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Thomson MH, et al. Inhaled formoterol dry powder versus ipratropium bromide in chronic obstructive pulmonary disease. J Respir Crit Care Med 2001; 164: 778-84. Chhabra SK, Bhatnagar S. Comparison of bronchodilator responsiveness in asthma and chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2002; 44: 91-7. Di Marco F, Milic-Emili J, Boveri B, Carlucci P, Santus P, Casanova F, et al. Effect of inhaled bronchodilators on inspiratory capacity and dyspnoea at rest in COPD. Eur Respir J 2003; 21: 86-94. Chhabra SK, Rajpal S, Gupta R. Patterns of smoking in Delhi: comparison of respiratory morbidity among bidi and cigarette smokers. Indian J Chest Dis Allied Sci 2001; 43: 19-26. Borg G. Psychological basis of perceived exertion. Med Sci Sports Exer 1982; 14: 377-81. American Thoracic Society : 1994 Update. Standardization of spirometry. J Resir Crit Care Med 1995; 152: 1107-36. American Thoracic Society. Medical section of the American Lung Association. Lung function testing: selection of reference values and interpretative strategies. Rev Respir Dis 1991; 144: 1202-18. Jain SK, Gupta CK. Age, height and body weight as determinants of ventilatory norms in healthy men above forty years of age. Indian J Med Res 1967; 55: 599-607. Beeh KM, Welte T, Buhl R. Anticholinergics in the treatment of chronic obstructive pulmonary disease. Respiration 2002; 69: 372-9. Greefhorst A, Dahl R, Nowak D. Effect of inhaled formoterol and ipratropium bromide in patients with COPD [abstract]. J Respir Crit Care Med 2000; 161: A805.

One million Walker 256 carcinosarcoma ascites cells were injected into the hindleg muscles of male rats. Later 23.25 hr.

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N this issue of Focus, we will discuss a Respiratory Care research project funded by an outside agency. An outside agency includes pharmaceutical companies, equipment manufacturers and private or government grant sources. We will continue to discuss each research project using the traditional Scientific Method format: Background or Introduction, Question, Hypothesis, Methods, Results, Conclusions, Reflections, Future Research, Bibliography, Acknowledgements, and Conflicts of Interest. Dey Laboratories, a pharmaceutical organization, sponsored this research project. Dey wanted to market DuoNebTM, a unit dose formulation combining albuterol and ipratropium bromide for patients with chronic obstructive pulmonary disease COPD ; . The Food and Drug Administration FDA ; required efficacy studies on the combination as an inhalant nebulizer ; solution, despite the market presence of CombiventTM as an MDI combination of the same drugs. The design for this research project was prospective, randomized, double blind, crossover and positive control. The prospective component was based on a tabulation of the future clinical course of patients. The randomized design was the unbiased selection of patients with COPD. Let's examine each of these terms for the research project design. Prospective means looking ahead from the time of patient. Increased ICa, the leftward shift in the current-voltage relations typically observed following adrenergic stimulation were not present following NAC exposure alone. Peak ICa densities for each group before and after isoproterenol stimulation are summarized and compared in Fig. 2F. Perhaps because of the upregulation of basal ICa, the relative response of NAC-treated myocytes to isoproterenol was attenuated relative to that of myocytes not treated with NAC Fig. 2F ; . These results suggest that NAC and isoproterenol have discrete effects on the calcium channel. Interestingly, in myocytes from two patients with no history of AF, incubation with 10 mM NAC had no significant effect on peak ICa 9.0 2.6 pA pF n control bath, versus 11.1 0.7 pA pF n NAC, p 0.68 ; . Effects of BSO on Canine Atrial Function, Muscle Contractility, and Calcium Currents--To more systematically evaluate the functional impact of glutathione depletion on atrial conVOLUME 282 NUMBER 38 SEPTEMBER 21, 2007.
COPD. Ipratropoum has a slower onset but longer duration of action than salbutamol and is preferred for patients with stable COPD who are symptomatic despite as-required use of a beta-2 agonist8. The place of the antimuscarinic agent oxitropium, which requires fewer daily doses than ipratropium, is uncertain. A limited trial of high dose inhaled steroids or oral steroids should be considered for patients with moderate airflow obstruction to determine the extent of the airway reversibility and to ensure that asthma has not been overlooked.9 The long-acting beta-2 agonists salmeterol and formoterol are options for additional treatment if objective evidence of improvement is available; both are superior to ipratropium10, 11. Combined treatment with an antimuscarinic agent and a beta-2 agonist may be useful when optimal monotherapy is insufficient.8.
Results: according to ims data from 1996 to 2001, the recommended use ofsalmeterol and formoterol for copd increased 1150% and 1975%, respectively, while recommendations for ipratropium bromide for copd decreased by 37 and tolterodine. See Trihexyphenidyl see Polyvinyl Alcohol see Mesalamine Various see Hydroxyzine Reyataz Tenormin see Lorazepam Strattera see Efavirenz Tenofovir Emtricitabine Various see Ipratropiu see Amoxicillin Clavulanate see Antipyrine Benzocaine Zithromax Tablet: 500mg, 600mg Restricted to HIV and Community Acquired Pneumonia if levofloxacin allergy failure. Must be documented on prescription. Injectable: 0.1mg ml Capsules: 10mg, 18mg, 25mg, Tablet: 200mg, 300mg Tablets: 25mg, 50mg, 100mg Tablets: 325mg, 325mg buffered, 81mg EC. Tolterodine [Detrol], diphenhyto either agent, to atropine, or any dramine [e.g., Benadryl] ; . If possible, of its other derivatives. A small number of patients have experienced concurrent use should be avoided. Tiotropium is more likely than immediate hypersensitivity reactions, ipratropium to be absorbed into the including angioedema. If such a systemic circulation from the surface response occurs, treatment should of the lungs following oral inhalabe discontinued immediately. Dry mouth is the most commonly tion. Approximately 14% of a dose is excreted in the urine, primarily as experienced adverse event and, in unchanged drug.Therefore, therapy clinical trials comparing the two in patients with moderate or severe agents, the incidence of dry mouth renal impairment should be closely in patients receiving tiotropium monitored. and ipratropium was 12% and 6%, The long duration of action of respectively. Other adverse events tiotropium permits administration with the use of tiotropium include just once a day.This represents a sigpharyngitis 7% ; and abdominal nificant advantage over ipratropium, pain 6% ; , which occurred at a slightly higher or the same incidence which is usually administered four times a day, and the opportunity to than in the patients treated with administer tiotropium much less freipratropium. Tiotropium and ipratropium must quently should facilitate patient combe used with caution in patients with conditions such as narrowangle glaucoma and Tiotropium bromide is the second prostatic hyperplasia that may be exacerbated by agents with antianticholinergic agent approved for cholinergic activity. A greater likelihood of use via oral inhalation for its anticholinergic adverse events e.g., dry mouth, blurred vision, bronchodilatory effects. constipation ; should be anticipated when these agents are used in patients also taking other medications with anticholinergic activity e.g., oxybutynin [Ditropan] and acetazolamide.
Table 2. Summary of pregnancy rates in lactating cows in Florida following artificial insemination or embryo transfer in the summera. I.A.M. was supported by National Institutes of Health National Institute of General Medical Sciences Grant T32-GM07612. 1. 2. 3. FitzGerald, G. A. 1996 ; in Cecil Loeb Textbook of Medicine Saunders, Philadelphia ; , pp. 11871193. Pace-Asciak, C. R. & Smith, W. L. 1983 ; Enzyme 16, 543603. Vane, J. R. & Botting, R. 1987 ; FASEB J. 1, 8996. Smith, W. L. 1992 ; Am. J. Physiol 263, F181F191. Funk, C. D., Funk, L. B., Kennedy, M. E., Pong, A. S. & FitzGerald, G. A. 1991 ; FASEB J. 5, 23042312. Xie, W., Chipman, J. G., Robertson, D. L., Erikson, R. L. & Simmons, D. L. 1991 ; Proc. Natl. Acad. Sci. USA 88, 26922696. O' Bannion, M. K., Winn, V. D. & Young, D. A. 1992 ; Proc. Natl. Acad. Sci. USA 89, 48884892. O'Neill, G. P. & Ford-Hutchinson, A. W. 1993 ; FEBS Lett. 330, 156160. Smith, W. L. 1989 ; Biochem J. 259, 315324. Fu, J., Masferrer, J. L., Siegel, N. & Needleman, P. 1990 ; J. Clin. Invest. 86, 13751379. Niiro, H., Otsuka, T., Izuhara, K., Yamaoka, K., Ohshima, K., Tanabe, T., Hara, S., Nemoto, Y., Tanaka, Y., Nakashima, H., et al. 1997 ; Blood 89, 16211628. Hla, T. & Neilson, K. 1992 ; Proc. Natl. Acad. Sci. USA 89, 73847388. O'Sullivan, M. G., Huggins, E. M., Meade, E. A., DeWitt, D. L. & McCall C. E. 1992 ; Biochem. Biophys. Res. Commun. 187, 11231127. Jones, D. A., Carlton, D. P., McIntyre, T. M., Zimmerman, G. A. & Prescott, S. M. 1993 ; J. Biol. Chem. 268, 90499054. Kujubu, D. A., Reddy, S. T., Fletcher, B. S. & Herschman, H. R. 1993 ; J. Biol. Chem. 268, 54255430. Evett, G. E., Xie, W., Chapman, J. G., Robertson, D. L. & Simmons, D. L. 1993 ; Arch. Biochem. Biophys. 306, 169177. Crofford, L. J., Wilder, R. L., Ristimaki, A. P., Sano, H., Remmers, E. F., Epps, H. R. & Hla, T. 1994 ; J. Clin. Invest. 93, 10951101. Masferrer, J. L., Zweifel, B. S. Seibert, K. & Needleman, P. 1990 ; J. Clin. Invest. 86, 13751379. Mertz, P. M, DeWitt, D. L., Steller-Stevenson, W. G. & Wahl, L. M. 1994 ; J. Biol. Chem. 269, 2132221329. Dworski, R. & Sheller, J. R. 1997 ; Prostaglandins 53, 237251 and bisacodyl.

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Ipratropium what is Any studies have been published in recent years examining the efficacy of inhaled ipratropium bromide in patients with asthma. In general, these have shown that the onset of action of ipratropium is somewhat slower than that of -adrenergicagent and that the bronchodilation achieved at peak effect is almost always less than that achieved with the 3adrenergic agent. Similarly, most studies have shown that the use ofboth types ofdrug together produces a and etidronate. The dopamine agonist pramipexole Mirapex ; , currently approved for use in Parkinson's disease, has been effective in several studies of major depressive disorder and as augmentation in treatment-resistant depression. The present naturalistic follow-up study was conducted to examine the long-term safety and efficacy of pramipexole. Methods: Study subjects with unipolar or bipolar depression n 23; mean age, 53 years; 70% female ; had participated in an acute-phase study of adjunctive pramipexole after nonresponse to at least 1 prior antidepressant trial of 4 weeks at a therapeutic dose. Participants had been hospitalized for the initial weeks of acute treatment and pramipexole at a maximum dosage of 1.5 mg day was added to an SSRI or TCA. Other concomitant treatments during the acute treatPSYCHIATRY DRUG ALERTS ISSN 0894-4873 ; is published monthly by M.J. Powers & Co. Publishers, 65 Madison Ave., Morristown, NJ 07960. Telephone 973-898-1200. e-mail: psych alertpubs . Periodical-class postage is paid at Morristown, NJ, and at additional mailing offices. POSTMASTER: Send address changes to Psychiatry Drug Alerts, 65 Madison Ave., Morristown, NJ 07960. 2005 by M.J. Powers & Co. Publishers. Written permission from M.J. Powers & Co. is required to reproduce material from this publication. Subscription a year in the U.S.; .50 Canada; 7.50 elsewhere; 0 institutional. Back issues and single copies are available for .50 each, prepaid. Loose-leaf binders are available for .00 each, prepaid. I a mother of 4 children, first 2 born by cesarean followed by 2 VBAC's. I believe in giving parents information to make their own decisions. I provide labor support for the birth that they chose. I also a childbirth educator and raloxifene.

March 21, 2001 No Dey 0.5 mg ipratropium bromide and 3 mg albuterol sulfate equiv. to 2.5 mg albuterol base ; , in 3 ml unit-dose vials. 4 times daily. Throughout the world the following approach is systematically applied at each of our sites: an HSE progress action plan is devised, implemented and monitored annually at every one of the Group's industrial and research sites; initial and ongoing workstation training to guarantee the integration of HSE practices into work procedures; investments in HSE that specifically target risk prevention and employee safety, as well as promoting environmental protection by minimizing consumption of natural resources, developing clean manufacturing, reducing and recycling waste. Monitoring performance and providing feedback, by means of several different methods: a set of indicators is used to consolidate safety and environmental data for all Group facilities throughout the world. These indicators form the basis for the HSE steering trends chart used by all facilities, and are also used along with the comparative analysis of the current situation and established objectivesto put in place corrective measures; HSE data are verified by auditors in compliance with French legislation on the New Economic Regulations Nouvelles Rgulations conomiquesNRE ; . Auditors also review the collection, verification and consolidation of the data by the Corporate HSE Department; audit programs are carried out every year by the HSE Department for all Group facilities, with the aim of verifying that HSE management and the HSE programs, practices and actions in place at each facility comply fully with Group standards and government regulations; major events and accidents in facilities are compiled and analyzed at Group level. This feedback is essential; it enables us to learn from events, accidents and any failures in compliance that occur at our sites. The knowledge thus acquired is used to regularly revise our internal standards and alendronate. Ala-cort . 34 ALAMAST . 47 ALBENZA . 21 albuterol inhaler . 50 albuterol sulfate er tablets . 50 albuterol sulfate solution for inhalation . 50 albuterol sulfate syrup . 50 albuterol sulfate tablets . 50 albuterol sulfate ipratropium solution for inhalation. 50 alclometasone dipropionate . 34.

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Assessing Risk for Aggressive Behaviour in a Maximum Security Hospital: Predictive Utility of Clinicians' Judgements, Psychopathy, and Interpersonal Style Ronald Blackburn and Caroline Logan Department of Clinical Psychology, University of Liverpool, UK This study examined the relative utility of staff judgements of risk and dispositional factors in predicting aggression within a maximum security hospital. Ratings of risk of aggression, psychopathy as measured by the Psychopathy Checklist-Revised PCL-R: Hare, 1991 ; and of interpersonal style as measured by the Chart of Interpersonal Reactions in Closed Living Environments CIRCLE: Blackburn & Renwick, 1996 ; were obtained on male patients detained in an English maximum security hospital N 114 ; . Patients were followed up for two years and incidents of verbal and physical aggression recorded. ROC analyses revealed that although all predictor variables had some utility in predicting subsequent aggression, a coercive interpersonal style was consistently the strongest predictor. Implications for the role of personality factors in institutional aggression are discussed and calcitriol.
Centage of predicted ; those treatments that agonist, compared with no significant difference treatments. ipratropium placebo. Both patients had a history of exposure to pet rats. The first patient worked in a pet shop and was bitten on her right index finger by a store rat 2 days before the onset of symptoms and 4 days before arriving at the hospital. Immediately after being bitten, this patient had self-treated the wound by using antiseptic ointment. The second patient worked as a dog groomer and owned nine pet rats. One of these rats had recently been diagnosed with respiratory signs at a veterinary hospital. This patient had no known animal bites during the 2 weeks preceding her death. patients can have severe disease before onset of the typical symptoms of septic arthritis and maculopapular rash. Because of the high prevalence of colonization and asymptomatic infection with S. moniliformis among rodents, testing and treating rats are not practical. Disease prevention should therefore focus on risk reduction among individuals with frequent exposure to rats. They should wear gloves, wash hands regularly, and avoid hand-to-mouth contact when handling rats or cleaning cages. If bitten by a rat, the victim should promptly clean and disinfect the wound; immediate medical attention with reported exposure history ; should be sought if subsequent illness develops. The disease is more common in children; therefore, adults should closely supervise young children to prevent bites and hand-tomouth contact and risedronate and Buy cheap ipratropium. DeNardo C, Fonsatti E, Sigalotti L, Calabr L, Colizzi F, Cortini E, Coral S, Altomonte M, Maio M: Recombinant transmembrane CD59 CD59-TM ; confers complement resistance to GPI-anchored protein defective melanoma cells. J CELL PHYSIOL 190: 200-206 2002 ; . Denkert C, Siegert A, Leclere A, Turzynski A, Hauptmann S: An inhibitor of stress-activated MAPkinases reduces invasion and MMP-2 expression of malignant melanoma cells. CLIN EXP METASTAS 19: 79-85 2002 ; . Dietrich PY, deTribolet N: Dendritic cells pulsed with a tumor-specific peptide induce long-lasting immunity and are effective against murine intracerebral melanoma - Comments. NEUROSURGERY 50: 164-166 2002 ; . Djukanovic D, Hofmann U, Sucker A, Schadendorf D: Melanoma tumour markers S100B and MIA: evaluation of stability in serum and blood upon storage and processing. BRIT J DERMATOL 145: 1030-1031 2001 ; . Dme B, Somlai B, Ladnyi A, Fazekas K, Zller M, Tmr J: Expression of CD44v3 splice variant is associated with the visceral metastatic phenotype of human melanoma. VIRCHOWS ARCHIV 439: 628-635 2001 ; . Eggert AO, Becker JC, Ammon M, McLellan AD, Renner G, Merkel A, Brcker EB, Kmpgen E: Specific peptide-mediated immunity against established melanoma tumors with dendritic cells requires IL-2 and fetal calf serum-free cell culture. EUR J IMMUNOL 32: 122-127 2002 ; . Ellerhorst JA, Cooksley CD, Grimm EA: Autoimmunity and hypothyroidism in patients with uveal melanoma. MELANOMA RES 11: 633-637 2001 ; . Fabrizi G, Massi G: Angiomatoid Spitz naevus: a close simulator of regressing malignant melanoma. BRIT J DERMATOL 145: 845-846 2001 ; . Falus A, Hegyesi H, Lzr-Molnr E, Ps Z, Lszl V, Darvas Z: Paracrine and autocrine interactions in melanoma: histamine is a relevant player in local regulation. TRENDS IMMUNOL 22: 648652 2001 ; . Fetsch PA, Steinberg SM, Riker AI, Marincola FM, Abati A: Melanoma antigen expression in serial fine-needle aspiration samples in patients with metastatic malignant melanoma participating in immunotherapy clinical trials - A preliminary look. CANCER CYTOPATHOL 93: 409-414 2001 ; . Fink-Puches R, Pilarski P, Schmidbauer U, Kerl H, Soyer HP: No evidence for c-erbB-2 overexpression in cutaneous melanoma. ANTICANCER RES 21: 2793-2795 2001 ; . Flanagan LA, Chou J, Falet H, Neujahr R, Hartwig JH, Stossel TP: Filamin A, the Arp2 3 complex, and the morphology and function of cortical actin filaments in human melanoma cells. J CELL BIOL 155: 511-517 2001 ; . Florenes VA, mlandsmo GM, Faye R, Nesland JM, Holm R: Cyclin A expression in superficial spreading malignant melanomas correlates with clinical outcome. J PATHOL 195: 530-536 2001 ; . Frster R, Ohl L, Henning G: Lessons learned from lymphocytes: CC chemokine receptor-7 involved in lymphogenic metastasis of melanoma. J NAT CANCER INST 93: 1588-1589 2001 ; . Frahm SO, Schubert C, Parwaresch R, Rudolph P: High proliferative activity may predict early metastasis of thin melanomas. HUM PATHOL 32: 1376-1381 2001 ; . Franco S, Segura I, Riese HH, Blasco MA: Decreased B16F10 melanoma growth and impaired vascularization in telomerase-deficient mice with critically short telomeres. CANCER RES 62: 552559 2002 ; . Giambernardi TA, Sakaguchi AY, Gluhak J, Pavlin D, Troyer DA, Das G, Rodeck U, Klebe RJ: Neutrophil collagenase MMP-8 ; is expressed during early development in neural crest cells as well as in adult melanoma cells. MATRIX BIOLOGY 20: 577-587 2001 ; . Gibbs P, Anderson C, Pearlman N, LaClaire S, Becker M, Gatlin K, O'Driscoll M, Stephens J, Gonzalez R: A phase II study of neoadjuvant biochemotherapy for stage III melanoma. CANCER 94: 470476 2002 ; . Goldstein AM, Tucker MA: Genetic epidemiology of cutaneous melanoma - A global perspective. ARCH DERMATOL 137: 1493-1496 2001 ; . Goto H, Usui M, Ishii I: Efficacy of single photon emission computed tomography for the diagnosis of uveal malignant melanoma. AMER J OPHTHALMOL 132: 937-939 2001 ; . Gradwell E: Small cell melanoma. J CLIN PATHOL 55: 78 2002. G.V. Gill et al. occurs for example because of steroid treatment ; , patients with unsuspected strongyloidiasis can develop a `hyperinfective syndrome`, with massive larval invasion of the peritoneum, liver, lungs and central nervous system--often with bacterial peritonitis, meningitis and septicaemia.12, 13 Mortality is high, and detection of Strongyloides infection is therefore highly important. Chronic strongyloidiasis in ex-FEPOWs was first described by Caplan in 1949 in the UK.14 Further British descriptions were made in 1977; 15 a larger series was reported by our group in 1979; 11 and a further group of cases from the UK was published in 1988.16 Other reports have concerned Australian, 17 American, 18 and Canadian19 ex-FEPOWs, as well as veterans of the WWII Burma Campaign20, 21 and the Vietnam conflict.22 Former FEPOWs are now of advanced years and declining numbers. Many have been investigated at the Liverpool School of Tropical Medicine, but very few are nowadays seen. We have therefore collated our total experience, and report it here and flutamide. Eliac disease CD ; is caused by damage to differentiated villus epithelial cells in response to the ingestion of dietary gluten. The rate of IDDM and CD association is generally estimated to be References 1. van Haeften TW: Glucose tolerance, 17% 1 ; . Some clues suggest that these insulin sensitivity, and the homeostasis two conditions are linked by a common model assessment method Letter ; . Dia - physiopathology. The first phase of insulin betes Care21: 673, 1998 response is altered in islet cell antibody 2. Matsumoto K, Yano M, Ueki Y, Miyake S: ICA ; -negative children with CD observed Response to van Haeften Letter ; . Diabetes in the prediabetic state 2 ; . In addition, Care 21: 673674, 1998 some of these children with CD developed 3. Matthews DR, Hosker JP Rudenski AS IDDM during a follow-up of 10 years 2 ; . Naylor BA, Treacher DF Turner RC: Home, ostasis model assessment: insulin resis- Furthermore, CD and IDDM are suptance and -cell function from fasting ported by an identical genetic background plasma glucose and insulin concentrations class II HLA DR3 and HLA DQ2 genotypes ; 1, 3, 4 ; . Finally, similar mechanisms in man. Diabetologia28: 412419, 1985 4. Rudenski AS, Hosker JP, Burnett MA, of -cell and enterocyte cell damage medi.
Inmates and use a low threshold for referral for emergency hospitalization when acute exacerbations develop Initial Treatment of Asthma Exacerbation Treat with inhaled short-acting beta2-agonists, up to three treatments of 2-4 puffs by MDI at 20 minute intervals, or single nebulizer treatments. Good Response: Findings Mild Exacerbation ; -PEFR 80% predicted or personal best with no wheezing or shortness of breath, and the response to beta2-agonist is sustained for 4 hours Action: May continue beta2-agonist every 3-4 hours for 2448 hours, and for inmates on inhaled corticosteroid, double dose for 7-10 days Incomplete Response: Findings Moderate Exacerbation ; -PEFR 50-80% predicted or personal best with persistent wheezing and shortness of breath Action: Add oral corticosteroid and continue beta2-agonist Poor Response: Findings Severe Exacerbation ; -PEFR is 50% predicted or personal best with marked wheezing and shortness of breath Action: Give systemic corticosteroid, such as IV SoluCortef. Repeat beta2-agonists immediately. If distress is severe and or inmate remains unresponsive to treatment, refer to local emergency department. Key Treatment Principles for Asthma Exacerbations include the following: - Oxygen is recommended for most persons to maintain an SaO2 90% 95 % in pregnant women and in persons with coexistent heart disease ; - Inhaled short-acting beta2-agonists are recommended for all inmates unless medically contraindicated - Anticholinergics should selectively be considered. Adding high doses of ipratropium 0.5 mg ; to an aerosolized solution of a selective beta2-agonist has been shown to 14.
Them are rather rare and will not be reviewed one of them, truncus arteriosus, is fascinating because it is cyanotic but it kills by overloading the pulmonary circulation, like the noncyanotic shunts do ; . The common ones follow. Tetralogy of Fallot, although crippling, often allows children to grow u p into infancy. It is also the most common cyanotic anomaly, and thus any exam question in which a 5 or year old is cyanotic is bound to be tetralogy. The children are small for their age, have a bluish hue in the lips and tips of their fingers, clubbing, and spells of cyanosis relieved by squatting. There is a systolic ejection murmur in the left third intercostal space, a small heart, diminished pulmonary vascular markings on chest x-ray, and ECG signs of right ventricular hypertrophy. Echocardiogram is diagnostic, surgical repair is done. Transposition of the great vessels leads to severe trouble early on. The kids are kept alive by an atrial septal defect, ventricular septal defect, or patent ductus or a combination ; , but die very soon if not corrected. Suspect this diagnosis in a 1- or 2-day-old child with cyanosis who is in deep trouble, and ask for echocardiogram. The technical details of the surgical correction are mind-boggling, and you do not have to know them. Short-acting beta-2 adrenergic agonist, salbutamol. This is based on evidence from numerous studies comparing beta-2 adrenergic and anticholinergic drugs that have reported that the latter are superior or at least equally effective in improving lung functions3-7. The suggestion that increased cholinergic tone may be playing an important role in COPD21 has provided further rationale for this approach. However, the recent availability of LABAs, salmeterol and formoterol, demonstration of their efficacy in COPD8-10 and the obvious advantage of a longer duration of action necessitate that this recommendation be reviewed. There have, however, been very few studies comparing either of these LABAs with anticholinergic drugs and often with conflicting results. Sichletidis et al9 compared 40 and 80 g doses of ipratropium bromide and 12 and 24 g doses of formoterol, and a combination of 40 g ipratropium bromide and 12 g formoterol in 27 patients with COPD with all drugs given from a metered dose inhaler MDI ; . The combination was found to give a greater peak improvement in 0-6 hours area under curve for FEV1 as compared to the two doses of ipratropium bromide. However, this was not different from that observed with formoterol alone. Further, the two drugs given singly were similar in their effect. Dahl et al13 compared the effects of a 12-week treatment with 12 or 24 b.i.d. doses of formoterol dry powder inhaler with 40 g q.i.d. ipratropium bromide. While both drugs were superior to placebo in increasing the FEV1, the effects of each of the doses of formoterol were superior. Further, formoterol decreased symptoms and improved the quality of life, while ipratropium bromide surprisingly was shown not to have significant effects on these parameters. The same workers have reported in another study published in an abstract form ; significant improvement with formoterol in quality of life and reduction in number of days with decreased PEFR or increased symptoms compared to ipratropium bromide22. Liesker et al10 compared the effects of one week treatment with 4, 5, 9 or 18 b.i.d. formoterol via turbuhaler with 80 g t.i.d. ipratropium bromide via MDI and spacer on exercise capacity using a bicycle ergometer, lung function and dyspnoea Borg score ; in 34 patients with COPD. All doses of formoterol and ipratropium bromide improved lung function. Surprisingly, a negative dose-response relationship was observed for formoterol with ipratropium bromide being superior to the highest dose of formoterol in improving exercise capacity but comparable to the lower doses of the latter. None of the doses of formoterol and ipratropium bromide improved dyspnoea. Thus, the above studies do not provide definite evidence of superiority of either drug over the other one. Our results showing these to be equally effective are thus quite in agreement with the other studies although formoterol appears to be a superior bronchodilator producing a greater immediate at 5.

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