START CARE: a protocol for a randomised controlled trial of step-wise budesonide-formoterol reliever-based treatment in children.

Background: Asthma is the most common chronic childhood respiratory condition globally. Inhaled corticosteroid (ICS)-formoterol reliever-based regimens reduce the risk of asthma exacerbations compared with conventional short-acting ß2-agonist (SABA) reliever-based regimens in adults and adolescents. The current limited evidence for anti-inflammatory reliever therapy in children means it is unknown whether these findings are also applicable to children. High-quality randomised controlled trials (RCTs) are needed. Objective: The study aim is to determine the efficacy and safety of budesonide-formoterol reliever alone or maintenance and reliever therapy (MART) compared with standard therapy: budesonide or budesonide-formoterol maintenance, both with terbutaline reliever, in children aged 5 to 11 years with mild, moderate and severe asthma. Methods: A 52-week, multicentre, open-label, parallel group, phase III, two-sided superiority RCT will recruit 400 children aged 5 to 11 years with asthma. Participants will be randomised 1:1 to either budesonide-formoterol 100/6 µg Turbuhaler reliever alone or MART; or budesonide or budesonide-formoterol Turbuhaler maintenance, with terbutaline Turbuhaler reliever. The primary outcome is moderate and severe asthma exacerbations as rate per participant per year. Secondary outcomes are asthma control, lung function, exhaled nitric oxide and treatment step change. Assessment of Turbuhaler technique and cost-effectiveness analysis are also planned. Conclusion: This will be the first RCT to compare the efficacy and safety of a step-wise budesonide-formoterol reliever alone or MART regimen with conventional inhaled ICS or ICS-long-acting ß-agonist maintenance plus SABA reliever in children. The results will provide a much-needed evidence base for the treatment of asthma in children.

Skin-to-deltoid-muscle distance at three recommended sites for intramuscular vaccination in a population with obesity: an observational study.

AIM: Worldwide, immunisation guidelines variably locate the deltoid injection site based on anatomical landmarks. This may influence the skin-to-deltoid-muscle distance and therefore the needle length required to achieve intramuscular injection. Obesity is associated with increased skin-to-deltoid-muscle distance, but it is unknown whether the injection site location chosen in individuals with obesity impacts the needle length required for intramuscular injection. The aim of the study was to estimate the differences in skin-to-deltoid-muscle distance between three different vaccine injection sites recommended by the national guidelines of the United States of America (USA), Australia and New Zealand, in obese adults. The study also explored i) the associations between skin-to-deltoid-muscle distance across the three recommended sites with sex, body mass index (BMI), and arm circumference, and ii) the proportion of participants with a skin-to-deltoid-muscle distance >20 millimetres (mm), in whom the standard 25mm needle length would not ensure deposition of vaccine within the deltoid muscle. METHOD: Non-interventional cross-sectional study in a single site, non-clinical setting in Wellington, New Zealand. Forty participants (29 females), aged ≥18 years, with obesity (BMI>30 kilograms [km]/m[[2]]). Measurements included distance from acromion to injection sites, BMI, arm circumference, and skin-to-deltoid-muscle distance measured by ultrasound at each recommended injection site. RESULTS: Mean (SD) skin-to-deltoid-muscle distances for USA, Australia and New Zealand sites were 13.96mm (4.54), 17.94mm (6.08) and 20.26mm (5.91) respectively, with a mean (95% confidence interval) for the distance between Australia minus New Zealand -2.7mm (-3.5 to -1.9), P<0.001; and USA minus New Zealand -7.6 mm (-8.5 to -6.7); P<0.001. Skin-to-deltoid-muscle distance was greater in females and was positively associated with BMI and arm circumference. The proportions with a skin-to-deltoid-muscle distance >20 mm were 45%, 40% and 15% for the New Zealand, Australia and USA sites respectively. However, the sample size was relatively small, limiting interpretation in specific sub-groups. CONCLUSION: There were marked differences in the skin-to-deltoid-muscle distance between the three recommended injection sites studied. When choosing the required needle length to achieve intramuscular vaccination in obese vaccine recipients, consideration needs to be given to the injection site location, sex, BMI and/or arm circumference, as these factors all influence the skin-to-deltoid-muscle distance. A standard needle length of 25mm may be insufficient to ensure deposition of vaccine into the deltoid muscle in a substantive proportion of adults with obesity. Research is urgently required to determine anthropometric measurement cut-points that can be used to enable appropriate needle length selection to ensure intramuscular vaccination.

COVID-19 vaccination and the skin to deltoid MUSCLE distance in adults with diabetes.

Objectives: To estimate the proportion of adult diabetics with a skin to deltoid muscle distance (SDMD) of > 25 mm, representing a distance greater than the standard needle length used for intramuscular COVID-19 vaccination, and to assess whether anthropometric measurements predict ultrasound SDMD measurements. Design: Non-interventional cross-sectional study. Setting: Single site, non-clinical setting, Wellington, New Zealand. Participants: One hundred participants (50 females) aged at least 18 years diagnosis with diabetes. All participants completed the study. Main outcome measures: The proportions of participants with a SDMD > 25 mm and a SDMD > 20 mm (indicating that the needle would not have penetrated at least 5 mm into the deltoid, which is considered necessary to ensure deposition of vaccine into muscle); the relationship between anthropometric measurements (body weight, body height, body mass index (BMI), skinfold thickness, arm circumference) and SDMD measured by ultrasound. Results: The proportion (95 %CI) of participants with a SDMD > 25 mm was 6/100; 6 % (2.2 to 12.6), and the proportion with a SDMD > 20 mm was 11 % (5.6 to 18.8), of which 9/11 had a BMI ≥ 30 kg/m2 and 9/11 were female. The strongest relationships between anthropometric measurements and SDMD were with arm circumference (r = 0.76, P < 0.001) and BMI (r = 0.73, P < 0.001). Arm circumference and BMI were the best predictors of SDMD measurements with AUC for ROC curves of 0.99 and 0.94 above the 25 mm cut point, 0.97 and 0.89 above the 20 mm cut point respectively. Conclusions: The standard needle length of 25 mm is likely to be insufficient to ensure deposition of COVID-19 vaccine within the deltoid muscle in a small but important proportion of obese adults with diabetes. Arm circumference and BMI are simple measurements that could identify those that need a long needle to ensure successful intramuscular vaccine administration. Funding: Ruth Maud Ring Spencer Estate; Health Research Council of New Zealand (Independent Research Organisation).

The anti-cancer, anti-inflammatory and tuberculostatic activities of a series of 6,7-substituted-5,8-quinolinequinones.

A variety of 6,7-substituted-5,8-quinolinequinones were synthesised and assessed for their anti-tumour and anti-inflammatory activities, and their ability to inhibit the growth of Mycobacterium bovis BCG. In particular, the introduction of a sulfur group at the 7-position of the quinolinequinone led to the discovery of two compounds, 6-methylamino-7-methylsulfanyl-5,8-quinolinequinone (10a) and 6-amino-7-methylsulfonyl-5,8-quinolinequinone (12), that exhibited selectivity for leukemic cells over T-cells, a highly desirable property for an anti-cancer drug. A number of anti-inflammatory (AI) compounds were also identified, with 6,7-bis-methylsulfanyl-5,8-quinolinequinone (18a) exhibiting the highest AI activity (0.11 microM), while 6,7-dichloro-5,8-quinolinequinone (7a), 6,7-dichloro-2-methyl-5,8-quinolinequinone (7b), and 6,7-bis-phenylsulfanyl-quinoline-5,8-diol (19) also exhibited good AI activity and specificity. Several quinolinequinone TB-drug candidates were identified. Of these, 6-amino-7-chloro-5,8-quinolinequinone (11) and 6-amino-7-methanesulfinyl-5,8-quinolinequinone (14), exhibited low MICs (1.56-3.13 microg/mL) for the 100% growth inhibition of M. Bovis BCG. Some general trends pertaining to the functional group substitution of the quinolinequinone core and biological activity were also identified.

Viscous food matrix influences absorption and excretion but not metabolism of blackcurrant anthocyanins in rats.

The aim of the present study was to investigate the effect of a simultaneous intake of food and anthocyanins (ACNs) on ACN absorption, metabolism, and excretion. Blackcurrant ACNs (BcACNs) were dissolved in water with or without the addition of oatmeal and orally administered to rats, providing approximately 250 mg total ACNs per kilogram BW. Blood, urine, digesta, and tissue samples of the stomach, jejunum, and colon were subsequently collected at 0.25, 0.5, 1, 2, 3, 7, and 24 h. Identification and quantification of ACNs were carried out by Reversed phase-high-performance liquid chromatography (RP-HPLC) and liquid chromatography-mass spectrometry (LC-MS). Four major ACNs were present in the blackcurrant extract: delphinidin 3-O-glucoside, delphinidin 3-O-rutinoside, cyanidin 3-O-glucoside, and cyanidin 3-O-rutinoside. In plasma, the 4 ACNs of blackcurrant were identified and quantified. The time to reach maximal total ACN plasma concentration (C(max) BcACN/water = 0.37 +/- 0.07 micromol/L; C(max) BcACN/oatmeal = 0.20 +/- 0.05 micromol/L) occurred faster after BcACN/water (t(max)= 0.25 h), than after BcACN/oatmeal administration (t(max)= 1.0 h). In digesta and tissue samples, the 4 original blackcurrant ACNs were detected. The relative concentration of rutinosides in the digesta increased during their passage through the gastrointestinal tract, while the glucosides decreased. Maximum ACN excretion in urine occurred later after BcACN/oatmeal than after BcACN/water administration (3 compared with 2 h). The 4 original ACNs of blackcurrant in their unchanged form, as well as several metabolites, were identified in the urine samples of both groups. The simultaneous intake of food affects ACN absorption and excretion in the urine, but not metabolism.

Resident macrophages initiating and driving inflammation in a monosodium urate monohydrate crystal-induced murine peritoneal model of acute gout.

OBJECTIVE: To determine whether infiltrating monocytes, neutrophils, or resident macrophages contribute to the early inflammatory response to monosodium urate monohydrate (MSU) crystals in vivo. METHODS: MSU crystal-induced inflammation was monitored using a peritoneal model of acute gout. The production of proinflammatory cytokines (interleukin-1beta [IL-1beta], tumor necrosis factor alpha [TNFalpha], IL-6) by resident macrophages, infiltrating monocytes, and neutrophils during the onset of gout was determined by flow cytometry. Infiltrating and resident peritoneal cells were cultured with MSU crystals ex vivo, and proinflammatory cytokine production was determined by multiplex cytokine array. Activated macrophages on the visceral epithelial lining of the peritoneum were identified by immunofluorescence histochemistry. The inflammatory immune response to MSU crystals was then compared with the inflammatory response in mice depleted of resident macrophages by pretreatment with clodronate liposomes. RESULTS: The production of cytokines in vivo preceded the influx of Gr-1(intermediate)7/4+ monocytes. Monocytes and neutrophils recruited during the inflammatory phase of the response to MSU crystals failed to produce proinflammatory cytokines either in vivo, or ex vivo following restimulation with MSU crystals. Stimulation of the naive peritoneal resident cell population with MSU crystals ex vivo resulted in positive staining of resident macrophages for the proinflammatory cytokines IL-1beta, TNFalpha, and IL-6. Depletion of the resident macrophage population resulted in a significant decrease in both MSU crystal-induced neutrophil infiltration and proinflammatory cytokine production in vivo despite the presence of infiltrating monocytes. CONCLUSION: These data indicate that resident macrophages, rather than infiltrating monocytes or neutrophils, are important for initiating and driving the early proinflammatory phase of acute gout.

Synthesis and anti-inflammatory structure-activity relationships of thiazine-quinoline-quinones: inhibitors of the neutrophil respiratory burst in a model of acute gouty arthritis.

Sixteen new thiazine-quinoline-quinones have been synthesised, plus one bicyclic analogue. These compounds inhibited neutrophil superoxide production in vitro with IC(50)s as low 60 nM. Compounds with high in vitro anti-inflammatory activity were also tested in a mouse model of acute inflammation. The most active compounds inhibited both neutrophil infiltration and superoxide production at doses 2.5 micromol/kg, highlighting their potential for development as novel NSAIDs.

The bioavailability and absorption of anthocyanins: towards a better understanding.

Evidence that anthocyanin compounds have beneficial effects for health are increasingly being reported in the scientific literature and these compounds are now widely recognised as potential therapeutic compounds. Berry fruit are rich sources of anthocyanins and berry fruit products or derived beverages can provide 10s to 100s of milligrams of anthocyanins in a single serve. Anthocyanins exhibit complex chemical behaviours in vitro and this will result in complex behaviour in vivo. This review attempts to summarize some aspects of anthocyanin biochemistry and discusses these in the context of what is currently known about bioavailability and absorption. Compared with other flavonoid groups, such as flavonols, relatively little is known about details and mechanisms of anthocyanin absorption and transport and much remains to be discovered.

Anthocyanin absorption and antioxidant status in pigs.

The effect of a simultaneous intake of food or flavonoids on anthocyanins absorption and antioxidant status in pigs was investigated. Twelve male pigs at 27.1 +/- 0.7 kg BW fitted with jugular venous cannulae were maintained in individual metabolic crates. The animals were each given one of three dietary treatments in random order: blackcurrant powder (BC) to give a dose of 100 mg total ACNs/kg BW mixed either with water and sugar (Diet A), cereal (Weet-Bix), milk, and sugar (Diet B), or cereal, milk, sugar, and an additional flavonol (rutin, approximately 100 mg/kg BW) (Diet C). The four major anthocyanins of BC, delphinidin-3-glucoside, delphinidin-3-rutinoside, cyanidin-3-glucoside, and cyanidin-3-rutinoside, were identified and quantified by HPLC-PDA in all three diets. In the pig plasma, four peaks with a reversed pattern to those of anthocyanins in the BC extract were detected. The total amount of anthocyanins absorbed was not significantly different between the three diets, but the rate of absorption and subsequent decline was slower following administration of diet B and C than diet A. All three diets increased antioxidant capacity when measured by the FRAP assay but not when measured by the ORAC and non-protein ORAC assay. However, the increase was delayed and did not appear until 4 h after ingestion, at a time when plasma anthocyanin levels had returned to baseline. The present study demonstrates that the simultaneous intake of food or other flavonoids delays the absorption profile for anthocyanins. Our results also suggest that the increase in antioxidant capacity is not due to dietary anthocyanins but may be due to metabolites that result from anthocyanin consumption.

The flavonol quercetin-3-glucoside inhibits cyanidin-3-glucoside absorption in vitro.

At present, little is known about the mechanisms responsible for intestinal absorption of anthocyanins (ACNs). For example, it has not yet been established if ACNs are absorbed through an active transport mechanism, such as the sodium-dependent glucose transporter (SGLT1), or by passive diffusion. Previously, we found that the absorption of ACNs differs between regions of the digestive tract and is maximal in the jejunum, suggesting that an active transport mechanism is involved. In the present study, we examined the effect of d-glucose (main substrate of SGLT1), phloridzin (inhibitor of SGLT1), and quercetin-3-glucose (Q3G, a flavonol) on the absorption of cyanidin-3-glucoside (C3G; approximately 5 micromol/L) by mouse jejunum mounted in Ussing chambers. We found that the presence of either D-glucose (10, 20, and 40 mmol/L) or phloridzin (50, 100, and 200 micromol/L) resulted in a small but insignificant inhibition of C3G disappearance from the mucosal solution (decrease of disappearance with glucose, 33%; with phloridzin, 18%; NS). However, when the flavonol Q3G (50 micromol/L) was added to the mucosal solution together with the C3G, the disappearance of C3G was significantly decreased (74%; p < 0.001), and Q3G disappeared instead. In addition, we found phloretin and quercetin, the aglycones of phloridzin and Q3G, respectively, present in the mucosal solution and tissue extracts, indicating hydrolysis of these compounds by the enterocytes of the jejunum. In contrast, the aglycone cyanidin was not detected at all. Our results show that in the mouse small intestine, ACN absorption is not solely dependent on the activity of the SGLT1 transporter, as d-glucose and phloridzin had only a slight effect on uptake. Q3G, however, clearly inhibited C3G disappearance. These results suggest that there might be a competitive inhibition between C3G and Q3G absorption. It is possible that an absorption mechanism other than the SGLT1 is involved, which has a structural preference toward flavonols.