAR score, and the reasons for paediatric care. The great difference in placental permeability for Fenoterol and Verapamil may cause a danger for the foetus. Since no reasonable improvements are seen, additional Verapamil therapy is not recommended.

Cost-effectiveness of ritodrine and fenoterol for treatment of preterm labor in a low-middle-income country: a case study

OBJECTIVES

In countries with high income, tocolytic therapy with beta-mimetic agents is a cost-effective strategy compared to placebo. In our study, the cost-effectiveness of two beta-mimetic agents, ritodrine and fenoterol, used in the management of preterm labor was compared in the setting of a low-middle-income transitional country, Serbia & Montenegro.

METHODS

This case study was conducted at the Gynecology-Obstetrics Clinic, Clinical Center "Kragujevac," in Kragujevac, Serbia & Montenegro, between October 2004 and January 2006. In total, 235 pregnant patients with threatened preterm labor were enrolled, but 35 were lost to follow-up. Of the remaining 200 patients, 85 were given ritodrine, and 115 fenoterol. The perspective of Republic Institute for Health Insurance in Serbia was taken into account. Only direct costs were calculated; primary outcomes of the study were length of pregnancy (in weeks), time passed from the onset of uterine contractions to delivery (in weeks), and score on modified Flanagan's quality-of-life scale for chronic diseases, measured after discharge from hospital.

RESULTS

Prolongation of pregnancy was significantly longer in the fenoterol group (12.7 +/- 8.4 weeks) than in the ritodrine group (11.6 +/- 7.1 weeks). The mean duration of hospitalization was shorter in the fenoterol group (11.9 +/- 8.8 days) than in the ritodrine group (14.9 +/- 11.3 days). The treatment with fenoterol was less costly and more cost-effective than the treatment with ritodrine, but the difference in cost-effectiveness was not statistically significant. The cost of treatment per gained week of pregnancy prolongation was 3345.51 +/- 7668.04 CSD in the fenoterol group, and 4181.96 +/- 12,069.83 CSD in the ritodrine group.

CONCLUSIONS

The observed differences in treatment costs and duration of hospitalization per patient did not translate into significant differences in cost-effectiveness ratios, because of low costs of hospitalization and human labor in Serbian health system. Nevertheless, fenoterol treatment still has a tendency to be more cost-effective, and its lower acquisition cost is an advantage to this treatment option.

Effect of ciclesonide treatment on allergen-induced changes in T cell regulation in asthma

BACKGROUND

The allergen-induced release of CCL17/thymus and activation-regulated chemokine (TARC) may be crucial in asthmatic airway inflammation by recruitment of Th2 cells. In addition, it might lead to aberrant Th2 cell activity through impairment of beta2-adrenergic receptor (beta2-AR) control. We questioned how chemokine patterns change upon allergen challenge and whether treatment with the inhaled steroid ciclesonide can reduce chemokine release and subsequently prevent allergen-induced changes in Th2 cell regulation and migration.

METHODS

Asthma patients were double-blindly treated with placebo or 80 microg ciclesonide for 7 days. We studied allergen-induced changes in sputum chemokines, migration of peripheral blood T cells and control of beta2-agonist fenoterol over T cell migration and alpha-CD3/alpha-CD28-induced cytokine production.

RESULTS

Treatment with 80 microg ciclesonide significantly diminished the late asthmatic response. The late asthmatic response was associated with increased sputum levels of CCL17 and CCL4 (but none of the other chemokines measured) and loss of beta2-AR control over T cell migration and Th2-type cytokine production. Although ciclesonide treatment did not prevent chemokine release nor altered beta2-AR function in circulating T cells, it exerted an inhibitory effect on TARC-induced T cell migration and alpha-CD3/alpha-CD28-induced cytokine production.

CONCLUSION

Our data support the hypothesis that CCL17 is involved in allergen-induced dysregulation of Th2 cell migration and cytokine production. Ciclesonide treatment inhibits T cell migration and cytokine production upon allergen inhalation, which is regulated independently from reducing CCL17 release, but may contribute to beneficial effects of ciclesonide on Th2-mediated airway inflammation.

Tocolysis and delayed delivery versus emergency delivery in cases of non-reassuring fetal status during labor

AIM

To determine whether fetal intrauterine resuscitation using tocolysis and delayed delivery is better for the fetus than emergency delivery when fetal hypoxia is suspected because of a non-reassuring fetal heart-rate (FHR) pattern using conventional heart rate monitoring.

METHODS

This was a prospective and randomized study, conducted between 2001 and 2004 at Pereira Rossell Hospital, Montevideo, Uruguay. The population consisted of 390 fetuses, in which intrauterine distress was diagnosed using electronic FHR monitoring. Of these, 197 were randomly assigned to the emergency delivery group and 193 to the fetal intrauterine resuscitation group. The inclusion criteria were: term singleton pregnancy, in labor, cephalic presentation, and no placental accidents.

RESULTS

The time between randomization and birth was 16.9 +/- 7.6 min (mean +/- SD) for the emergency delivery group, and 34.5 +/- 11.7 min (mean +/- SD) for the resuscitation group. The relative risk (RR) of acidosis in the umbilical artery (pH < 7.1) in the emergency delivery group was 1.47 (0.95-2.27). The RR of base deficit < or =12 mEq/L in the emergency delivery group was higher than in the resuscitation group (RR = 1.48 [1.0-2.2], P = 0.04). When considering the need for admission to the neonatal care unit, the relative risk was higher in the emergency delivery group than in the resuscitation group (RR = 2.14 [1.23.3.74], P = 0.005). No maternal adverse effects were reported.

CONCLUSION

Tocolysis and delayed delivery renders better immediate neonatal results than emergency delivery when fetal distress is suspected because of a non-reassuring fetal heart pattern. In addition, it may decrease the need for emergency delivery without increasing maternal and fetal adverse side-effects.

Barusiban, an effective long-term treatment of oxytocin-induced preterm labor in nonhuman primates

Preterm labor (PTL) affects up to 25% of human pregnancies in developing countries, but there are few therapeutic options. Based on the key role of oxytocin (OXT) in labor and parturition, OXT antagonists are a potentially useful class of drugs for PTL. Barusiban is a new selective, potent, and long-acting OXT receptor antagonist. In this study barusiban was given by continuous i.v. infusion to monkeys during the last 3 wk of pregnancy; the monkeys were also given daily doses of OXT to induce uterine contractions and simulate PTL. Barusiban effectively suppressed OXT-induced PTL-like contractions and prevented early delivery. In contrast, fenoterol (a beta2-adrenoceptor [beta2-AR] agonist used as a comparative control) did not inhibit uterine contractions in this model. Barusiban was particularly effective in maintaining low intrauterine pressure (IUP) near the end of pregnancy, which is when IUP in both OXT controls and fenoterol-treated females increased substantially. Although barusiban delayed the onset of labor, it did not prevent normal delivery. These data demonstrate the safety and efficacy of barusiban in reducing uterine contractility in response to repeated OXT challenge, and suggest that barusiban may be therapeutically effective in long-term treatment of PTL.

[Forced oscillation technique in the study of a bronchial response in patients with tuberculosis during drug test using berotec]

A comparative study of the data obtained from the use of forced oscillation (FO) technique, spirography (SG), flow-forced expiratory volume (F-FEC) curve recording has provided evidence that the FO technique is highly effective in assessing a drug test. The FO technique revealed changes in bronchial patency in 69.5% of patients with bronchial obstruction whereas F-FEV recording indicated this pathology only in 42.4% (p < 0.05). A concurrent use of the pooled values of viscous respiratory resistance, SG, F-FEV curve to assess the results of a broncholytic test could diagnose bronchospasm in 79.7% of patients with pulmonary tuberculosis with impaired bronchial patiency.

Robust tests for treatment effects based on censored recurrent event data observed over multiple periods

We derive semiparametric methods for estimating and testing treatment effects when censored recurrent event data are available over multiple periods. These methods are based on estimating functions motivated by a working "mixed-Poisson" assumption under which conditioning can eliminate subject-specific random effects. Robust pseudoscore test statistics are obtained via "sandwich" variance estimation. The relative efficiency of conditional versus marginal analyses is assessed analytically under a mixed time-homogeneous Poisson model. The robustness and empirical power of the semiparametric approach are assessed through simulation. Adaptations to handle recurrent events arising in crossover trials are described and these methods are applied to data from a two-period crossover trial of patients with bronchial asthma.

Respimat Soft Mist inhaler versus hydrofluoroalkane metered dose inhaler: patient preference and satisfaction

INTRODUCTION

In addition to offering favorable pharmaceutical performance, an ideal inhaler should be well accepted by patients, as this may facilitate compliance. We report a study that specifically assessed inhaler preference in patients with obstructive lung disease after treatment with ipratropium bromide/fenoterol hydrobromide (Berodual delivered via either Respimat Soft Mist Inhaler (SMI) or hydrofluoroalkane metered dose inhaler (HFA-MDI).

METHODS

Patients with COPD, asthma or mixed disease were randomized to receive ipratropium bromide/fenoterol hydrobromide 20/50 microg via Respimat SMI or 40/100 microg via HFA-MDI for 7 weeks each, in a crossover design. Patients were trained in inhaler use and given < or =5 attempts to demonstrate satisfactory technique. At the end of each treatment period, patients completed a 15-item satisfaction questionnaire, and inhaler technique was re-tested. On study completion, patients were asked which inhaler they preferred and they rated their willingness to continue using each inhaler. Clinical efficacy outcomes were measured by diary card to check whether switching inhaler affected efficacy.

RESULTS

In total, 245 patients were randomized and 224 used both inhalers within their respective treatment periods. Of 201 patients expressing a preference, 162 (81%) preferred Respimat SMI and 39 (19%) preferred HFA-MDI (p < 0.001). Patients would rather continue using Respimat SMI than HFA-MDI (p < 0.001). Mean scores for 13 of the 15 satisfaction questions were significantly higher for Respimat SMI than HFA-MDI (p < 0.05); in addition, the total score was also significantly higher for Respimat SMI (p < 0.001). Most patients (217/224; 97%) were judged to have good technique with Respimat SMI after 7 weeks' use. Differences in efficacy measures between the devices were not significant.

CONCLUSION

These data indicated that a large majority of patients preferred Respimat SMI to HFA-MDI.

Short-acting inhaled beta-2-agonists increased the mortality from chronic obstructive pulmonary disease in observational designs

OBJECTIVE

The effect of short-acting inhaled beta(2)-agonists on mortality from chronic obstructive pulmonary disease (COPD) is controversial. Different observational designs were used to investigate about this topic.

STUDY DESIGN AND SETTING

A population-based case-control design was performed, by linking automated health databases from the Varese Province of Italy. Deaths of COPD generated from the cohort of 135,871 patients for whom at least one prescription for drugs used to treat COPD had been dispensed between 1997 and 1999 entered into the study as cases. Up to 20 controls were randomly selected for each case from the cohort after matching on gender, age, and date of cohort entry. Risk ratios were estimated using the case-control, case-crossover, and case-time-control approaches.

RESULTS

A total of 222 cases and 3022 controls met the inclusion criteria. Odds ratios (and corresponding 95% confidence intervals) corresponding to more than 0.5 defined-daily-doses were 2.6 (1.7, 4.0), 1.9 (1.1, 3.3), 2.1 (1.1, 4.0), and 2.3 (1.2, 4.6) by using crude and adjusted case-control, case-crossover, and case-time-control estimates, respectively.

CONCLUSION

Evidence that higher doses of short-acting inhaled beta(2)-agonists are associated with higher mortality from COPD was consistently supplied by three observational approaches.

A review of ipratropium bromide/fenoterol hydrobromide (Berodual) delivered via Respimat Soft Mist Inhaler in patients with asthma and chronic obstructive pulmonary disease

Asthma and chronic obstructive pulmonary disease (COPD) can be effectively treated by the use of bronchodilator therapies delivered by inhalation. Berodual is a fixed combination of the anticholinergic agent ipratropium bromide (IB) and the beta2-adrenergic agonist fenoterol hydrobromide (FEN). IB/FEN has been available for the treatment of asthma and COPD in a pressurised metered dose inhaler (MDI) [pMDI] formulation for many years. The pMDI is the most widely used device for the delivery of inhaled medications, such as IB/FEN. However, most conventional pMDIs contain chlorofluorocarbon (CFC) propellants, which are currently being withdrawn because of their detrimental effects on the environment. This has resulted in alternative methods of drug delivery being developed. Respimat Soft Mist Inhaler (SMI) is a new generation, propellant-free inhaler that generates a fine, slow-moving cloud (the Soft Mist) which can be easily inhaled. Scintigraphic studies have shown that this improves deposition of drugs in the lung and results in less oropharyngeal deposition than the CFC-MDI. A clinical development programme has been conducted to compare the efficacy and safety of IB/FEN delivered via Respimat SMI with that of IB/FEN via CFC-MDI in the treatment of patients with asthma or COPD. Five clinical studies (two phase II and three phase III) investigated dosages of IB/FEN 5/12.5 microg to 320/800 microg via Respimat SMI in single and multiple dose administration regimens. Four of the trials were conducted in patients with asthma (three in adults and one in children), while one phase III trial was conducted in patients with COPD. In phase III, 2058 patients participated, with a total of 1112 patients treated with IB/FEN via Respimat SMI. In the phase III studies, each dose from Respimat SMI was given in one actuation compared with two actuations with the CFC-MDI. In the paediatric asthma phase III study, all CFC-MDI doses were delivered via a spacer device. The results of the trials demonstrated that IB/FEN via Respimat SMI allows a reduction in the nominal dose of IB/FEN, while offering similar therapeutic efficacy and safety to a CFC-MDI. In children, Respimat SMI obviates the need for a spacer.

Betamimetics for inhibiting preterm labour

BACKGROUND

Preterm birth is a major contributor to perinatal mortality and morbidity worldwide. Tocolytic agents are drugs used to inhibit uterine contractions. The most widely used tocolytic agents are betamimetics especially in resource-poor countries.

OBJECTIVES

To assess the effects of betamimetics given to women with preterm labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (May 2003) without language restrictions.

SELECTION CRITERIA

Randomised controlled trials of betamimetics, administered by any route or any dose, in the treatment of women in preterm labour where betamimetics are compared with other betamimetics, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers evaluated independently methodological quality and extracted the data. We sought additional information to enable assessment of methodology and conduct intention-to-treat analyses. We present the results using the relative risk for categorical data and the weighted mean difference for continuous data.

MAIN RESULTS

Eleven randomised controlled trials, involving 1332 women, compared betamimetics with placebo. Betamimetics decreased the number of women in preterm labour giving birth within 48 hours (relative risk (RR) 0.63; 95% confidence interval (CI) 0.53 to 0.75) but there was no decrease in the number of births within seven days after carrying out a sensitivity analysis of studies with adequate allocation of concealment. No benefit was demonstrated for betamimetics on perinatal death (RR 0.84; 95% CI 0.46 to 1.55, 7 trials, n = 1332), or neonatal death (RR 1.00; 95% CI 0.48 to 2.09, 5 trials, n = 1174). No significant effect was demonstrated for respiratory distress syndrome (RR 0.87; 95% CI 0.71 to 1.08, 8 trials, n = 1239). A few trials reported the following outcomes, with no difference detected: cerebral palsy, infant death and necrotizing enterocolitis. Betamimetics were significantly associated with the following: withdrawal from treatment due to adverse effects; chest pain; dyspnoea; tachycardia; palpitation; tremor; headaches; hypokalemia; hyperglycemia; nausea/vomiting; and nasal stuffiness; and fetal tachycardia. Other betamimetics were compared with ritodrine in five trials (n = 948). Trials were small, varied and of insufficient quality to delineate any consistent patterns of effect.

REVIEWERS' CONCLUSIONS

Betamimetics help to delay delivery for women transferred to tertiary care or completed a course of antenatal corticosteroids. However, multiple adverse effects must be considered. The data are too few to support the use of any particular betamimetics.

Beneficial Effects of Chronic Pharmacological Manipulation of β-Adrenoreceptor Subtype Signaling in Rodent Dilated Ischemic Cardiomyopathy

Background— Studies in isolated cardiac myocytes have demonstrated that signaling via specific β 1 -adrenergic receptor subtypes (β 1 ARs) promotes but that signaling via β 2 ARs protects from cell death. We hypothesized that prolonged β 2 AR stimulation or β 1 AR blockade would each protect myocytes from death and thereby ameliorate cardiac remodeling in chronic heart failure.

Methods and Results— A large myocardial infarction (MI) induced in rats by coronary artery ligation resulted in a dilated cardiomyopathy (DCM) characterized by infarct expansion and a progressive increase in left ventricular (LV) end-diastolic volume, accompanied by a reduction in ejection fraction (EF), as assessed by repeated echocardiography. Pressure-volume analysis at 8 weeks after ligation showed that diastolic stiffness (Eed) and arterial elastance (Ea) were increased, end-systolic elastance (Ees) was decreased, and arterioventricular (AV) coupling (Ea/Ees) had deteriorated. Apoptosis was present in both peri-infarct and remote myocardium. Chronic (6-week) administration of the β 2 AR agonists fenoterol or zinterol, starting at 2 weeks after MI, reduced the extent of LV dilation, infarct expansion, and EF decline. The β 1 AR blocker metoprolol did not affect the former and preserved EF to a lesser extent than did the β 2 AR agonists. At 8 weeks after ligation, apoptosis was reduced by all drugs but to a greater extent by β 2 AR agonists than by the β 1 AR blocker. Both β 2 AR agonists and the β 1 AR blocker improved AV coupling, the former mainly by reducing Ea and the latter mainly by increasing Ees. Only the β 2 AR agonists reduced the Eed and the MI size by reducing infarct expansion.

Conclusions— These results provide proof of concept for the efficacy of chronic β 2 AR stimulation in this DCM model.

[Comparison of the cost of treatment of premature labor with atosiban or beta-sympathomimetics from the perspective of the health care payer--a pharmacoeconomic model]

OBJECTIVE

To evaluate the cost of treating premature delivery with atosiban or beta-sympatomimetic drugs (fenoterol and hexoprenalin) from the perspective of health care payer--the medical insurance company.

DESIGN

A pharmaco-economic model based on the results of randomized, controlled clinical study.

SETTING

Hospital Pharmacy at Vitkovice Hospital of Blessed Mary Antonia, Ostrava.

METHODS

The study is based on the application of clinical decision-making analysis, which includes results of a randomized controlled clinical study as well as data on the cost of clinical interventions and cost of drug therapy. The pharmaco-economic model was created from the perspective of the payer of health care--the insurance company. This model presumes the administration of atosiban or beta-sympatomimetic drugs (fenoterol and hexoprenalin) for the period of 18 and 48 h and the therapy of possible untoward effects for the next 72 h after the administration of the drugs. The analysis of sensitivity of pharmacokinetic model also employs so called low and high estimate of supplementary cost for the treatment of untoward effects.

RESULTS

After the administration of the drugs for the period of 18 h the total cost of the payer of medical care was in the range of 21,914.5-21,974.4 CKr in atosiban, 19,878.7-22,661.4 CKr in fenoterol and 19,942.9-21,974.4 CKr in hexoprenalin. In the administration of the drugs for 48 h, the overall cost of the payer of medical care was in the range of 43,082.5-43,142.4 CKr in atosiban, 19,960.3-23,150.7 CKr in fenoterol and 20,131.3-23,574.0 in hexoprenalin.

CONCLUSIONS

This study compared overall cost associated with hospitalization of a premature delivery from the perspective of the medical care payer, i.e. the health insurance company. The authors applied a pharmaco-economic model evaluating hospitalization for the period of 48 h and subsequent therapy of possible untoward effects for the period of up to 72 h. In case of a shorter administration of atosiban (up to 18 h) the overall cost of hospitalization for premature delivery for the period of 48 h from the point of view of medical insurance company is basically comparable with the administration of beta-sympatomimetic drugs. If atosiban is administered for more than 18 h, the overall cost of hospitalization is higher than with beta-sympatomimetic drugs, and the cost increases in relation to the duration of atosiban administration.

[Effects of nebuliser treatment with berotec on external respiratory function, bronchial permeability, hemodynamics, acid-alkaline balance, oxygen saturation, and their circadian structure in elderly patients with chronic obstructive pulmonary disease]

AIM

To study the effects of nebuliser therapy with berotek on clinical symptoms, external respiration function (ERF), bronchial permeability, hemodynamics and their temporal organisation in elderly patients with chronic obstructive pulmonary disease (COPD).

MATERIAL AND METHODS

The study enrolled 20 COPD patients (mean age 64.9 +/- 1.9 years) with obstructive respiratory insufficiency of the second-third degree given nebuliser therapy with berotek as adjuvant to conventional treatment (the study group) and 12 COPD patients (mean age 69.7 +/- 2.5 years) given only conventional treatment (the control group). The following parameters were examined: ERF, BP, HD, AAB, OS (SaO2) in venous blood before and after treatment. Chronobiological studies of BP and HD were performed for 7 days at the beginning and end of the study.

RESULTS

Berotek efficacy manifested on the treatment day 3 as improvement in the symptoms, IRF, BP, a rise in SaO2 and PaCO2 and a fall in PaCO2 in venous blood. Circadian chronostructure of peakflowmetry, systolic and diastolic blood pressure, mean arterial pressure persisted. Circaseptal and circasemiseptal rhythms of BP and HD disappeared.

CONCLUSION

Nebuliser therapy with berotek has a positive effect on clinical symptoms, ERF, BP, gas exchange in the lungs, SaO2, HD and their circadian chronostructure.

Fenoterol delivery by Respimat soft mist inhaler versus CFC metered dose inhaler: cumulative dose-response study in asthma patients

OBJECTIVES

Respimat (RMT) soft mist inhaler (SMI) is a novel, propellant-free alternative to chlorofluorocarbon metered-dose inhalers (CFC-MDIs). The aim of this study was to evaluate the safety and establish the equipotent dose of fenoterol delivered by RMT SMI vs. a conventional MDI.

DESIGN

Double-blind, randomized, crossover, comparative study between fenoterol inhaled via RMT (either 50 microg/actuation, RMT50; or 100 microg/actuation. RMT100) and MDI (100 microg/actuation; MDI100).

PATIENTS AND INTERVENTIONS

A total of 41 asthma patients received cumulative doses of fenoterol 600 microg (RMT50) or 1200 microg (RMT100 and MDI100) on 3 test days.

MEASUREMENTS AND RESULTS

The bronchodilator response (forced expiratory volume in 1 second [FEV1]) was considered therapeutically equivalent (i.e., noninferior) if the 95% confidence intervals for the difference in their mean changes from baseline were within limits of +/- 0.15L. Systemic exposure was evaluated from plasma fenoterol levels. Adverse events (AEs) were recorded. RMT50 and RMT100 produced noninferior bronchodilatation to MDI100 from 30minutes after the first dose. RMT50 showed equivalent safety and tolerability to MDI100, whereas RMT100 produced a higher incidence of AEs, a significantly greater plasma potassium reduction and a significant increase in pulse rate. Fenoterol plasma levels were twice as high with RMT100 as with RMT50 or MDI100. CONCLUSIONS; The nominal dose of fenoterol administered via RMT SMI can be at least halved to achieve equivalent efficacy, safety, and tolerability to a MDI.

Beta 2-agonist administration reverses muscle wasting and improves muscle function in aged rats

The beta2-adrenoceptor agonist (beta2-agonist) fenoterol has potent anabolic effects on rat skeletal muscle. We conducted an extensive dose-response study to determine the most efficacious dose of fenoterol for increasing skeletal muscle mass in adult rats and used this dose in testing the hypothesis that fenoterol may have therapeutic potential for ameliorating age-related muscle wasting and weakness. We used adult (16-month-old) rats that had completed their growth and development, and old (28-month-old) rats that exhibited characteristic muscle wasting and weakness, and treated them daily with either fenoterol (1.4 mg kg(-1), i.p), or saline vehicle, for 4 weeks. Following treatment, functional characteristics of fast-twitch extensor digitorum longus (EDL) and predominantly slow-twitch soleus muscles of the hindlimb were assessed in vitro. Untreated old rats exhibited a loss of skeletal muscle mass and a decrease in force-producing capacity, in both fast and slow muscles, compared with adult rats (P < 0.05). However, there was no age-associated decrease in skeletal muscle beta-adrenoceptor density, nor was the muscle response to chronic beta-agonist stimulation reduced with age. Thus, muscle mass and force-producing capacity of EDL and soleus muscles from old rats treated with fenoterol was equivalent to, or greater than, untreated adult rats. The increase in mass and strength was attributed to a non-selective increase in the cross-sectional area of all muscle fibre types, in both the EDL and soleus. Fenoterol treatment caused a small increase in fatiguability due to a decrease in oxidative metabolism in both EDL and soleus muscles, with some cardiac hypertrophy. Further studies are needed to fully separate the desirable effects on skeletal muscle and the undesirable effects on the heart. Nevertheless, our results demonstrate that fenoterol is a powerful anabolic agent that can restore muscle mass and strength in old rats, and provide preliminary evidence of therapeutic potential for age-related muscle wasting and weakness.

Reproducibility of forced inspiratory and expiratory volumes after bronchodilation in patients with COPD or asthma

The aim of the present study was to assess the reproducibility of changes in forced inspiratory volumes after bronchodilator inhalation. Thirteen patients with chronic obstructive pulmonary disease (COPD) (FEV1, 32-75%pred) and 10 patients with asthma (FEV1, 43-75%pred) inhaled either 200 microg fenoterol or 200 microg oxitropium bromide or placebo, each of them on three occasions, on nine different days in a randomised, cross-over, double-blind fashion. Forced expiratory (FEV1) and inspiratory (FIV1) volumes were measured before and 30 min after inhalation. In patients with COPD, the increase in FEV1 (coefficient of variation) was 221 ml (43%) after fenoterol and 235 ml (33%) after oxitropium; changes in FIV1 were 301 ml (45%) and 360 ml (29%). In patients with asthma, FEV1 improved by 618 ml (26%) and 482 ml (25%), FIV1 by 553 ml (41%) and 475 ml (23%). In less severe COPD or asthma, the reduction in dyspnoea was associated with the improvements in both FIV1 and FEV1, but in severe COPD with the improvement in FIV1 only. The data demonstrate that, at least in terms of relative changes, the reproducibility of bronchodilator responses in terms of FIV1 is similar to that of FEV1 and they underline the assertion of FIV1 being a sensible parameter particularly in severe COPD.

[Cerebral hemorrhage and periventricular leucomalacia in preterm neonates after intravenous tocolysis with fenoterol: results of postnatal ultrasound examination]

BACKGROUND

This study tested whether tocolysis with beta-adrenergic agonists (Fenoterol) had an effect on the frequency of cerebral lesions in preterm neonates.

PATIENTS AND METHODS

Head ultrasound scans of preterm neonates who were born after long-term (> 24 h) tocolysis were compared with scans of preterm neonates without preceding tocolysis. The gestational and neonatal data were analyzed retrospectively.

RESULTS

Preterm neonates after (n = 102) and without (n = 101) tocolysis were subdivided into three groups according to their gestational age (23 - 28 wk: n = 41; 29 - 33 wk: n = 66; 34 - 36 wk: n = 96). Within these groups, no significant differences were found with respect to birth weight, rate of cesarean section, or pulmonary morbidity. Preterm babies < 28 weeks of gestation from the control group had lower Apgar scores (after 1 and 5 minutes, respectively) and arterial umbilical cord pH values. Intravenous tocolysis did not lead to an increase in pseudocystic periventricular leucomalacia (PVL) or intracerebral hemorrhage (ICH) in any of the subgroups studies. However, cerebral lesions were found in preterm neonates after tocolysis who exhibited signs of infection (29 - 33 wk: PVL n = 2; 23 - 28 wk: ICH n = 1) and in preterm neonates without tocolysis who had undergone fetal hypoxia or abruptio placentae (29 - 33 wk: PVL n = 4; antenatal terminal vein bleeding n = 1; 23 - 28 wk: PVL n = 2; terminal vein bleeding n = 5; posterior cerebral artery bleeding n = 1). When compared to preterm neonates of 34 - 36 weeks of gestation, the risk of infection was increased 4-fold in neonates of 29 - 33 weeks of gestation (odds ratio 5.43, 1.10 - 26.83) and 10-fold in neonates of 23 - 28 weeks of gestation (odds ratio 20.50, 3.65 - 115.03). Chorioamnionitis also was a more common finding in preterm neonates < 28 weeks of gestation.

CONCLUSION

Preterm neonates who were born after intravenous long-term (> 24 h) tocolysis with Fenoterol do not exhibit an increase in periventricular leucomalacia or intracranial hemorrhage. The occurrence of cerebral lesions in these patients merely depends on their degree of immaturity and on the presence or absence of perinatal infection. In preterm neonates without tocolysis, brain lesions are mainly associated with hypoxic events.

[Comparison of acute bronchiolytic effect of inhaling solutions of berodual vs salgim using a nebulizer in patients with chronic obstructive bronchitis and bronchial asthma]

AIM

Comparison of acute response to nebulizer inhalation of therapeutic doses of combined broncholitic berodual and domestic bronchoselective adrenomimetic salgim in patients with bronchial asthma (BA) and chronic obstructive bronchitis (COB).

MATERIAL AND METHODS

The trial included 17 COB and 15 BA patients who for two consecutive days inhaled berodual and salgim solutions. Before and after the inhalations, subjective condition of the patients and parameters of the forced expiration were recorded. The sequence of the solutions use was determined randomly.

RESULTS

Nebulizer inhalations of berodual and salgim relieved respiration subjectively in 83.9 and 93.5% patients, respectively. Significant bronchodilation was registered 30 min after inhalation of each of the solutions both in BA and COB. Berodual caused no side effects, salgim provoked short-term cough in 6(19.4%) patients.

CONCLUSION

Nebulizer therapy of berodual or salgim is clinically and cost effective in moderate and severe obstruction in BA and COB patients.

A comparison of terbutaline and fenoterol unit dose vials in treating children with acute asthmatic attacks

To compare the bronchodilation and adverse effects of two commercially marketed short-acting beta2-adrenergic agonists, terbutaline (Bricanyl, 5.0 mg/2ml) and fenoterol (Berotec,1.25 mg/2ml) unit dose vials (UDV), 108 acute asthmatic children, aged 5 to 14, were randomly enrolled into this study. Nebulization treatment for 10 minutes using an air compressor nebulizer was performed after measurements of baseline spirometry, SaO2, blood pressure and pulse rate. Same measurements were repeated at 0, 5, 15 and 30 minutes after the end of the nebulization treatment. The blood pressure was also monitored immediately and 30 minutes after treatment. Almost all the spirometric parameters of both treatments at various time points significantly improved. The pulse rate significantly increased at 15 and 30 min. The SaO2 significantly increased at 30 min. The systolic blood pressure significantly decreased immediately (terbutaline only) and at 30 min (fenoterol only). No significant change was found in diastolic blood pressure. When the laboratory parameters at the same time points were compared. Significant better results for fenoterol treatment were found in FEV, at 30 min (p = 0.048), PEF at 15 and 30 min (p = 0.049 and p = 0.027, respectively), FEF25-75% at 30 min (p = 0.033), mean absolute increase of PEF at 15 min (p = 0.034) and 30 min (p = 0.021), FEF25-75% at 30 min (p = 0.046), and in mean percent increase of FEF25-75% at 30 min (p = 0.047). The adverse effects for both groups were almost equal and around 21%. In conclusion, both terbutaline and fenoterol UDV nebulization treatments are effective in treating acute asthmatic children. The adverse effects are nearly equal. The fenoterol UDV nebulization treatment shows a little better result in improving pulmonary function than does terbutaline.

[Pharmacodynamics of inhalation broncholytic agents introduced in a single dose by nebulizer in patients with severe exacerbation of bronchial asthma]

AIM

To study pharmacodynamics and safety of inhalatory beta-2-adrenostimulators and M-cholinolytics given via nebulizer in patients with severe exacerbation of bronchial asthma (BA).

MATERIAL AND METHODS

The study covered 78 patients with severe exacerbation of BA (mean age--48.6 +/- 15.0 years). The patients were randomized into 4 groups: 23, 20, 18 and 17 patients, respectively. They were treated with: ventolin nebuly (2.5 mg), berodual (0.25 mg ipratropium bromide and 0.5 mg phenoterol), atrovent (0.5 mg), berotek (1.0 mg by nebulizer Pulmo-Aide 56501). Efficiency and safety of the treatment was assessed by the data of external respiration function, arterial blood gases and ECG each 30 min for 3 hours.

RESULTS

In patients with severe exacerbation of BA pharmacodynamics of all the studied drugs was characterized by less duration and potency of the action. Salbutamol and berotek were effective for 180 min, atrovent--for 30-60 min. Inhalation broncholytics had no such serious side effects as prolongation of corrected interval Q-T or onset of arrhythmia. Berotek demonstrated longer action on heart rate than salbutamol.

CONCLUSION

Severe complication of BA is treated more effectively with combination of beta 2-adrenomimetic with atrovent.

Sonographic cervical volumetry in higher order multiple gestation

OBJECTIVE

The aim of this study of multifetal pregnancies was the comparison of three-dimensional (3D) volumetry of the cervix, conventional sonographic cervical length measurement and clinical assessment.

METHODS

10 mothers were investigated in an observational study between 5/1999 and 9/2000. A total of 34 consecutive 2D- and 3D-transabdominal ultrasound measurements were performed.

RESULTS

Volumetry of the cervix was possible in all 34 exams. 2D-cervical length assessment could not be obtained in 6% because the presenting fetal part obstructed the sonographic plane. Both methods allowed equal judgement of the configuration of the cervix. A significant correlation was found between mean 2D-cervical length (28.7 mm, 7.7 SD) and mean cervical volume (30.0 cm3, 16.0 SD). Parity, subjective preterm labor or need of tocolytics showed no correlation with any biometrical parameter studied.

CONCLUSION

Volumetry was superior for the assessment of cervical biometry and conformation in women when the transabdominal 2D-plane was obstructed. When cervical length was obtainable by a conventional scan, the technically more complex 3D-imaging did not provide further information.

Rise and fall of asthma-related mortality in Italy and sales of beta2-agonists, 1980-1994

We performed this study with the aims of describing the trend of asthma-related mortality in Italy between 1980 and 1994, and to evaluate the relationship between sale estimates of beta2-agonists drugs and mortality from asthma. For asthma mortality we used data provided by National Institute of Statistics, for sale estimates of beta2-agonists we used data provided by IMS HEALTH. We calculated the gender specific age-standardized incidence rates of asthma-related deaths for all ages and for age classes. We found that estimates for asthma-related mortality steadily increased between 1980 and 1987 in both sexes, and thereafter decreased. In people, aged between 34 and 64 and over 64, death rates in males were significantly higher than in females while the rates in those aged less than 34, were mostly similar in both gender. The overall exposure to beta2-agonists (alone and in combination) increased from 1980 to 1990, remained stable between 1990 and 1993, and increased steeply in 1994. We conclude that asthma-related death rates have declined since the mid-1980's. This decline has been more pronounced in males and in the older ages, while the rates in younger patients of both genders have remained nearly unchanged. Our data do not substantiate the hypothesis of an increased risk of asthma-related mortality associated to the use of inhaled beta2-agonists in general nor fenoterol or salbutamol in particular.

Determination of chronic methamphetamine abuse by hair analysis

A 30-year-old male truck driver, known to be asthmatic, was found dead at the roadside lying near his car. A nebulizer bottle of Berotec (fenoterol hydrobromide) was found near his hand. The anatomic cause of death was suspected to be asthma. Toxicological screening of urine using Triage demonstrated the presence of methamphetamine. The blood concentration of methamphetamine was 0.4 microg/ml, and fenoterol was not detected. Hair analysis clearly indicated chronic methamphetamine abuse and medium dependency during the 2 months before death. We conclude that death might have been induced by the interaction of fenoterol and methamphetamine.

[Influence of berotec inhalations on pulmonary gas exchange in patients with bronchial asthma]

AIM

To determine mechanisms inducing changes in lung gas exchange after berotec inhalation in patients with bronchial asthma (BA).

MATERIALS AND METHODS

A study was made of external respiration function including estimation of lung transfer factor (TLCO sbh.) and its components--transfer coefficient (KCO), membrane diffusion capacity (DM), pulmonary capillary blood volume (Vc)--by the single breath holding method on CO in 14 healthy persons and 39 patients with BA before and after berotec inhalation. The data were obtained in the absolute values and their changes after berotec inhalation were measured in percent to initial ones.

RESULTS

In healthy subjects we did not observe changes of TLCO sbh. and its components after berotec inhalation, only an insignificant decrease of VA eff. was registered (p < 0.01). After berotec inhalation a considerable improvement in Sgaw, FEV1, RPV and a decrease of TLCO sbh., KCO were observed. Changes in TLCO sbh. were caused by a decrease in DM without changes in VA eff. in BA patients with initial normal values of KCO. In patients with smaller initial values of KCO moderate improvement of bronchial permeability without changes in KCO, PaO2 were observed. These changes occurred due to a decrease of VA eff.

CONCLUSION

Changes of the transfer factor and its components in patients with BA reflect two types of adaptation reactions in response to berotec inhalation and their role in mechanisms of compensation of gas exchange in the lungs.

Individual results of treatment of COPD with low doses of fenoterol compared with treatment with ipratropium bromide

We compared the effects of 30-day treatments with fenoterol in low doses (4 x 100 mcg) and ipratropium bromide (4 x 40 mcg) on the lung function parameters (LFP), dyspnea and physical capacity of patients with severe chronic obstructive pulmonary disease (COPD) (FEV1 < 35% pred.) and analysed the individual response of patients to the administered therapy. The study included two groups of patients treated with fenoterol (n = 22) and ipratropium bromide (n = 22). The patients were matched by functional characteristics (age: 60 +/- 7 and 57 +/- 9 years; ATS Dyspnea Scale: 2.7 +/- 0.8 and 2.4 +/- 0.9; FEV1%: 25 +/- 7% and 23 +/- 6%; pO2: 62.4 +/- 5.3 mm Hg and 61.0 +/- 9.5 mm Hg; all values mean +/- SD). After 30 days of treatment we measured the lung function parameters (FEV1, FVC), dyspnea indices (ATS dyspnea scale, Borg scale) and the physical capacity of the patients (6-minute walking distance test). The results showed that in an open experiment fenoterol (4 x 100 mcg daily), unlike ipratropium bromide (4 x 40 mcg daily), cannot improve statistically and clinically significantly the lung function parameters, dyspnea and the physical capacity of the group as a whole. However, when the findings were assessed for each patient individually, 32% of the patients proved to have responded positively to the treatment. Therefore efficaciousness of fenoterol in low doses should be determined by assessing the lung function parameters, dyspnea and the physical capacity individually for each patient.

Inhaled budesonide for the treatment of acute wheezing and dyspnea in children up to 24 months old receiving intravenous hydrocortisone

BACKGROUND

Inhaled corticosteroids are highly effective in the treatment of asthma at all ages, and their use in younger children is increasing. There are no data currently available on the treatment of infants with acute wheeze and dyspnea with nebulized budesonide.

OBJECTIVE

Our purpose was to assess the clinical effect of nebulized budesonide in infants with acute wheeze and dyspnea.

METHODS

A prospective study was performed comparing the addition of nebulized budesonide 0.25 mg every 6 hours (group A, n = 32) and nebulized ipratropium bromide 0.1 mg every 6 hours (group B, n = 39) with the normal treatment regimen with intravenous fluid, hydrocortisone, and nebulized fenoterol. A clinical score was made at admission and every 12 hours. The score included wheezing and costal retraction (0-6) and respiratory rate (counts per minute).

RESULTS

Seventy-one infants aged 3 to 24 months were studied (42 boys). A statistically significant reduction was seen in clinical score and respiratory rate in both groups 12 hours after admission. The children who received budesonide improved significantly faster than the children who received ipratropium bromide, and the hospitalization period was significantly lower in the budesonide group (66.4 hours) compared with the ipratropium bromide group (93 hours) (P <.01). Three patients from the budesonide group and 2 from the ipratropium bromide group were readmitted within the first 4 weeks.

CONCLUSION

Treatment of infants with acute wheeze with nebulized budesonide is associated with faster clinical improvement and reduction in hospital stay period.

Effects of fenoterol and ipratropium on respiratory resistance of asthmatics after tracheal intubation

We have studied the effects of a beta-agonist, fenoterol, and a cholinergic antagonist, ipratropium, on post-intubation total respiratory system resistance (Rrs) in asthmatics who developed increased Rrs after tracheal intubation. Sixteen stable asthmatics in whom Rrs increased after intubation were allocated randomly to receive either 10 puffs of fenoterol (group F) or 10 puffs of ipratropium (group IB) via a metered dose inhaler 5 min after intubation. Anaesthesia was induced and maintained with propofol i.v. Rrs was recorded before treatment and again 5, 15 and 30 min after treatment. Rrs decreased significantly from pretreatment values by mean 53 (SD 8)%, 53 (7)% and 58 (6)% at 5, 15 and 30 min, respectively, in group F, but declined by only 12 (6)%, 15 (4)% and 17 (5)% in group IB. At all times after treatment, patients in the fenoterol group had significantly lower Rrs values than those in the ipratropium group. We conclude that increased Rrs after tracheal intubation in asthmatics can be reduced effectively by treatment with fenoterol. A secondary finding of our study was that even after induction of anaesthesia with propofol, patients with a history of asthma may develop high Rrs.

A meta-analysis of the effects of ipratropium bromide in adults with acute asthma

PURPOSE

To review the literature to determine whether inhaled ipratropium bromide provides additive benefits to adults with acute asthma who are being treated with beta-agonists in an emergency department.

SUBJECTS AND METHODS

English-language studies, both published (1978 to 1999) and unpublished, were retrieved using Medline, Science Citation Index, Current Contents, bibliographic reviews of primary research, review articles, consultation with experts, and the register of Medical Editors' Trial Amnesty. Only randomized, double-blind, controlled trials that enrolled patients having an exacerbation of asthma were included. The main outcome measure was pulmonary function; hospital admission rate was also evaluated.

RESULTS

Ten studies including 1,483 adults with acute asthma were selected (mean age 32 +/- 13 years, 36% men). The overall effect size in SD units of pulmonary function showed a significant benefit from ipratropium (effect size 0.14, 95% confidence interval [CI]: 0.04 to 0.24, P = 0.008). Study-specific effect sizes ranged from 0.03 to 0.63. This pooled effect size was equivalent to a 10% (95% CI: 2% to 18%) increase in forced expiratory volume in 1 second (FEV1) or peak expiratory flow in the ipratropium group compared with the control group. Analysis of the four studies that included patients with extreme obstruction (FEV1 or peak flow <35% of predicted at presentation) showed substantial improvement with ipratropium therapy (effect size 0.38, 95% CI: 0.09 to 0.67). In the five trials (1,186 patients) that studied the effect of ipratropium administration on hospital admissions, pooled results revealed that ipratropium reduced admission rates significantly (odds ratio 0.62, 95% CI: 0.44 to 0.88, P = 0.007).

CONCLUSIONS

The addition of ipratropium to beta-agonist therapy offers a statistically significant, albeit modest, improvement in pulmonary function, as well as a reduction in the rate of hospital admissions.

Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial

BACKGROUND

A metered-dose inhaler (MDI) with spacer is the best way to deliver bronchodilator therapy for treatment of acute asthma. In developing countries, commercially produced spacers are generally unavailable or too costly. We tested the efficacy of home-made spacers (500 mL plastic bottle, polystyrene cup) compared with a conventional spacer for delivery of a beta2 agonist via MDI for children with acute asthma.

METHODS

We studied children aged 5 to 13 years with acute asthma, stratified into those with mild airways obstruction (peak expiratory flow [PEF] 60-79% of predicted value) or moderate to severe airways obstruction (PEF 20-59% of predicted value). A beta2 agonist (fenoterol hydrobromide) was given via MDI and one of four randomly assigned spacers (conventional spacer, sealed 500 mL plastic bottle, unsealed 500 mL bottle, 200 mL polystyrene cup). Clinical score, pulmonary function tests, and oximetry were recorded at baseline and 15 min after treatment. If a second bronchodilator treatment was needed, nebulised fenoterol was given and the assessment repeated 15 min later. Primary outcome measures were changes in clinical score and pulmonary function, and need for and response to nebulisation.

FINDINGS

88 children were eligible for study. In 44 children with moderate to severe airways obstruction, a cup gave significantly less bronchodilation (median increase in: forced expiratory volume in 1 s [FEV1] 0%; PEF 12%) compared with the conventional spacer (37%; 59%), sealed bottle (33%; 36%), or unsealed bottle (18%; 21%, p<0.05 for difference between groups). Nebulisation was required by ten of 11 who had used a cup, nine of 11 who had used an unsealed bottle, eight of 11 who had used a sealed bottle, and only four of 11 who had used a conventional spacer. After nebulisation, improvement in FEV1 (15.5%) and PEF (26%) was more marked in children who had used a cup than in those who had used a conventional spacer (5.5% FEV1; 4% PEF), sealed bottle (3%; 0%), or unsealed bottle (7%; 9%). For 44 children with mild airways obstruction, response to bronchodilator was similar for all spacers and need for nebulisation was not associated with use of a particular spacer.

INTERPRETATION

A conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction. Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries.

Spontaneous labour at term is associated with fetal monocyte activation

The aetiology of both term and preterm labour remains incompletely understood. Maternal infectious diseases as well as intra-uterine infections were shown to be a well established cause of uncontrollable preterm delivery, indicating that inflammatory reactions, regulated by maternal immunecompetent cells, are implicated in labour-promoting mechanisms. To investigate the possibility that the activation of the fetal immune system may be involved in labour induction, we examined cytokine production patterns of different cord blood cell populations obtained from neonates after spontaneous onset of normal term labour and vaginal delivery (n = 25), vaginal delivery but induced term labour (n = 17), and preterm delivery because of uncontrollable labour (n = 27, 20 patients received corticoid treatment for fetal lung maturation), in comparison with cells obtained from neonates after elective term caesarean delivery in the absence of labour (n = 15). Our results demonstrate that spontaneous term labour, but not induced term labour, was associated with significantly increased IL-6 production by myelomonocytic cell populations. Preterm delivery due to uncontrollable labour with resistance to tocolysis was not associated with increased IL-6 production by fetal myelomonocytic cells. Two-colour flow cytometry combined with intracellular cytokine staining was used to identify fetal monocytes as sources of labour-associated IL-6 release at term. We did not find any activation of cord blood T cells in association with spontaneous term or uncontrollable preterm labour. Therefore, fetal T cell responses may not cause monocyte activation. Our results suggest that increased release of IL-6 from fetal monocytes is involved in mechanisms promoting normal term, but not preterm labour, and that mechanisms inducing term and preterm labour are completely different.

Pulse oximetry in the evaluation of the severity of acute asthma and/or wheezing in children

We evaluated 174 children with acute asthma and/or wheezing attending two different settings, the allergy clinic (AC) and the emergency room (ER), and compared clinical symptoms and spirometric findings with arterial oxygen saturation as measured by pulse oximetry (SpO2). Seventy-four children (4 months to 15 years old) seen at the AC and 100 children (2 months to 14 years old) seen at the ER for the treatment of acute asthma and/or wheezing were evaluated and a clinical score was attributed on the basis of their symptoms. In addition, the heart rate (HR) was recorded and SpO2 was measured. Among the children seen at the AC, 58 were able to perform pulmonary function tests, and the forced respiratory volume in 1 sec (FEV1) and forced expiratory flow between 25% and 75% of the forced vital capacity (FEF(25-75)) were determined. Children from both groups underwent treatment with a nebulized beta2-agonist (Fenoterol 0.5% solution, 0.08 mg/kg/dose, maximum 2.5 mg) and were re-evaluated after 30 min. Our results showed a significant correlation between decrease in clinical scores and increase of SpO2 following treatment with bronchodilator in both groups of children. SpO2 levels correlated positively with FEV1 and FEF(25-75) values, and negatively with clinical scores and heart rate. The data revealed that a clinical score greater than 3 and an SpO2 < 94% were associated with increased severity of the asthma attack. In addition, SpO2 levels < or = 92% were associated with a 6.3-fold greater relative risk for requiring additional treatment. We concluded that determination of oxygen saturation by pulse oximetry is helpful in monitoring the severity of an acute exacerbation of asthma and/or wheezing, and has a prognostic value.

[Psychological features of patients with bronchial asthma during long-term basic therapy at the "Asthma School"]

AIM

To evaluate changes in psychological status of bronchial asthma (BA) patients in the course of the basic treatment (BT) and attending "Asthma-school".

MATERIALS AND METHODS

107 patients with BA were observed for 2 years. 26 of them had BA stage II (group 1), 54 had stage III (group 2) and stage IV was in 27 patients (group 3). The criteria of PQBI (personal questionnaire of the Bekhterev Institute) and MMPI (Minnesota Multiphasic Personality Inventory) were used. Also, clinical symptoms and external respiration (ER) were studied.

RESULTS

2 years of treatment led to a decline in clinical symptoms (p < 0.001) and ER (p < 0.05) in patients of groups 1 and 2. Their attitude to the disease and treatment has also improved in many cases (p < 0.05). In all the groups the number of patients with neurotic reaction decreased (p < 0.05). In group 3, more patients had sensitive and egocentric reactions (p < 0.05).

CONCLUSION

BT and studies in "Asthma-school" brought about harmonic changes in personality and attenuation of neurotic disorders without application of routine psychotherapeutic methods.