Assessment of efficacy and safety of the herbal medicinal product BNO 1016 in chronic rhinosinusitis.

BACKGROUND: The objective of this clinical trial (CRS-02) was to assess the efficacy, safety and tolerability of two dosages of the herbal medicinal product BNO 1016 (Sinupret extract) in patients with chronic rhinosinusitis (CRS). METHODOLOGY: 929 patients suffering from CRS were enrolled in this randomised placebo-controlled trial with a treatment period of 12 weeks. The primary endpoint was the mean Major Symptom Score (MSS) in week 8 and week 12 compared to placebo. Secondary endpoints included further MSS related parameters and responder rates over time. Pharmacoeconomic endpoints were also analysed. Finally, safety and tolerability were evaluated. RESULTS: Sinupret extract was not superior over placebo regarding the primary endpoint. However, the results of the secondary endpoints showed a clear trend towards superior efficacy. Therefore, additional post-hoc sensitivity analyses were performed in patients with a baseline MSS over 9 and persistence of disease more than 1 year diagnosed by specialists in otorhinolaryngology. Those patients significantly benefited from Sinupret extract. Therapy was superior for the primary endpoint analysis. Patients were less impaired with respect to work and daily activities. A good safety and tolerability of Sinupret extract was assured in all patients. CONCLUSIONS: Sinupret extract can safely be administered in patients with CRS. Although the primary endpoint of the study was not significant, a post-hoc subgroup analysis in patients whose disease was diagnosed by a specialist revealed a pronounced treatment effect. Effects in that subgroup were even stronger with longer disease persistence and stronger severity.

In vitro methods to support transporter evaluation in drug discovery and development.

This white paper addresses current approaches and knowledge gaps concerning methods to assess the role of transport proteins in drug/metabolite disposition in humans. The discussion focuses on in vitro tools to address key questions in drug development, including vesicle- and cell-based systems. How these methods can be used to assess the liability of compounds for transporter-based drug-drug interactions (DDIs) in vivo is also explored. Existing challenges and approaches to examine the involvement of transporters in drug disposition are discussed.

[The use of deslorelin acetate (Suprelorin®) in companion animal medicine]. / Der Einsatz von Deslorelinazetat (Suprelorin®) in der Kleintiermedizin.

In 2009 Suprelorin® was released in Switzerland for the temporary suppression of fertility in male dogs. However, in practice it has also been used to treat other conditions in male dogs and in bitches. These include treatment of benign hyperplasia of the prostate, the induction or suppression of oestrus and treatment for the side effects of gonadectomy. Also in feline reproductive medicine GnRH-agonists gain increased importance. These areas of application are listed here in terms of treatment success and possible adverse effects after treatment of which owners have to be informed beforehand.

Release of metabolic enzymes by Giardia in response to interaction with intestinal epithelial cells.

Giardia lamblia, an important cause of diarrheal disease, resides in the small intestinal lumen in close apposition to epithelial cells. Since the disease mechanisms underlying giardiasis are poorly understood, elucidating the specific interactions of the parasite with the host epithelium is likely to provide clues to understanding the pathogenesis. Here we tested the hypothesis that contact of Giardia lamblia with intestinal epithelial cells might lead to release of specific proteins. Using established co-culture models, intestinal ligated loops and a proteomics approach, we identified three G. lamblia proteins (arginine deiminase, ornithine carbamoyl transferase and enolase), previously recognized as immunodominant antigens during acute giardiasis. Release was stimulated by cell-cell interactions, since only small amounts of arginine deiminase and enolase were detected in the medium after culturing of G. lamblia alone. The secreted G. lamblia proteins were localized to the cytoplasm and the inside of the plasma membrane of trophozoites. Furthermore, in vitro studies with recombinant arginine deiminase showed that the secreted Giardia proteins can disable host innate immune factors such as nitric oxide production. These results indicate that contact of Giardia with epithelial cells triggers metabolic enzyme release, which might facilitate effective colonization of the human small intestine.

Polymeric immunoglobulin receptor in intestinal immune defense against the lumen-dwelling protozoan parasite Giardia.

The polymeric Ig receptor (pIgR) is conserved in mammals and has an avian homologue, suggesting evolutionarily important functions in vertebrates. It transports multimeric IgA and IgM across polarized epithelia and is highly expressed in the intestine, yet little direct evidence exists for its importance in defense against common enteric pathogens. In this study, we demonstrate that pIgR can play a critical role in intestinal defense against the lumen-dwelling protozoan parasite Giardia, a leading cause of diarrheal disease. The receptor was essential for the eradication of Giardia when high luminal IgA levels were required. Clearance of Giardia muris, in which IgA plays a dominant role, was severely compromised in pIgR-deficient mice despite significant fecal IgA output at 10% of normal levels. In contrast, eradication of the human strain Giardia lamblia GS/M, for which adaptive immunity is less IgA dependent in mice, was unaffected by pIgR deficiency, indicating that pIgR had no physiologic role when lower luminal IgA levels were sufficient for parasite elimination. Immune IgA was greatly increased in the serum of pIgR-deficient mice, conferred passive protection against Giardia, and recognized several conserved giardial Ags, including ornithine carbamoyltransferase, arginine deiminase, alpha-enolase, and alpha- and beta-giardins, that are also detected in human giardiasis. Corroborative observations were made in mice lacking the J chain, which is required for pIgR-dependent transepithelial IgA transport. These results, together with prior data on pIgR-mediated immune neutralization of luminal cholera toxin, suggest that pIgR is essential in intestinal defense against pathogenic microbes with high-level and persistent luminal presence.

Nitric oxide formation in the oropharyngeal tract: possible influence of cigarette smoking.

Cigarette smoking reduces the level of nitric oxide (NO) in exhaled air by an unknown mechanism. The view that part of the effect of cigarette smoking on NO production should occur in the oropharyngeal tract is supported by several studies. We have therefore compared smokers and non-smokers regarding non-enzymatic formation of NO from nitrite in the oral cavity since this is a primary candidate target for cigarette smoke. We have also looked at NO synthase-dependent NO formation in the mucosa of the oropharyngeal tract as an alternative target for the inhibitory effect induced by cigarette smoke. Smokers exhaled 67% lower levels of NO than controls (p<0.01, n=15 each group). We could not detect any significant difference in salivary nitrite, nitrate or ascorbate between smokers and non-smokers. Mouthwash with the antibacterial agent chlorhexidine reduced salivary nitrite (-65%) and exhaled NO levels (-10%) similarly in the two groups. Immunohistochemical techniques revealed dense expression of inducible (but not endothelial or neuronal) NO synthase in the squamous epithelium of non-inflamed tonsillar and gingival tissue biopsies. In the same biopsies, significant Ca2+ -independent citrulline-forming activity was detected. We found no difference between smoking and non-smoking subjects regarding NO-synthase expression and in vitro activity. In another group of non-smoking subjects (n=10), spraying the oropharyngeal tract with the NO-synthase inhibitor NG-monomethyl-L-arginine (250 mg) significantly reduced exhaled NO levels for at least 30 min (-18%, p<0.01). Our data suggest that cigarette smoking does not affect non-enzymatic NO formation from nitrite in saliva. However, NO is also formed by inducible NO synthase in the squamous epithelium of the normal oropharyngeal tract. We suggest that cigarette smoking may down-regulate enzymatic NO formation in the oropharyngeal compartment as well as in the bronchial compartment.

Characterisation of alpha-1 giardin: an immunodominant Giardia lamblia annexin with glycosaminoglycan-binding activity.

Alpha-1 giardin is an immunodominant protein in the intestinal protozoan parasite Giardia lamblia. The Triage((R)) parasite panel, used to detect copro-antigens in stool from giardiasis patients, reacts with an epitope between amino acids 160 and 200 in alpha-1 giardin. This region of the protein is also highly immunogenic during human infections. Alpha-1 giardin is related to annexins and like many other annexins it was shown to be plasma membrane associated. Immunoelectron and immunofluorescence microscopy revealed that some alpha-1 giardin are displayed on the surface of recently excysted cells. Recombinant alpha-1 giardin displayed a Ca(2+)-dependent binding to glycosaminoglycans (GAGs), in particular heparan sulphate, a common GAG in the intestinal tract. Recombinant alpha-1 giardin bound to thin sections of human small intestine, a binding which could be inhibited by adding increasing concentrations of sulphated sugars. A surface associated trypsin activated Giardia lectin (taglin) has been suggested to be important for G. lamblia attachment. In this study we show that a monoclonal antibody that inhibits taglin recognises alpha-1 and alpha-2 giardin. Thus, alpha-1 giardin is a highly immunoreactive GAG-binding protein, which may play a key role in the parasite-host interaction. Our results further show a conserved function of annexins from lower to higher eukaryotes.

Characterization of airway nitric oxide in allergic rhinitis: the effect of intranasal administration of L-NAME.

BACKGROUND: Several studies have attempted to assess nasal nitric oxide (NO) levels in allergic rhinitis (AR). However, there seem to be differences in the results obtained. We therefore wanted to investigate this further by studying airway NO in AR and controls at several modalities, and also the effect of intranasal administration of the nitric oxide synthase (NOS) inhibitor NG-nitro-L-arginine-methyl ester.HCl (L-NAME). METHODS: Airway NO was determined through repeated measurements at three flow rates of air (0.5, 3, and 9 l/min), using a single-breath method and a method of nasal aspiration, in 18 patients with birch pollen AR during season and in 18 controls. RESULTS: Patients with AR were characterized by no difference in nasal but higher orally exhaled NO and a larger interindividual spread in nasal and orally exhaled NO compared to controls. We also found a greater reduction in nasal NO after L-NAME in patients compared to controls. DISCUSSION: These results indicate that several factors determine the levels of nasal NO in rhinitis. NO production in the nasal mucosa of patients with AR may be upregulated. On the other hand, this increase could be counteracted by swelling of the mucosa and secretions resulting in impaired NO diffusion from, for example, the paranasal sinuses, where particularly high levels of NO have been found. Also, the high background levels of NO from constitutive sources in the nose may blunt smaller increases in mucosal NO output. CONCLUSION: It seems that the methods for measurement of nasal NO need to be improved and standardized before we can consider to use this test in monitoring inflammation in AR.

Identification of immunoreactive proteins during acute human giardiasis.

The protozoan Giardia lamblia is a major cause of parasite-induced diarrhea in humans. Humoral immunity has been shown to be important for clearance of the infection, but only a few antigens have been identified. In this study, we focused on the immunoreactivity of nonvariant antigens. Serum samples from 93 patients with acute giardiasis who were infected during a waterborne outbreak in a nonendemic country were screened on 1-dimensional Western blots. Representative serum samples that reacted strongly with proteins of different molecular weights were further analyzed on 2-dimensional Western blots. Sixteen immunoreactive proteins were identified using mass spectrometry analysis, among them variable surface proteins, alpha-giardins, arginine deiminase, ornithine carbamoyl transferase, and fructose-1,6-bisphosphate aldolase. Several of the identified proteins were immunoreactive in recombinant form, and they may be important in the development of new diagnostic tools and vaccines.

Exhaled NO and plasma cGMP increase after endotoxin infusion in healthy volunteers.

Nitric oxide (NO) is believed to be involved in the pathophysiology of sepsis. This study evaluated the activity of the NO pathway in a human endotoxin model. At baseline and after endotoxin, on-line measurements of exhaled NO (eNO) were made using a chemiluminescence technique with a single-breath method. NO-free air was inhaled prior to exhalation against a resistance. NO in orally and nasally exhaled air and in rectal gas was investigated. Plasma nitrite, nitrate, and guanosine 3', 5'-monophosphate (cGMP) and the events after diclophenac administration were also studied. Endotoxin infusion resulted in tachycardia and fever. An early increase in oral eNO concentration was observed and oral eNO decreased after diclophenac administration. NO exhaled nasally, NO in rectum gas and nitrite/nitrate levels remained unchanged over the study period, cGMP increased after 4 h. These findings suggest an early increase in nitric oxide production from the lungs, probably due to increased activity of the constitutive nitric oxide synthase upon endotoxin stimulation. In contrast, nitric oxide production in the upper airways, measured as nasally exhaled nitric oxide and nitric oxide in rectal gas, remained unchanged. Further studies will elucidate if exhaled nitric oxide is a valuable marker of sepsis-induced lung injury and if monitoring of treatment is possible.

Giardia lamblia -- a model organism for eukaryotic cell differentiation.

Giardia lamblia is a binucleated, flagellated protozoan parasite that inhabits the upper small intestine of its vertebrate hosts. The entire life cycle, which can be completed in vitro, is simple with cycling between a vegetative trophozoite and a highly resistant cystic form. The parasite is one of the earliest diverging eukaryotes known and more than 95% of the genome is sequenced. This makes Giardia an excellent model system for studies of basic eukaryotic processes like cell differentiation. In this review we will discuss recent data concerning Giardia differentiation with a focus on DNA replication and cytokinesis.

Nitric oxide but not carbon monoxide is continuously released in the human nasal airways.

Results from different laboratories indicate that nitric oxide (NO) and carbon monoxide (CO) coexist in the human airways both in health and disease. These gases are present in exhaled human breath and high concentrations of NO as well as CO have been reported in the nasal airways. In addition, exhaled CO and NO are increased in patients with airways inflammation. NO and CO were measured simultaneously in orally exhaled air and in air sampled from the nose in 18 healthy subjects using chemiluminescence (for NO) and infrared (for CO) techniques at different fixed flow rates. The acute effects of smoking on airway release of NO and CO were also studied. Nasal NO was detected in all subjects and the concentrations were highly flow-dependent (mean+/-SEM: 236+/-23 and 527+/-49 parts per billion (ppb), at 2 and 0.5 L x min(-1), respectively). In contrast, no evidence of CO release in the nasal airways regardless of sample flow rate was found. In fact, additional experiments indicated a net absorption of CO when low levels of this gas were flushed through the nasal cavity. Nasal CO also remained undetectable after smoking. Both NO (22+/-2 ppb) and CO (1.1+/-0.1 parts per million) were consistently found in orally exhaled air. CO, but not NO, levels increased acutely after smoking a cigarette. The authors conclude that the patterns of nitric oxide and carbon monoxide release in the airways seem to differ profoundly in healthy subjects. Orally exhaled air contains both nitric oxide and carbon dioxide whereas nasal air contains nitric oxide only.

Genome ploidy in different stages of the Giardia lamblia life cycle.

The early diverging eukaryotic parasite Giardia lamblia is unusual in that it contains two apparently identical nuclei in the vegetative trophozoite stage. We have determined the nuclear and cellular genome ploidy of G. lamblia cells during all stages of the life cycle. During vegetative growth, the nuclei cycle between a diploid (2N) and tetraploid (4N) genome content and the cell, consequently, cycles between 4N and 8N. Stationary phase trophozoites arrest in the G2 phase with a ploidy of 8N (two nuclei, each with a 4N ploidy). On its way to cyst formation, a G1 trophozoite goes through two successive rounds of chromosome replication without an intervening cell division event. Fully differentiated cysts contain four nuclei, each with a ploidy of 4N, resulting in a cyst ploidy of 16N. The newly excysted cell, for which we suggest the term 'excyzoite', contains four nuclei (cellular ploidy 16N). In a reversal of the events occurring during encystation, the excyzoite divides twice to form four trophozoites containing two diploid nuclei each. The formation of multiple cells from a single cyst is likely to be one of the main reasons for the low infectious doses of G. lamblia.

Characterization of exhaled nitric oxide: introducing a new reproducible method for nasal nitric oxide measurements.

Nitric oxide (NO) is present in the human nasal airways and has been suggested to originate primarily from the paranasal sinuses. The aim of this study was to establish a new and reproducible method for measurement of nasal NO. Through repeated single-breath measurements the intra- and inter-individual variations of NO levels in nasally (into a tightly fitting mask covering the nose) and orally exhaled air were determined in healthy humans. Variations due to the methods used were investigated. The contribution of oral NO to the nasal exhalations by introducing a mouthwash procedure was also studied. This study shows distinct individual values of NO in nasally and orally exhaled air of healthy humans. Some diurnal variability was also found with a rise in NO in nasally and orally exhaled air over the day, but no, or little, day-to-day variability when comparing the results from separate mornings. There was no correlation between NO levels in nasally and orally exhaled air, whereas there was a strong correlation between NO levels in air exhaled through the left and right nostril. The levels of NO in air exhaled at 0.17 L x s(-1) through either nostril separately were higher than in air exhaled at the same flow rate through both nostrils simultaneously. After the introduction of a mouthwash procedure the level of NO in orally, but not nasally exhaled air was reduced. To conclude the method using nasal exhalation into a nose mask is highly reproducible. It is also suggested that subtracting the level of NO in orally exhaled air, after mouthwash, from that in nasally exhaled air, would adequately reflect nasal NO levels.

Nasal nitric oxide is reduced in patients with HIV.

The gas nitric oxide (NO) is present in high concentrations in human nasal airways. Since NO is known to inhibit the growth of bacteria and viruses, it has been suggested that airborne NO represents the first line of defence against pathogens in the upper airways. Low nasal NO levels have been reported previously in patients susceptible to upper airway infection. Since HIV-positive patients are at risk for respiratory tract infections, including sinusitis, we studied the levels of NO in the upper and lower airways of these patients. A cross-sectional study with age-matched HIV patients and controls was carried out. Nasal and orally exhaled NO were measured in 31 HIV patients and 26 controls using a well-established chemiluminescence method developed for measurements of gaseous NO in the airways. Nasal NO was 21%, lower (p < 0.05, Student's t-test) in HIV patients than in controls, whereas orally exhaled NO did not differ between the two groups. We conclude that nasal NO is reduced in patients with HIV infection. The reduction in nasal NO may contribute to the decreased resistance to airway infections in these patients.

Adenoma of the papillae of Vater. Report of eleven cases.

Eleven patients with a preoperative diagnosis of adenoma of the papillae of Vater were followed up during the fifteen-year period from 1984 till 1998 in the Oulu University Hospital. Seven patients were treated primarily by transduodenal excision without any recurrences so far. One of these seven patients was found to have adenocarcinoma in a histological examination. Active surgery for adenoma of the papillae of Vater is recommended because of the precancerous nature of the lesion, and because malignancy cannot always be detected by endoscopic biopsies. Transduodenal excision could be recommend for patients at high operative risk, especially in cases with small adenomas and low-grade dysplasia, where histologically free resection margins can be achieved, but pancreaticoduodenectomy should still be performed on patients at low operative risk.

Effects of sustained-release oral phenylpropanolamine on the nasal mucosa of healthy subjects.

Phenylpropanolamine (PPA) is widely used as a nasal decongestant administered orally in sustained release preparations and, in Sweden, the recommended dose nowadays is 50 mg twice daily for adults. The aim of this placebo-controlled, cross-over study was to determine the onset and duration of the decongestive effect of 50 and 100 mg PPA in 15 healthy subjects. All subjects arrived at the laboratory at 07.30 h. After an acclimatisation, the nasal mucosal baseline was established with rhinostereometry and the minimal cross-sectional area was measured using acoustic rhinometry. The systolic and diastolic blood pressures were also determined. Then all subjects were given their study drugs for the day and the measurements were repeated every hour for 8 h. This procedure was repeated for 3 days at 48 h intervals between the days. For purposes of comparison, the decongestive effect of oxymetazoline nasal spray was studied on a separate day. The decongestive effect of 100 mg PPA was similar to that of topical oxymetazoline. It develops after 1 h and lasts for approximately 6 h. The decongestive effect of oxymetazoline was significantly greater than that of 50 mg PPA and that of 100 mg PPA was significantly greater than that of 50 mg PPA using rhinostereometry, but not when using acoustic rhinometry. However, 50 mg PPA had no significant decongestive effect, compared with placebo, with rhinostereometry or acoustic rhinometry. In the first 3 h after administration of PPA, there was a dose-response increase in the systolic and diastolic blood pressures, which then returned to baseline. In conclusion, this study shows that PPA in double the recommended dose, i.e. 100 mg, has a significant decongestive effect on the nasal mucosa in healthy subjects. However, when the dose of PPA is increased the systolic and diastolic blood pressures also increase.

Laparoscopic cholecystectomy: the Finnish experience.

Between January 1992 and December 1994, 5,742 patients were treated by laparoscopic cholecystectomy in 35 Finnish hospitals. The operation was converted to open laparotomy in 360 (6.3%) patients, the most common causes for conversion being technical difficulties in dissection of the gall bladder (2.8%), bleeding (0.9%) and bile duct injury (0.48%). Intraoperative cholangiography was performed selectively in 18%, and common bile duct stones were found in 10.2% of these cases. Postoperative complications occurred in 208 (3.6%) patients, of whom 65 (1.1%) required reoperation. Twenty-eight (0.48%) of these patients had common bile duct injury. In eighteen patients bilio-digestive Roux-en-Y reconstruction was performed, whereas 10 cases could be handled by endoscopic drainage or suturing and T-tube drainage. Thus, the total number of patients with bile duct injury was 56 (0.96%). The reported hospital mortality was 0.08%. The mean hospital stay and the mean sick leave were three days (range 1-41) and 13 days (range 1-60), respectively. These data demonstrate that laparoscopic cholecystectomy can be performed with acceptable morbidity and mortality rates as a routine method in various different hospitals.

The value of herniography in the diagnosis of unexplained groin pain.

Herniographies were performed on 106 outpatients with obscure groin pain. A total of 39 hernias were found in 38 patients (36%) and the 46 patients either operated on (40 patients) or who had undergone laparoscopy (six patients), included one false positive and two false negative ones. All three cases were inpatients who had earlier undergone surgery for inguinal hernia 27% of the patients with a normal clinical finding (19/70), 67% of those with previous inguinal herniotomy (8/12) and 50% of those with symptoms suggestive of hernia (12/24) had diagnostic findings on herniography. Thirteen out of the 48 women (27%) and 25 of the 58 men (43%) had positive finding at herniography. The valve of herniography was that 56 patients were spared subsequent surgical exploration because of normal herniographic finding. Our results indicate that herniography is a useful tool for the examination of patients with unexplained groin pain.