Infection and labor. V. Prevalence, microbiology, and clinical significance of intraamniotic infection in women with preterm labor and intact membranes

Amniotic fluid was retrieved by amniocentesis from 264 patients with preterm labor and intact membranes admitted to Yale-New Haven Hospital from Jan. 1, 1985, to July 31, 1988. The prevalence of a positive amniotic fluid culture was 9.1% (24/264). A total of 111 patients (42%) delivered preterm neonates, and 24 (21.6%) of those had positive amniotic fluid cultures. The diagnostic indexes of the Gram stain of amniotic fluid in the prediction of a positive amniotic fluid culture were as follows: sensitivity, 79.1%; specificity, 99.6%; positive predictive value, 95%; and negative predictive value, 98%. Endotoxin was detected with the limulus amebocyte lysate assay in 4.9% (13/264) of patients with preterm labor. All patients with endotoxin in the amniotic fluid delivered preterm neonates. The three most frequently isolated organisms were Ureaplasma urealyticum (n = 6), Fusobacterium species (n = 5), and Mycoplasma hominis (n = 4). Clinical chorioamnionitis was present in only 12.5% of the patients with positive amniotic fluid cultures. Women with positive amniotic fluid cultures had lower gestational ages and more advanced cervical dilatation on admission than women with negative cultures. Preterm infants born to mothers with positive amniotic fluid cultures had a higher incidence of respiratory distress syndrome and infectious complications than preterm neonates born after negative amniotic fluid cultures. These data underscore the frequency and importance of intraamniotic infections in women with preterm labor.

First trimester diagnosis of a partial mole with the combined use of ultrasound and chorionic villous sampling

A patient with vaginal bleeding in the first trimester of pregnancy had a serum human chorionic gonadotropin (hCG) titer of 495,132 mlU/ml and an abdominal ultrasound examination revealed an intrauterine gestational sac without a fetal pole. Two and a half weeks later the hCG titer was 385,000 mlU/ml and a fetal pole was visualized. Transabdominal villous sampling was performed because of the suspicion of a partial mole. Histopathologic examination showed hydropic villi and chromosomal studies were consistent with triploidy. The diagnosis of partial mole in the first trimester of pregnancy was made and the pregnancy terminated.

Mechanisms of HDL reduction after probucol. Changes in HDL subfractions and increased reverse cholesteryl ester transfer

Treatment with probucol, a widely used lipid-lowering agent, is associated with a significant reduction of high density lipoprotein (HDL) cholesterol levels, but with an apparently improved removal of cholesteryl esters from tissues (e.g., from tendon xanthomas). The effects of probucol (500 mg twice daily) on HDL subfraction distribution and cholesteryl ester transfer activity were tested in 12 patients with stable type II hyperlipidemia [low density lipoprotein (LDL) cholesterol greater than 180 mg/dl] after a placebo-controlled cross-over trial. Probucol significantly lowered total cholesterol (-13.8%), LDL cholesterol (-9.1%), and HDL cholesterol (-30%). By rate zonal ultracentrifugation, a marked reduction of HDL2 cholesterol (-68%) was shown, whereas changes in HDL3 were less significant (-21%). These findings were confirmed by polyacrylamide gradient gel electrophoresis, typically showing a reduction or disappearance of HDL2b particles and the prevalence of particles in the HDL3a range. Cholesteryl ester transfer from HDL to lower density lipoproteins was significantly increased (30%) in all patients. These findings suggest that, in addition to the well-documented in vitro changes (prevention of LDL peroxidation and macrophage uptake), probucol characteristically modifies HDL particle distribution in vivo, and is associated with a significant increase of cholesteryl ester transfer activity.

Accuracy of ultrasound in the prenatal diagnosis of spinal anomalies

This study was undertaken to determine the accuracy of sonographic examination in the prenatal diagnosis of neural tube defects. The study population consisted of 237 patients divided into three groups according to the indication for the sonographic examination. The overall sensitivity of sonography in the diagnosis of neural tube defects was 94.7%, and the specificity was 98.3%. A false positive diagnosis of spina bifida occurred in a fetus affected with ventriculomegaly, omphalocele, severe kyphosis and scoliosis. There were three false negative diagnoses of spina bifida.

Lipid effects of celiprolol, a new cardioselective beta-blocker, versus propranolol

The metabolic effects of celiprolol, a new beta-adrenoceptor blocking agent with intrinsic sympathomimetic activity and alpha 2-blocking properties, were evaluated in a series of patients with hypertension, both with and without hyperlipidemia. Propranolol was tested as the reference drug in a randomized double-blind trial. Of the 35 patients of both sexes who completed the study, 17 were hyperlipidemic (low-density lipoprotein cholesterol greater than or equal to 170 mg/dl) and 18 were normolipidemic. Both drugs exerted a similar hypotensive effect after gradual dose adjustment; however, propranolol reduced heart rate to a higher extent (-20.5%) than celiprolol (-7.7%). Propranolol determined a significant rise of total and very low-density lipoprotein (VLDL) associated triglyceridemia, whereas high-density lipoprotein cholesterol (HDL cholesterol) levels and the total cholesterol/HDL cholesterol ratios were significantly depressed, particularly in hyperlipidemic patients. Celiprolol, in contrast, slightly decreased triglyceridemia (significantly in the hyperlipidemic group at week 12) and caused a 5% increase of the HDL cholesterol levels. The total cholesterol/HDL cholesterol ratio was reduced by celiprolol at week 16 in both hyperlipidemic and normolipidemic patients. The effects of the two beta-adrenoceptor blockers on HDL cholesterol and triglyceride levels differed significantly after 12 and 16 weeks of treatment, which confirm the divergent metabolic effects of the two agents.

Meta-analysis of the relationship between asymptomatic bacteriuria and preterm delivery/low birth weight

The relationship between asymptomatic bacteriuria and prematurity/low birth weight (LBW) is still a controversial issue, despite many studies. Meta-analysis, a research tool designed to analyze and combine the results of previous studies, may resolve this discrepancy among contradictory results of clinical trials. The purpose of this study was to examine the relationship between asymptomatic bacteriuria and preterm delivery/LBW using meta-analysis. Reports from the literature were classified according to study design into cohort or randomized-treatment control trials. Meta-analysis of cohort studies showed that untreated asymptomatic bacteriuria during pregnancy significantly increased rates of LBW and preterm delivery. Nonbacteriuric patients had only about two-thirds the risk (typical relative risk = 0.65; 95% confidence interval 0.57, 0.74) of LBW and half the risk (typical relative risk = 0.50; 95% confidence interval 0.36, 0.70) of preterm delivery of those with untreated asymptomatic bacteriuria. These reduced risks correspond to a 3.4 (confidence interval 1.8, 5.0) percentage-point difference in LBW and a 3.8 (1.1, 6.4) percentage-point difference in preterm delivery. The analysis of randomized clinical trials showed that antibiotic treatment significantly reduced the risk of LBW (typical relative risk = 0.56; 95% confidence interval 0.43, 0.73), with a substantial reduction of 6.4 (confidence interval 3.3, 9.5) percentage points in the rate of LBW. We conclude that clinical and epidemiologic evidence indicates a strong association between untreated asymptomatic bacteriuria and LBW/preterm delivery and that antibiotic treatment is effective in reducing the occurrence of LBW.

Is genital colonization with Mycoplasma hominis or Ureaplasma urealyticum associated with prematurity/low birth weight?

Mycoplasma species have been implicated in the pathogenesis of prematurity, intrauterine growth retardation, low birth weight (LBW), and preterm premature rupture of membranes. The purpose of this study was to review the available literature to determine whether there is an association between genital colonization with Mycoplasma hominis or Ureaplasma urealyticum and prematurity/LBW. Twelve studies were reviewed: nine cohort studies, two case-control studies, and one randomized clinical trial of treatment. The overall isolation rate of M hominis from the genital tract was 27.2%, whereas that of U urealyticum was 70.4% (cohort studies). Results from the randomized clinical trial showed that treatment did not alter the rate of prematurity in women carrying mycoplasma species in the genital tract. None of the cohort studies supported an association between genital colonization with U urealyticum and prematurity/LBW. Similarly, no association between M hominis and prematurity/LBW could be demonstrated in seven of the eight and in six of the eight cohort studies, respectively. On the other hand, two case-control studies showed an association between U urealyticum colonization and prematurity without an association with M hominis. We conclude that the weight of the evidence does not support an association between genital colonization with mycoplasma species and prematurity/LBW.

Fetal intracranial calcifications

In utero sonographic visualization of fetal intracranial calcifications during the second trimester is reported. Its diagnostic process, which included percutaneous umbilical cord blood sampling and fetal paracentesis, is described.

Amniotic fluid concentrations of prostaglandin F2 alpha, 13,14-dihydro-15-keto-prostaglandin F2 alpha (PGFM) and 11-deoxy-13,14-dihydro-15-keto-11, 16-cyclo-prostaglandin E2 (PGEM-LL) in preterm labor

Although prostaglandins (PGs) are considered the key mediators of human parturition at term, there is a paucity of data regarding their participation in the mechanisms responsible for preterm labor. The purpose of this study was to establish if preterm labor is associated with changes in the amniotic fluid concentrations of prostaglandins. PGF2 alpha, 13,14-dihydro-15-keto-prostaglandin F2 alpha (PGFM) and 11-deoxy-13,14-dihydro-15-keto-11,16-cyclo-prostaglandin E2 (PGEM-ll) were measured by using specific and sensitive radioimmunoassays. Amniotic fluid was retrieved by transabdominal amniocentesis from 55 women with preterm labor and intact membranes. Patients were divided into three groups according to the response to tocolysis and the presence or absence of an intra-amniotic infection. Amniotic fluid concentrations of PGFM and PGEM-ll were significantly greater in women with preterm labor and intra-amniotic infection than in women without infection. In addition, patients unresponsive to tocolysis without intra-amniotic infection also had a significantly greater concentration of PGFM and PGEM-ll in amniotic fluid than those responsive to tocolysis. Amniotic fluid concentrations of PGF2 alpha were greater in women with intra-amniotic infection than in women without intra-amniotic infection. In the absence of intra-amniotic infection, no difference in amniotic fluid PGF2 alpha concentrations could be found between women who responded to tocolytic treatment and those who did not.

Changes in high-density lipoprotein subfraction distribution and increased cholesteryl ester transfer after probucol

The effects of probucol (500 mg twice daily) on high-density lipoprotein (HDL) subfractions and cholesteryl ester transfer from HDL to lower density lipoproteins were tested in a series of patients with Type II hypercholesterolemia. In this placebo-controlled crossover trial, patients received probucol or placebo for 8 weeks, then switched to the other agent for another 8 weeks. Probucol significantly lowered total, low-density lipoprotein and HDL cholesterol levels. HDL subfractions, separated by rate zonal ultracentrifugation, showed a dramatic reduction in HDL2, whereas changes in HDL3 were not significant. Both subfractions eluted at a characteristically lower volume, indicating a reduced flotation rate. These findings were confirmed by gradient gel electrophoretic separation, which showed a typical reduction or disappearance of HDL2b particles and the prevalence of particles in the HDL3a-HDL3b electrophoretic range in almost all patients. After treatment, cholesteryl ester transfer from HDL to lower density lipoproteins was significantly increased in all patients. These data suggest that probucol may accelerate HDL particle conversion, leading to improvement in reverse cholesterol transport from the periphery to the liver, through HDL and very low density lipoprotein.

Detection and management of anatomic congenital anomalies. A new obstetric challenge

Whereas once the obstetrician was primarily concerned with diseases affecting the mother, the scope of antenatal fetal care has expanded to include a broader range of fetal diseases such as growth disorders and congenital anomalies. The feasibility of identifying congenital anomalies before birth has created an entirely new field of obstetrics. The specialist is now expected to be informed about the differential diagnosis, pattern of inheritance, mechanism of disease, prognosis, optimal obstetric management of the pregnancy, and counseling for future pregnancies.

Ultrasonographic measurement of the common carotid artery wall thickness in hypercholesterolemic patients. A new model for the quantitation and follow-up of preclinical atherosclerosis in living human subjects

Ultrasound high resolution B-mode imaging of human arteries allows in vivo an accurate and non-invasive determination of the thickness of the intimal-medial complex. A computer assisted procedure to measure this parameter at the level of common carotid arteries was developed. The average difference between duplicate thickness determinations was 4.6%. The thickness of the intimal medial complex of common carotid arteries was then measured in a group of hypercholesterolemic patients. This parameter was significantly greater in these patients as compared to controls (P less than 0.001). The prevalence of small plaques in the carotid arterial tree was also significantly increased in patients. Analysis of data showed that in controls, but not in patients, the thickness of the intimal medial complex increases with age (r = 0.46, P less than 0.05). Within the hypercholesterolemic group, intimal-medial complex values were greater in male patients and in smokers. It is concluded that the common carotid arteries of hypercholesterolemic patients show thickening of the intimal-medial complex. Cigarette smoking, male sex and age increase the extent of this modification. The determination of this parameter using a non-invasive technique may represent an important tool to monitor in vivo the progression and/or the regression of early atherosclerosis in man.

Soybean protein diet increases low density lipoprotein receptor activity in mononuclear cells from hypercholesterolemic patients

The effect of two diets containing different protein sources (animal vs. soybean) on the low density lipoprotein (LDL) receptor activity was tested in freshly isolated mononuclear cells from 12 individuals with severe type II hyperlipoproteinemia. The two diets, both taken for 4 wk in a crossover design were of otherwise identical composition. During the soybean protein diet period, total cholesterol was reduced by 15.9% and LDL-cholesterol by 16.4%. The diet containing animal proteins exerted no significant change in plasma lipid levels vs. the baseline findings. The soybean diet regimen dramatically affected the degradation of LDL by mononuclear cells. Degradation was increased 16-fold vs. the basal activity and 8-fold compared with the standard low lipid diet with animal proteins. There was, however, no clear relationship between the reduction of total and LDL-cholesterolemia and the increased LDL degradation. These findings confirm similar data previously obtained in cholesterol-fed rats and suggest that some factor/s, most likely of a protein nature, may regulate the expression of lipoprotein receptors in peripheral cells, particularly when receptor activity is suppressed by experimental diets and/or spontaneous hypercholesterolemia.

Metabolic approach to the diagnosis and treatment of atherosclerotic peripheral vascular disease

Metabolic and clinical peculiarities of patients with peripheral vascular disease (PVD) were evaluated in two studies. In the first study lipid and lipoprotein composition of 20 patients with PVD were examined. Twelve of these patients were normolipidemic, the other 8 hypertriglyceridemic. Ten normolipidemic and ten hyperlipidemic age-matched subjects served as controls. High density lipoprotein cholesterol (HDL-C) levels were markedly reduced in the hypertriglyceridemic, both with (35.1 +/- 5.0 mg/dl) and without (36.2 +/- 11.7 mg/dl) PVD as compared to the normolipidemic patients (47.0 +/- 6.3 mg/dl) and controls (48.1 +/- 10 mg/dl). All the PVD patients showed an increased apolipoprotein B content in the very low density lipoproteins (VLDL) as compared to controls (p less than 0.001). A significant correlation between VLDL-cholesterol and apo B levels was detected in both groups; however, two distinct populations could be clearly separated (slopes of the regression lines: PVD patients = 0.350; controls = 0.215, p less than 0.0001). These data suggest a possible discriminatory power of VLDL-apo B levels in PVD patients independent of other metabolic parameters. In the second study, the clinical activity of metformin (N, N-dimethylbiguanide) a widely used antidiabetic agent, on arterial blood flow was evaluated in 15 patients with PVD. Flow was determined by quantitative strain-gauge plethysmography during a cross-over trial, comparing 6 months of drug and placebo administration. Metformin (850 mg tid) significantly increased arterial flow after a standardized ischemia in both sequences. In spite of the minimal changes of plasma lipid levels during metformin, a highly significant increase of HDL-C levels (+8.3% during the whole treatment) was demonstrated. Plasma levels of isoprotein AI-1 were also raised during the metformin period. Although the mechanism/s of the beneficial effects of metformin on flow cannot, at present be defined, the reported results underline the significant therapeutic potential of this metabolic drug treatment in PVD.

Effects of gemfibrozil on plasma lipoprotein-apolipoprotein distribution and platelet reactivity in patients with hypertriglyceridemia

The effects of gemfibrozil on plasma lipoprotein distribution and composition and on platelet function were investigated in 11 patients with stable hypertriglyceridemia, six belonging to Fredrickson type IIb and five to type IV. Gemfibrozil (600 mg twice a day) significantly reduced total and very low density lipoprotein (VLDL)--associated triglyceridemia (respectively-32.4% and -40.4%, after 6 weeks of treatment). No significant variations were noted in the lipid components of low-density lipoproteins; by contrast, a marked increase (18%) was detected in high-density lipoprotein (HDL)--associated cholesterol. Comparison of the two patient groups (type IIb and type IV) showed that those with type IIb had both a more significant reduction of triglyceridemia and a more marked increase of HDL-cholesterol. Apolipoprotein B levels were reduced in both groups (-12%) with no change in apolipoprotein AI. The cholesterol content in the HDL subfractions, separated by rate zonal ultracentrifugation, was raised in HDL3 (18%) and in HDL2 (14%). Both particles also showed significant increases of the cholesterol/protein and the cholesterol/phospholipid ratios. A non-statistically significant decrease in collagen-induced aggregation and in the release of thromboxane B2 was noted after treatment. These findings suggest that, similar to what was recently reported in normal individuals and in laboratory animals, the probable mode of action of gemfibrozil is in reducing the secretion of atherogenic lipoproteins, particularly VLDL, while stimulating the production of small HDL particles.

Hypercholesterolaemia treated by soybean protein diet

After a period of stabilisation on a controlled low lipid low cholesterol diet with animal proteins a group of 16 children with familial hypercholesterolaemia were given a textured soybean protein based diet, with a similar fat composition. All the children had a highly significant reduction in total cholesterol, averaging -21.8% against the baseline after eight weeks. Compliance became less strict afterwards, but more than half of the patients have regularly continued the diet and results have been maintained for one year. Minimal changes were noted in triglyceridaemia and in high density lipoprotein cholesterol concentrations, which showed a slight rise only at the end of treatment. The children's growth during the trial was normal. In view of the psychological difficulties of prescribing treatment with drugs to children with severe hypercholesterolaemia before puberty and of the relative ineffectiveness of standard low lipid diets in this condition the soybean protein diet may offer a satisfactory alternative.

Controlled evaluation of fat intake in the Mediterranean diet: comparative activities of olive oil and corn oil on plasma lipids and platelets in high-risk patients

Activities of low-fat diets with olive oil or corn oil on lipids and platelets were studied in 23 middle-aged patients with high atherosclerosis risk for 8 wk. The olive oil diet had a polyunsaturated-saturated ratio of 0.33 vs 1.28 for the corn oil diet. Plasma total cholesterol was reduced with corn oil, but high-density lipoprotein cholesterol levels were lower with corn oil and unchanged or raised by olive. Plasma apolipoprotein B levels were equally reduced by both diets; apolipoprotein AI and the apo AI:B ratio rose only with olive oil. Plasma-glucose levels were lowered significantly with olive oil. Changes in platelet function were characterized by a reduced sensitivity to arachidonic acid (particularly with corn oil) and to collagen (particularly with olive). An olive oil diet with a moderate fat intake (about 30% of total calories) leads to favorable plasma lipoprotein and platelet changes.

Cholesterol-lowering and HDL-raising properties of lecithinated soy proteins in type II hyperlipidemic patients

Plasma lipoprotein changes were evaluated in 65 type II patients undergoing sequential 4-week dietary treatments with: (I) standard low-lipid diet; (II) low-lipid diet with total replacement of animal proteins with textured soy proteins containing 6% of lecithin (L-TVP); (III) standard low-lipid diet; (IV) low-lipid diet with a 50% substitution of animal proteins with L-TVP. Total cholesterolemia was significantly reduced in both periods of L-TVP administration: -18.6% during phase II (total replacement) and -13.2% during phase IV (partial replacement). High-density lipoprotein (HDL) cholesterol levels tended to increase during L-TVP administration. However, only patients in the mid- and low tertiles for HDL cholesterolemia showed a significant increase of HDL levels during L-TVP. This 'normalizing' activity of L-TVP on plasma lipoproteins, even when administered as a partial dietary substituent, may be of clinical interest for subgroups of patients at high vascular risk.

Correlation between plasma levels of fenofibrate and lipoprotein changes in hyperlipidaemic patients

Eleven hyperlipidaemic patients received two formulations of fenofibrate (differing in in vitro dissolution) in randomized sequence, each for 6 weeks. Formulation N, giving a 2-3-fold higher plasma fenofibrate level compared to R, lowered both the cholesterol and triglyceride levels far more than R. Changes in the total and high density lipoprotein cholesterol levels were not significantly correlated with the fenofibrate level. A highly significant correlation was detected for triglycerides in Type IV patients, and for changes both in very low density lipoprotein (VLDL) cholesterol and triglycerides in the entire group of patients. In conditions of widely distributed steady state levels of an absorbable hypolipidaemic drug, a significant correlation may thus be detected between the plasma level and the reduction of VLDL - associated lipids.

Increased platelet sensitivity and thromboxane B2 formation in type-II hyperlipoproteinaemic patients

Platelet aggregation induced by collagen, ADP and epinephrine, was monitored in 150 type-II patients (115 type IIA and 35 type IIB) and compared with a reference group of normolipidaemic controls; in addition, malondialydehyde formation and thromboxane B2 were examined in a subsample of the type-IIA patients. Threshold aggregatory concentrations were significantly lower in the whole group of type-II patients for all three aggregating agents; no difference in terms of aggregatory response was detected between platelets from type-IIA and -IIB patients. Only 56% of type-II patients, however, exceeded the 95th percentile of the threshold aggregatory concentrations in controls. The formation of malondialdehyde in platelet-rich plasma stimulated with thrombin and collagen, was significantly higher in platelets from type-IIA patients. The production of thromboxane B2 by platelets, from endogenous arachidonic acid in type-IIA patients, was significantly higher and exceeded the highest level found in controls.

Metformin improves peripheral vascular flow in nonhyperlipidemic patients with arterial disease

The clinical activity of metformin (N,N-dimethyl biguanide), a widely used antidiabetic agent, on arterial blood flow was evaluated in 15 patients with peripheral atherosclerosis. Flow was determined by quantitative strain-gauge plethysmography; plasma lipid, lipoprotein, and apoprotein levels were repeatedly tested during the cross-over trial, comparing 6 months of drug and placebo administration. Metformin (850 mg tid) significantly increased arterial flow after a standardized ischemia (+17.3% after 3 months and +40.0% after 6 months). The increase in arterial flow was reversible after the switch to placebo was made. The drug was similarly effective, although to a lesser extent (+18.6% after 6 months), when given after the placebo. A highly significant effect of drug treatment, as well as of the sequence of administration, could be established by analysis of variance. In spite of the minimal changes of plasma lipid levels during metformin, a highly significant increase of high density lipoprotein cholesterol (+ 8.3% during the whole treatment) was demonstrated; plasma levels of isoprotein AI-1 were also raised during the metformin period. This controlled experiment confirms data from previous open studies, as well as from a longstanding clinical experience. Although the mechanism of the metformin effect cannot, at present, be defined, the reported results indicate that treatments not markedly affecting plasma lipid-lipoprotein levels may improve vascular function in selected arterial districts.

Clofibrate and tiadenol treatment in hyperlipoproteinemias. A comparative trial of drugs affecting lipoprotein catabolism and biosynthesis

Changes in plasma lipoprotein levels and platelet reactivity were evaluated during sequential treatments with clofibrate and tiadenol, two hypolipidemic agents with apparently different mechanisms, in 27 hyperlipoproteinemic patients. The objective of the study was to determine the pattern of plasma lipoprotein variations, induced by a drug mainly affecting lipoprotein catabolism (clofibrate) and by a drug affecting biosynthesis (tiadenol), and to single out-patients specifically responding to either treatment. Both drugs proved significantly active in type IIA and IV hyperlipoproteinemias, not in type IIB. Clofibrate significantly lowered very low density lipoprotein (VLDL) associated cholesterol in all three hyperlipoproteinemia phenotypes, and it also lowered VLDL triglycerides in type IV, while increasing high density lipoprotein (HDL) cholesterol in type IIA patients. Low density lipoprotein (LDL) cholesterol levels were minimally reduced by clofibrate in type IIA (-4%), and increased in types IIB (+ 14.2%) and IV (+ 6.1%) patients. Conversely, tiadenol lowered VLDL cholesterol and triglycerides to a lesser extent, but it did significantly reduce LDL cholesterolemia in type IIA (-17.6%), while increasing HDL cholesterol in type IIB. Statistical evaluation of the results did not permit identification of parameters associated with the response to either drug, although individuals specifically responding to one or the other agent, or to both, were detected in all three phenotypes. The sensitivity to the major platelet aggregating factors, ADP, adrenaline and collagen, was not significantly altered after drug treatments. Evaluation of the hypolipidemic response to agents with different mechanisms may be of help in selecting the best treatment for individual patients.