Randomized controlled trial of belladonna and opiate suppository during intravesical onabotulinum toxin A injection.

BACKGROUND: Intravesical injection with onabotulinum toxin A injection can be performed in-office under local anesthesia. Rectally administered pain medication presents a potentially feasible and previously uninvestigated adjunct to office-based anesthesia protocols. OBJECTIVE: The primary aim of this study was to determine whether adding a belladonna and opiate suppository to standard lidocaine instillation resulted in reduction of bladder injection pain during onabotulinum toxin A injection procedure. STUDY DESIGN: This was a prospective, randomized, double-blind, placebo-controlled study of patients undergoing onabotulinum toxin A bladder injection at a single clinic. Patients age ≥18 years, who met clinical criteria for invasive treatment of refractory urinary symptoms, had previously documented postvoid residual volumes <150 mL, and elected for in-office intravesical onabotulinum toxin A injection were eligible to participate. Participants were randomized by computer-generated block randomization to receive a belladonna and opiate (belladonna alkaloid with morphine 16.2/7.5 mg) or placebo suppository. Suppositories were placed immediately prior to lidocaine-based anesthesia, which all participants received. All participants underwent a standardized injection procedure using the same rigid cystoscope, needle type, and injection pattern (20 injections total). A 0-10 numeric rating scale was used to assess pain intensity before anesthesia and suppository, 40 minutes after administration of anesthesia and suppository, after first 10 bladder injections, and immediately after completion of 20 injections. Pain increase during procedure was calculated using the difference between score 40 minutes after administration of anesthesia and suppository and score after first 10 bladder injections. Postvoid residual were measured immediately postprocedure and 2 weeks later. Patient satisfaction with pain control was measured using a Likert scale. Our primary outcome was change in pain level from anesthetic baseline to midprocedure (score after first 10 bladder injections to score 40 minutes after administration of anesthesia and suppository). A final sample size of 26 patients was needed to have 80% power (alpha = 0.05) to detect a 50% reduction in bladder injection pain during the procedure as defined by our primary outcome. An intent-to-treat approach was used for all analyses. RESULTS: In all, 26 participants were enrolled and randomized with 13 in each study arm. Participants in the treatment group were slightly older than in the placebo group (P = .05); there were no statistically significant differences in medical comorbidities. Median score after first 10 bladder injections to score 40 minutes after administration of anesthesia and suppository for the placebo group and treatment group was 4 (range 1-10) and 5 (range 0,9), respectively (P = .94). Median scores immediately after completion of 20 injections for the placebo group and treatment group were 3 (range 0-10) and 2 (range 0,8), respectively (P = .29). There were no significant differences in preinjection pain scores reported before anesthesia and suppository and at 40 minutes after administration of anesthesia and suppository. Postprocedure postvoid residual >200 mL was noted in 5 (38%) of the placebo group and 3 (23%) of the treatment group (P = .67). Two-week postprocedure postvoid residual >200 mL was noted in 3 (25%) of the placebo group and 2 (15%) of the treatment group (P = .64) for an overall rate of 20%. Eleven (84%) participants in each group reported being "mostly satisfied" or "very much satisfied" with pain control. CONCLUSION: Belladonna and opiate suppository use did not significantly reduce bladder injection pain, or increase risk of urinary retention immediately postprocedure or 2 weeks later. Satisfaction with pain control among onabotulinum toxin A injection patients is high.

Efficacy of treatment with belladonna in children with severe pallid breath-holding spells.

IntroductionPallid breath-holding spells are common and dramatic forms of recurrent syncope in infancy. They are very stressful despite their harmless nature and sometimes require treatment. OBJECTIVE: The objective of this study was to evaluate the efficacy of belladonna in severe breath-holding spells. METHODS: This is a multicentric, retrospective series involving 84 children with severe pallid breath-holding spells. Inclusion criteria were >1 pallid breath-holding spell with loss of consciousness, paediatric cardiology evaluation, and follow-up >6 months. In total, 45 patients received belladonna and 39 patients did not receive treatment, according to physician preference. RESULTS: Mean age was 11 months, ranging from 4 to 18 months, with 54% of males. Mean spell duration was 30 seconds (interquartile range 15, 60), and the frequency was four episodes per month (interquartile range 0.5, 6.5). Comparison of baseline characteristics between groups showed similar demographics, with the single difference in the severity of the spells, being more severe in the treated group. When comparing the treated and non-treated groups at 3 months, only two (5%) patients had a complete remission in the first group, whereas 20 (44%) had remission in the belladonna group (p<0.01). When considering the characteristics of the spells before and after the initiation of treatment with belladonna, 75% of the patients presented a positive response, with 44% of the patients presenting with complete resolution of the spells (p<0.01). No major adverse reaction was reported, with only 5% minor adverse events. CONCLUSIONS: Belladonna is highly effective to alleviate severe breath-holding spells in young children, without any major adverse effects.

Belladonna Alkaloid Intoxication: The 10-Year Experience of a Large Tertiary Care Pediatric Hospital.

The belladonna alkaloids can be isolated from a number of plants, which contain hallucinogens that represent a serious danger to infants, children, and adolescents. Roots, leaves, and fruits of the plant contain the alkaloids atropine, hyoscyamine, and scopolamine, which can lead to an anticholinergic toxidrome; however, not all characteristics of the toxidrome are necessarily present in each case of poisoning. A retrospective chart review of all children seen following anticholinergic ingestions, between April 2001 and November 2010, at the Hospital for Sick Children in Toronto. Ten children, with a mean age of 15.5 years (range, 15-18 years), were identified; 5 had used jimsonweed and the others had a variety of tablets containing atropine. All 10 presented with severe anticholinergic symptoms and 2 with suicide attempts. Treatments included charcoal, benzodiazepines, haloperidol, and physostigmine, and 2 patients were intubated. Ingestion and subsequent severe anticholinergic toxidrome occurred exclusively in adolescents. It is important to educate this age group regarding the toxicity and potential risks associated with the recreational use of these plants and substances. Physostigmine can help in both the diagnosis and management of patients intoxicated with these substances.

[EFFECT OF MEDIATOR-TYPE DRUGS ON HUMAN PSYCHOPHYSIOLOGICAL STATUS DURING MODEL OPERATOR ACTIVITY].

In a placebo-controlled study, changes in psychophysiological status of operators (38 healthy male volunteers aged 23-35 years) performing 4-hour model operator activity were evaluated after a single oral administration of typical representatives of the different classes of drugs (haloperidol, proroxan, yohimbine hydrochloride, propranolol, mesocarb, isoprenaline, Belladonna extract, anabasine hydrochloride, valproate sodium, and phenazepam), which are used for the treatment, rehabilitation and prophylaxis of common diseases. It was found that all the drugs modified to a greater or lesser extent some components of the model operator activity. Isoprenaline and phenazepam had the most negative effect on the psychophysiological indicators and quality of the modeled operator activity. The results should be considered before administration of such drugs to working operators.

An Automated Data-Driven Pipeline for Improving Heterologous Enzyme Expression.

Enzymes are the ultimate entities responsible for chemical transformations in natural and engineered biosynthetic pathways. However, many natural enzymes suffer from suboptimal functional expression due to poor intrinsic protein stability. Further, stability enhancing mutations often come at the cost of impaired function. Here we demonstrate an automated protein engineering strategy for stabilizing enzymes while retaining catalytic function using deep mutational scanning coupled to multiple-filter based screening and combinatorial mutagenesis. We validated this strategy by improving the functional expression of a Type III polyketide synthase from the Atropa belladonna biosynthetic pathway for tropane alkaloids. The best variant had a total of 8 mutations with over 25-fold improved activity over wild-type in E. coli cell lysates, an improved melting temperature of 11.5 ± 0.6 °C, and only minimal reduction in catalytic efficiency. We show that the multiple-filter approach maintains acceptable sensitivity with homology modeling structures up to 4 Å RMS. Our results highlight an automated protein engineering tool for improving the stability and solubility of difficult to express enzymes, which has impact for biotechnological applications.

Delirium: an under-recognized problem.

CASE STUDY: Ms. G, a 78-year-old woman with a history of heart failure and a left ventricular ejection fraction of 45%, had an exploratory laparotomy with colon resection and colostomy two days ago for an obstructive stage IIIB adenocarcinoma of the colon. She is a patient on a general surgical unit. Upon assessment at 7 am, Ms. G was easily aroused and oriented. She has a patient-controlled analgesia (PCA) pump for postoperative pain control with 1 mg of morphine available every 30 minutes; she used a total of 4 mg of morphine via IV since midnight. Ms. G requires belladonna and opium suppositories about every eight hours to treat bladder spasms associated with her urinary catheter.

Tropinone reductases, enzymes at the branch point of tropane alkaloid metabolism.

Two stereospecific oxidoreductases constitute a branch point in tropane alkaloid metabolism. Products of tropane metabolism are the alkaloids hyoscyamine, scopolamine, cocaine, and polyhydroxylated nortropane alkaloids, the calystegines. Both tropinone reductases reduce the precursor tropinone to yield either tropine or pseudotropine. In Solanaceae, tropine is incorporated into hyoscyamine and scopolamine; pseudotropine is the first specific metabolite on the way to the calystegines. Isolation, cloning and heterologous expression of both tropinone reductases enabled kinetic characterisation, protein crystallisation, and structure elucidation. Stereospecificity of reduction is achieved by binding tropinone in the respective enzyme active centre in opposite orientation. Immunolocalisation of both enzyme proteins in cultured roots revealed a tissue-specific protein accumulation. Metabolite flux through both arms of the tropane alkaloid pathway appears to be regulated by the activity of both enzymes and by their access to the precursor tropinone. Both tropinone reductases are NADPH-dependent short-chain dehydrogenases with amino acid sequence similarity of more than 50% suggesting their descent from a common ancestor. Putative tropinone reductase sequences annotated in plant genomes other that Solanaceae await functional characterisation.

Characteristics of Atropa belladonna hairy roots cryopreserved by vitrification method.

Atropa belladonna hairy roots (clone M8) were successfully cryopreserved by using the vitrification method. A. belladonna hairy root tips were precultured on a half strength of Murashige and Skoog (MS) solid medium with 0.1 mg per L 2,4-D or without phytohormone for 1 day, and then dehydrated with PVS2 solution for 15 minutes prior to immersion into liquid nitrogen for 1 day, 1 week, 1 month and 3 months. Hairy root tips kept in liquid nitrogen were rapidly thawed at 36 degree C in a water bath. The root tips were recultured on half strength MS medium. The hairy root tips, precultured with 2,4-D before cryopreservation, showed a higher survival rate than those precultured without phytohormone. The hairy root tips, precultured with 2,4-D, showed an average survival rate of 83 percent. There was no significant difference in the viability of the hairy roots cryopreserved for different periods. The regrowth of cryopreserved hairy roots was similar to that of untreated hairy roots and tropane alkaloid productivity became stable after 4th subculture. PCR analysis of hairy roots demonstrated the conservation of the T-DNA in cryopreserved hairy roots. These results indicate that cryopreservation by vitrification method is useful to preserve A.belladonna hairy root clone M8.

[Colorimetric determination of eccrine sudoriferous glands functional condition in case of hyperhidrosis and their correction by belladonna].

For study of the sweat secretion in 27 patients suffered by local hyperhidrosis method of colorimetric determination of functioning sudoriferous glands number and a Minor's tests were used. The confines and intensity of sweat secretion have been determined. Study was carried out before and during the treatment as well as at the moment of clinical recovery. Revealing of vegetative syndromes was provided by Vein's inquirer. In patients with hyperhidrosis vegetative abnormalities were combined with asthenic disorders. Duration of illness had impact on frequency and character of neurasthenic syndrome manifestation. Offered scheme of local hyperhidrosis treatment with staged use of belladonna and antihistaminic preparation "hydroxyzine" (having antimuscarinic action) could be characterized as a well endurable and significantly ameliorative of patient's clinical status.

Anticholinergic poisoning associated with herbal tea.

An outbreak of cholinergic poisoning occurred in New York City during a 3-day period. Seven individuals from three families of South American origin were affected. Signs and symptoms of illness included dry skin, hyperthermia, tachycardia, dilated pupils, agitation, and hallucinations. Onset of illness in all cases was temporally associated with consumption of a tea that was labeled "Paraguay Tea" and was purchased from a grocery store specializing in South American foods. Paraguay tea, made from the leaves of the holly, Ilex paraguariensis, contains caffeine and theophylline and is a popular beverage in South America. Samples of the tea analyzed with gas chromatography contained belladonna alkaloids but neither caffeine nor theophylline. An investigation by the New York City Department of Health personnel determined that the tea was from a single lot, imported by one distributor, and sold at one grocery store. Unsold inventories of the tea were quarantined, and no further cases of anticholinergic poisoning were reported.

Identification and estimation of the levo isomer in raw materials and finished products containing atropine and/or hyoscyamine.

The belladonna alkaloids atropine sulfate and hyoscyamine sulfate, occasionally used as anticholinergic and antimuscarinic agents, have identical molecular formulas but different stereo configurations. Hyoscyamine sulfate contains almost 100% of the levo isomer, whereas atropine sulfate is composed of equal parts of dextro and levo isomers. It is believed that the therapeutic properties of these alkaloids are due exclusively or primarily to the levo isomer. Currently available methods determine only the total amount of atropine (hyoscyamine) sulfate. A method has been developed and is reported for the identification and estimation of the levo and dextro isomers of atropine and hyoscyamine. Reference solutions are prepared in methanol at the following weights per 100 mL: 8.0 mg atropine sulfate; 4.0 mg hyoscyamine sulfate; 7.0 mg scopolamine hydrobromide; and 10.0 mg homatropine methylbromide. Samples of raw materials are similarly prepared in methanol, commercial products are also extracted or diluted with methanol, and solutions are filtered. Liquid chromatography is used for separations on a 25 cm Chirobiotic T2 column. The mobile phase is prepared by mixing 3.0 mL acetic acid and 2.0 mL triethylamine with 1000 mL methanol. The injection volume is 100 or 200 microL; the flow rate is about 0.35 mL/min. Fluorescence detection is at 255 nm excitation and 285 nm emission. Scopolamine hydrobromide and hyoscyamine eluted after 20 and 60 min, respectively. Atropine sulfate generated 2 peaks after 60 and 65 min. Homatropine methylbromide also produced 2 peaks after 70 and 85 min. Samples tested in this study included raw materials and commercial tablets or injections containing belladonna alkaloids. In all cases, the percentage calculated was that of the levo isomer relative to the total amount of atropine (hyoscyamine) present.

Assessing homeopathic proving using questionnaire methodology: consideration and implications for future studies.

Homeopathic pathogenetic trials (or provings) provide the foundations for the clinical practice of homeopathy. The most recent review of proving studies indicated that provings are generally of poor methodological quality. Methods to improve the quality and scientific rigour are needed to critically assess the clinical basis of homeopathy. This article describes a methodology using a symptom diary with a selection of predefined remedy specific symptoms (proving questionnaire). The proving questionnaire was developed as an alternative to the traditional qualitative proving methods in an attempt to provide a quantitative method that could rigorously validate the original provings. This article considers the advantages and disadvantages of this approach and provides suggestions for future work in this area.

Anticholinergic poisoning associated with an herbal tea--New York City, 1994.

Inadvertent anticholinergic poisoning can result from consumption of foods contaminated with plants that contain belladonna alkaloids. During March 1994, the New York City Department of Health (NYCDOH) investigated seven cases of anticholinergic poisoning in members of three families; three of the seven ill persons required emergency treatment for characteristic manifestations. For all cases, manifestations occurred within 2 hours after drinking tea made from leaves purchased commercially and labeled as Paraguay tea--an herbal tea derived from the plant llex paraguariensis, which is native to South America. This report summarizes the investigation of these cases.

Delirium induced by poisoning with anticholinergic agents.

The authors report that anticholinergic poisoning may be increasing in frequency and present two such cases. They recommend the use of the physostigmine test and special laboratory requests for toxicologic screens as aids to the diagnosis.

Nonestrogen management of menopausal symptoms.

Women who cannot or choose not to take estrogens do have alternatives; however, the options are few and unproven in longterm clinical trials with respect to safety and efficacy. Many available alternative treatments may alleviate the symptoms of the menopause, but do not convey long-term protection against osteoporosis and cardiovascular disease. This article reviews treatment alternatives to estrogen replacement therapy for symptomatic relief.

Prevention of airway obstructions during sleep in infants with breath-holding spells by means of oral belladonna: a prospective double-blind crossover evaluation.

We investigated whether the brief airway obstructions seen during sleep in infants with breath-holding spells were controlled by the autonomic nervous system. We studied 20 infants, with a history of breath-holding spells and a median age of 12 wk (range 4-46 wk). During sleep they had a median of 6 airway obstructions per 10-hr recording (range 3-16 events), with a median duration of 8 sec (range 4-12 sec). No explanation was found for the airway obstructions. In every infant, a double-blind crossover challenge was conducted. It included oral administration of tincture of belladonna, equivalent to 0.01 mg/kg weight of atropine, and placebo syrup containing no belladonna. The belladonna, or the placebo, was administered at bedtime for 7 days, followed by a 7-day washout period. Another 7-day series of syrup administration was then undertaken. A nighttime polygraphic recording was made after each 7-day series. It was the belladonna, and not the placebo, that induced the disappearance of the obstructions in 10 infants; these were called "drug responsive". In 5 children no effect was observed after either the placebo or belladonna; these infants were defined as "drug unresponsive". In 4 subjects the obstructions disappeared after both belladonna and the placebo; the children were considered to have an "inconclusive response". One infant was excluded from the study because he developed an airway infection. It is concluded that in some breath-holding infants, obstructed breathing episodes during sleep disappear after the administration of an atropinic drug. The observation could indicate a role of the autonomic nervous system in the control of the upper airways during sleep in infants.

Controlled clinical trial of sedative-anticholinergic drugs in patients with the irritable bowel syndrome.

We studied 16 patients with long-standing irritable bowel syndrome of moderate severity using a controlled, double-blind crossover method. Five sedative-anticholinergic drug combinations and a placebo were tested. The subjective response was assessed with four subjective methods to include an increasing number of response variables. The patients preferred 30 mg phenobarbital plus 8 mg belladonna (P & B) to placebo (P = 0.02). Five of ten patients were helped "some" or "a lot" with placebo, while ten of 15 were helped "some" or "a lot" with P & B (P = 0.07). The ten prominent-symptoms method revealed that subjective symptoms such as nervousness, sleep difficulties, and tiredness were experienced as greater problems than diarrhea. The factor analysis method documented a strong placebo response. Simpler evaluation methods such as drug preference and a five-choice method appear more likely to show a positive drug effect, while the inclusion of a larger number of variables appears to emphasize the placebo portion of the response. These observations may help explain some of the apparent discrepancies between the conclusions of some controlled clinical trials and subsequent clinical experience.

Uropharmacology: part VI. Parasympathetic depressants.

A discussion of the various parasympathetic depressants is presented. Belladonna alkaloids include atropine, the prototype, and scopolamine. Synthetic drugs include quaternary ammonium compounds with antimuscarinic activity such as methantheline, propantheline, and other drugs such as isopropamide, pipenzolate methylbromide, and diphemanil methylsulfate. A miscellaneous class of drugs such as hemicholinium, valethamate, and oxybutynin chloride also possesses parasympathetic depressant activity. The pharmacologic properties and clinical usage of these drugs are discussed.