A randomized open-label trial on the use of budesonide/formoterol (Symbicort®) as an alternative reliever medication for mild to moderate asthmatic attacks

BACKGROUND Conventionally, a nebulized short-acting β-2 agonist like salbutamol is often used as the reliever in acute exacerbations of asthma. However, recent worldwide respiratory outbreaks discourage routine use of nebulization. Previous studies have shown that combined budesonide/formoterol (Symbicort®, AstraZeneca) is effective as both a maintenance and reliever anti-asthmatic medication. METHODS We performed a randomized, open-label study from March until August 2011 to compare the bronchodilatory effects of Symbicort® vs. nebulized salbutamol in acute exacerbation of mild to moderate asthmatic attack in an emergency department. Initial objective parameters measured include the oxygen saturation, peak expiratory flow rate (PEFR) and respiratory rate. During clinical reassessment, subjective parameters [i.e., Visual Analog Scale (VAS) and 5-point Likert scale of breathlessness] and the second reading of the objective parameters were measured. For the 5-point Likert scale, the patients were asked to describe their symptom relief as 1, much worse; 2, a little worse; 3, no change; 4, a little better; 5, much better. RESULTS Out of the total of 32 patients enrolled, 17 patients (53%) were randomized to receive nebulized salbutamol and 15 (47%) to receive Symbicort®. For both treatment arms, by using paired t- and Wilcoxon signed rank tests, it was shown that there were statistically significant improvements in oxygen saturation, PEFR and respiratory rate within the individual treatment groups (pre- vs. post-treatment). Comparing the effects of Symbicort® vs. nebulized salbutamol, the average improvement of oxygen saturation was 1% in both treatment arms (p = 0.464), PEFR 78.67 l/min vs. 89.41 l/min, respectively (p = 0.507), and respiratory rate 2/min vs. 2/min (p = 0.890). For subjective evaluation, all patients reported improvement in the VAS (average 2.45 cm vs. 2.20 cm), respectively (p = 0.765). All patients in both treatment arms reported either "a little better" or "much better" on the 5-point Likert scale, with none reporting "no change" or getting worse. CONCLUSION This study suggests that there is no statistical difference between using Symbicort® vs. nebulized salbutamol as the reliever for the first 15 min post-intervention

Effects of different fluting medium geometries on von-mises stress and deformation in single fluted board: a three-dimensional finite element analysis

Paperboard box produced in large volume for packaging purpose either to pack light or heavy product. When a heavy product is packed, high strength and structural stability against compression and deformation of the paperboard box are demanded. This paper investigates the effects of different shape of fluting mediums on the von Mises stress and deformation using finite element analysis (FEA) tool. Solidworks and ANSYS software were used to design a 3-D model and perform static structural analysis, respectively. The result from the analysis and simulation revealed that common s-shape geometry experienced the lowest von Mises stress and deformation. Honeycomb geometry experienced the highest von Mises stress of 0.19576 MPa while triangle fluting medium recorded the highest deformation at 1.8695E-4mm

Obstetrics and gynaecology training in Malaysia: guide for applicants 2020

This document is a guide for those applying to enter postgraduate training in Obstetrics & Gynaecology. It contains information on the entry requirements for the specialty training programme, the selection process and what training entails. It is an extract from the New Postgraduate Curriculum for Obstetrics & Gynaecology and provides key summaries about the training structure, syllabus and assessments

A randomized controlled trial on the use of Budesonide/formoterol (symbicortr) as an alternative Reliever medication for mild to moderate asthmatic attack in Adult patients in emergency department, hospital universiti Sains malaysia

A RANDOMIZED CONTROLLED TRIAL ON THE USE OF BUDESONIDE/FORMOTEROL (SYMBICORT®) AS AN ALTERNATIVE RELIEVER MEDICATION FOR MILD TO MODERATE ASTHMATIC ATTACK IN ADULT PATIENTS IN EMERGENCY DEPARTMENT, HOSPITAL UNFVERSITI SAINS MALAYSIA. Nebulized Salbutamol has been commonly used as the conventional reliever in the treatment of patients with acute exacerbations of asthma regardless of whether in outpatient clinic settings or in the emergency departments. On the other hand, Symbicort turbuhaler is a combination of Formoterol (long acting 02- agonist) and Budesonide (steroid). Salbutamol and Formoterol are 02-agonist that acts as bronchodilators, but Salbutamol is a short acting 02-agonist, whereas Formoterol is a long acting 02-agonist. Budesonide is a steroid that plays a role as an anti-inflammatory agent that usually occur in acute asthma attack. This research is done to evaluate the effectiveness of Symbicort turbuhaler which is a combined long acting 02-agonist and steroid as an alternative reliever in mild to moderate acute axacerbation of bronchial asthma and to look at patient’s acceptance regarding the use of Symbicort turbuhaler and the feasibility in starting Symbicort maintanance and reliever therapy (SMART) in emergency department. To evaluate the effectiveness of Symbicort therapy as an alternative reliever in treating mild to moderate acute exacerbation of bronchial asthma. To evaluate control of asthma based on Asthma Control Test (ACT) among adult asthmatic patients that presented to emergency department HUSM. To evaluate the effectiveness of Symbicort turbuhaler as an alternative treatment for mild to moderate asthma exacerbation by using respiratory rate, oxygen saturation and peak expiratory flow rate (PEFR) as objective assessment tools for the severity of asthmatic attack and patient’s response to treatment. To evaluate the effectiveness of symbicort turbuhaler as an alternative treatment for mild to moderate asthma exacerbation by using Visual Analog Score (VAS) and 5-point Likert Scale of breathlessness as subjective assessment tools for the severity of asthmatic attack and patient’s response to treatment. To understand patient’s acceptance regarding the use of Symbicort turbuhaler as an acute asthma reliever and maintainance therapy (SMART). To evaluate the fraction exhaled nitric oxide (FENO) level in asthmatic patient and its association with asthma control. A randomized controlled trial was done from March until August 2011 between nebulizer Salbutamol and Symbicort turbuhaler in adult patients with mild to moderate acute exacerbation of bronchial asthma who presented to Emergency Department HUSM. Patients who fulfilled the criteria and agreed to participate in this study were randomly assigned either nebulizer Salbutamol or Symbicort turbuhaler as the treatment. Objective and clinical parameters such as respiratory rate (RR), oxygen saturation (SPO2), peak expiratory flow rate (PEFR) and fraction of exhale nitric oxide (FENO) were recorded before and after treatment. Parameters were analyzed using SPSS version 18.0. A total of 32 patients fulfilled the inclusion criteria and consented to participate in this study. After randomization, 17 patients were chosen to receive nebulized salbutamol and another 15 patients received symbicort turbuhaler. There were significant improvements in respiratory rate (RR), oxygen saturation (SPO2) and PEFR in patients received symbicort turbuhler (p=0.001, p=0.027 and p=<0.001 respectively). This result is as significant as patients received nebulized salbutamol. When comparing the means difference between this two groups using ‘Independence ttest’, it showed that there were no significant difference in terms of changes in respiratory rate, SPO2 and PEFR (p=0.687,p=0.350 and p=0.507 respectively). In terms of subjective parameters using ‘Visual Analog Score’ and ‘5-point Likert Scale’ of breathlessness, it also showed that there were no significant difference in patients who received symbicort turbuhaler or nebulized salbutamol (p=0.765 and p=0.688 respectively). Regarding asthma control based on Asthma Control Test (ACT) score, by using Me Nemar test, there were no significant difference in asthma control in patients started on SMART therapy or with MDI salbutamol plus MDI budesonide (p=0.754). We also found that SMART therapy were well accepted by most of the patients based on questionnaires answered. From this randomized controlled trial study, it showed that symbicort turbuhaler can be used as an alternative treatment for patients with mild to moderate exacerbation of asthma as there were no significant difference improvements in objective parameters and in subjective parameters compared to nebulized salbutamol

E-learning adoption in the classroom: implementation strategy, effectiveness and challenges

Towards the development of 21st century teaching and learning, exist variation of teaching methods adapted in the classroom instruction. All these are to ensure learners' interest and participation in the teaching and learning keeps on going interactively. Electronic teaching is one of the popular methods that have been carried out by teachers, known as e-learning. This paper discusses the provision of new experience in the process of teaching and learning to both teachers and students. The focus on the implementation strategies of e-learning, its effectiveness for students, and limitation encountered in its implementation are highlighted too

Maternal risk factors for group B streptococcus (GBS) vaginal colonization

Approximately 18% of pregnant women are colonized with Group B streptococcus (GBS), which are βhemolytic, gram-positive bacteria. GBS conversion from the asymptomatic commensal in the vagina to an invasive pathogen predisposes the pregnant women to ascending intrauterine infection that tiggers preterm birth and initiate fetal and neonatal infections. The prevalence of colonizing GBS serotypes and sequence types (STs) are elucidated in this review in addition to the maternal components including demographical and obstetric factors that increase the risk for GBS colonization during pregnancy. Investigating the epidemiology is crucial for the development of new therapeutic and preventive measures to reduce the burden of invasive GBS disease worldwide including risk-factor based screening protocols

A review of group B streptococcus (Gbs) vaginal colonization and ascending intrauterine infection: interaction between host immune responses and gbs virulence factors

Vaginal colonization with Group B streptococcus (GBS) or Streptococcus agalactiae can potentially cause ascending intrauterine infection among pregnant women, and hence it is known as one of the risk factors for preterm delivery. Ascending intrauterine infection may also cause the transmission of GBS to the fetus in utero and the newborn during delivery, leading to the development of early onset of neonatal infection. GBS are βhemolytic, gram-positive bacteria that are opportunistic commensal of the gastrointestinal and urogenital tract of approximately 18% of pregnant women globally. Intrapartum antibiotic prophylaxis (IAP) only reduces the rate of early onset neonatal infection, but not the late onset neonatal infection. Thus, the development of GBS vaccine is thought to be important to decrease the rate of preterm delivery and neonatal infections particularly in low-and-middle income countries where IAP program is not feasible. Vaccination can also be cost-effective for the healthcare system when executed together with IAP program. The aim of the current review is to summarize the mechanisms on how the GBS virulence factors interact with host immune components in the gestational tissues, leading to cervicovaginal colonization and ascending intrauterine infection. The elucidation of these mechanisms is essential for expediting the development of vaccines and novel therapeutic measures targeting these GBS virulence factors that will hamper the vaginal colonization, ascending intrauterine infection and conceptus tissue invasion by GBS. These strategies are crucial to potentially reduce the rate of preterm delivery and subsequent serious complications in the newborn

Expression of virulence genes in group B streptococcus isolated from symptomatic pregnant women with term and preterm delivery

Aims: Maternal vaginal Group B Streptococcus (GBS) colonization is considered a risk factor for preterm delivery and, consequently, neonatal infections. Previous studies have portrayed the important roles of these virulence factors, including hemolytic pigment, hyaluronidase (HylB), serine-rich protein (Srr) and bacterial surface adhesion of GBS (BsaB) in mediating GBS colonization and intrauterine ascending infection, causing preterm delivery. This study aimed to investigate the association between mRNA expression of virulence genes in GBS isolates obtained from symptomatic pregnant women and preterm delivery. Methodology and results: GBS isolates were obtained from high vaginal swabs of 40 symptomatic pregnant women of gestational age of less than 37 weeks. RNA was extracted from these GBS isolates and RT-qPCR was performed to determine the relative mRNA expression of GBS virulence genes, including CylE (encode enzyme required for the biosynthesis of the hemolytic pigment), HylB, Srr-1 and BsaB. Socio-demographic details and obstetric history were not found to be associated with the delivery outcomes of these women. The GBS isolates from symptomatic pregnant women who delivered prematurely showed a higher expression of CylE gene and a trend towards an elevated expression of HylB gene compared to women with term delivery. While the expression of both Srr-1 and BsaB genes was similar between symptomatic pregnant women who had term or preterm delivery. Conclusion, significance and impact of study: The results suggest that following vaginal colonization, both CylE and HylB genes are likely to contribute to intrauterine ascending infection and inflammation, leading to preterm delivery in humans. These virulence factors may be targeted for the pre-clinical stages of vaccine development or therapeutic intervention

Flavonoids as potential wound-healing molecules: emphasis on pathways perspective

Wounds are considered to be a serious problem that affects the healthcare sector in many countries, primarily due to diabetes and obesity. Wounds become worse because of unhealthy lifestyles and habits. Wound healing is a complicated physiological process that is essential for restoring the epithelial barrier after an injury. Numerous studies have reported that flavonoids possess wound-healing properties due to their well-acclaimed anti-inflammatory, angiogenesis, re-epithelialization, and antioxidant effects. They have been shown to be able to act on the wound-healing process via expression of biomarkers respective to the pathways that mainly include Wnt/β-catenin, Hippo, Transforming Growth Factor-beta (TGF-β), Hedgehog, c-Jun N-Terminal Kinase (JNK), NF-E2-related factor 2/antioxidant responsive element (Nrf2/ARE), Nuclear Factor Kappa B (NF-κB), MAPK/ERK, Ras/Raf/MEK/ERK, phosphatidylinositol 3-kinase (PI3K)/Akt, Nitric oxide (NO) pathways, etc. Hence, we have compiled existing evidence on the manipulation of flavonoids towards achieving skin wound healing, together with current limitations and future perspectives in support of these polyphenolic compounds as safe wound-healing agents, in this review