Combination neurohormonal blockade with ACE inhibitors, angiotensin II antagonists and beta-blockers in patients with congestive heart failure: design of the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) Pilot Study

BACKGROUND

The Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) Pilot Study is a trial of combination neurohormonal blockade using an angiotensin II antagonist (candesartan), an angiotensin-converting enzyme inhibitor (enalapril) and a beta-blocker (metoprolol) in patients with congestive heart failure (CHF).

OBJECTIVES

Primary objectives of stage I are to determine the efficacy (via the 6 min walk test) and safety of candesartan alone, and in combination with enalapril, versus enalapril alone. Secondary objectives are to determine the effect of the above combinations on neurohormones, ventricular function, quality of life and symptoms. Stage II objectives are similar, evaluating the effect of the addition of metoprolol or placebo to the above medication(s).

DESIGN

Randomized, two-stage trial consisting of a three-way comparison (stage I), followed by a 3 x 2 partial factorial design (stage II).

SETTING

Sixty out-patient clinics in five countries.

PATIENTS

Patients with symptoms of CHF (New York Heart Association functional classes II to IV), ejection fraction less than 40% and 6 min walk distance of 500 m or less.

INTERVENTIONS

In stage I, 770 patients are randomized to receive candesartan alone, enalapril alone, or candesartan plus enalapril. After five months (end of stage I), patients are assessed for eligibility to be randomized in stage II. Those who are not candidates for randomization to beta-blocker or placebo are followed on their stage I medications until the end of the study. In stage II, patients are randomized to receive metoprolol or placebo for a further six months in addition to their stage I medications. Endpoints are measured at baseline, end of stage I (week 20) and end of stage II (week 46). STUDY STATUS: The study has recently completed follow-up in both stages. The findings from this study will be used to design a large scale mortality study that will help further define the role of neurohormonal blockade in patients with CHF.

Family dynamics of families with mental health problems in Finland

This study forms part of the International Family Dynamics Project. Its purpose was describe the family functioning of families with mental health problems on the basis of Barnhill's framework for healthy family systems. The sample consisted of 160 families in which one family member had mental health problems. Both the patients and their relatives took part. The data were collected by questionnaires, i.e. The Family Dynamics Measure and The Family Dynamics Questionnaire. According to the results, mental health patients described family functioning as fairly poor, while relatives described it as fairly good. However, patients' and relatives' perceptions of family functioning did not differ significantly. There were some statistically significant differences between patients' and relatives' perceptions of different family dynamics dimensions. Relatives reported more mutuality (P = 0.006) and clearer communication (P = 0.009) than patients. Older mental health patients reported more isolation than patients under 30. Relatives who mentioned some serious illness in the family reported more role conflict than those who didn't. No differences were found by gender, family structure or education. The results indicated that the mental health problems of a single family member did not impair family dynamics. The study showed that the resources and functioning of families are fairly good in spite of the illness in the family.

Low levels of cardiovascular risk factors and coronary heart disease in a UK Chinese population

OBJECTIVE

To compare the prevalence of cardiovascular risk factors and coronary heart disease in Chinese and Europid adults.

DESIGN

Population based, cross sectional survey.

SETTING

Newcastle upon Tyne, UK, 1991-93.

SUBJECTS

Altogether 380 Chinese and 625 Europid adults, aged 25-64 years.

MAIN OUTCOME MEASURES

Fasting lipid levels, blood pressure, body mass index (BMI), the proportions who smoked, and the prevalence of coronary heart disease based on the Rose angina questionnaire and major electrocardiographic abnormalities on resting 12 lead electrocardiogram (Minnesota codes 1.1-1.2). All figures were age adjusted to the 1991 England and Wales population.

RESULTS

Altogether 183 and 197 Chinese, and 310 and 315 Europid men and women respectively were seen. Compared with Europid men, Chinese men had a lower mean total cholesterol concentration (5.1 versus 5.6 mmol/l, p < 0.001) and LDL cholesterol (3.2 versus 3.6 mmol/l, p < 0.001); lower BMI values (23.8 versus 26.1 kg/m-2, p < 0.001); and smoked less (23% versus 35%, p < 0.01)). Compared with Europid women, Chinese women also had lower mean lipid levels (total cholesterol: 4.9 versus 5.4 mmol/l p < 0.001, LDL cholesterol: 2.8 versus 3.1 mmol/l p < 0.001); BMI values (23.5 versus 26.1 kg/m-2, p < 0.001); and far fewer were smokers (1.4% versus 33%, p < 0.001). Chinese women, however, had higher mean systolic (121 versus 117 mmHg, p > 0.05) and diastolic (75 versus 68 mmHg, p < 0.001) blood pressures. The prevalence of coronary heart disease was significantly lower in Chinese than Europid men (4.9% versus 16.6%, p < 0.001) but not significantly different in women (7.3% versus 11.1%, p = 0.16).

CONCLUSION

Strategies for UK Chinese are needed to maintain this favourable risk factor profile and prevent any potential increase in the risk of coronary heart disease associated with increasing acculturation.

Preimplantation diagnosis of single gene disorders by two-step oocyte genetic analysis using first and second polar body

Previous work on preimplantation genetic diagnosis (PGD) of single gene disorders by the first polar body (IPB) analysis has demonstrated that the genotype of a considerable number of embryos resulting from heterozygous oocytes cannot be predicted without testing their second PB (IIPB). To overcome this limitation we introduce a two-step DNA analysis of oocytes using both IPB and IIPB to identify hemizygous mutation-free oocytes following the second meiotic division. In the application of the approach to PGD of cystic fibrosis (CF) Delta F-508 mutation, sickle cell disease, and hemophilia B, 80 oocytes were studied by both PBs, resulting in the identification and transfer of 32 homozygous normal embryos. A follow-up genotyping of 52 embryos, resulting from oocytes tested by both IPB and IIPB demonstrated the accuracy of the predicted genotypes. In addition to a nested PCR analysis of the mutant genes in PBs and resulting embryos, simultaneous amplification of different polymorphic markers was performed, demonstrating the reliability of the two-step polar body analysis of oocytes.

Migration, fertility, and state policy in Hubei Province, China

Despite China's one-child family planning policy, the nation experienced a slight rise in the birth rate in the mid-1980s. Many observers attributed this rise to the heightened fertility of those rural-to-urban migrants who moved without a change in registration (temporary migrants), presumably to avoid the surveillance of family planning programs at origin and destination. Using a sequential logit analysis with life-history data from a 1988 survey of Hubei Province, we test this possibility by comparing nonmigrants, permanent migrants, and temporary migrants. While changing family planning policies have a strong impact on timing of first birth and on the likelihood of higher-order births, migrants generally do not have more children than nonmigrants. In fact, migration tends to lower the propensity to have a child. More specifically, the fertility of temporary migrants does not differ significantly from that of other women.

Serum concentrations of vitamins A and E in impaired glucose tolerance

Serum concentrations of vitamins A and E were measured in 32 subjects with impaired glucose tolerance (IGT) and 148 subjects with normal glucose tolerance using reversed-phase high-performance liquid chromatography. Fasting glucose, insulin and lipid concentrations were also measured. Serum vitamin A concentrations were higher in subjects with IGT 2.5 (1.1-3.4) vs. 2.1 (1.4-3.2) mumol/l [median (2.5-97.5 percentiles)] (P = 0.002), the difference remaining significant after adjustment for triglycerides (P = 0.028). There was a univariate association between vitamin A levels and insulin resistance (r = 0.164; P = 0.02) and in multivariate logistic regression analysis the relative risk of subjects with high vitamin A concentrations having IGT was 3.8 (P = 0.002). There were no differences in serum vitamin E concentrations between the groups. These data suggest that higher vitamin A concentrations found in non-insulin-dependent diabetes pre-date the onset of diabetes. Further studies are required to confirm this finding and to investigate the possibility of a role for vitamin A in the aetiology of diabetes and IGT.

Risk factors associated with the likelihood of leptospiral seropositivity in horses in the state of New York

OBJECTIVE

To determine and quantify risk factors associated with exposure of horses to the following serovars of Leptospira interrogans: pomona, autumnalis, and bratislava.

ANIMALS

2,551 horses were randomly selected from a target population during the period of May 1991 to August 1993.

PROCEDURES

Blood was collected from the horses and tested for antibodies to serovars, using the microscopic agglutination test. A titer > or = 1:100 indicated seropositivity. Information was collected on each horse, its environment, and each farm's management practices. Logistic regression analysis was used to develop a multidimensional indexing system for indices of exposure and to identify factors significantly-associated with the risk of seropositivity. These indices were: 1) rodent exposure; 2) wildlife exposure; 3) soil and water; and 4) management.

RESULTS

Rodent exposure index value was associated with the risk of exposure to all 3 serovars. Management index value was positively associated with the risk of exposure to serovars pomona and bratislava, but not with risk of exposure to serovar autumnalis. Soil and water index value had a positive association with risk of exposure to serovars pomona and autumnalis, but not to serovar bratislava. The wild-life index value and the population density of horses turned out together were associated with the risk of exposure to serovar autumnalis. Age of horse in years was associated nonlinearly (years) and linearly (years) with the risk of exposure to serovars autumnalis and bratislava, and only linearly with the risk of exposure to serovar pomona.

CONCLUSION

Risk of seropositivity to the 3 serovars of L interrogans varies according to age, management practices, population density of horses turned out together, and the values of the rodent exposure, wildlife exposure, and soil and water indices.

Age- and gender-related changes in endothelin and catecholamine release, and in autonomic balance in response to head-up tilt

1. There is an increase in circulating levels of vasoconstrictive hormones and an alteration in baroreceptor responsiveness with aging. The role of changes in endothelium-dependent and -independent vasoconstrictive hormones in relation to age and gender, with simultaneous assessment of autonomic balance in response to head-up tilt, has been incompletely studied. 2. Sixteen young [25 +/- 3 years (mean +/- SEM)] and 16 older normal volunteers (68 +/- 7 years) underwent a 30 min head-up tilt test at 60 degrees. Haemodynamics were measured every 5 min and blood samples for neurohormone measurement were drawn at baseline, 5, 10, 15 and 30 min into the test. Heart rate variability was analysed in 5 min segments at the baseline, and during the test. The younger subjects exhibited a greater increase in heart rate and diastolic blood pressure, despite lower absolute levels of noradrenaline (norepinephrine) and endothelin-1. Analysis of heart rate variability yielded a decrease in both high- and low-frequency bands in the aged; power at low-frequency decreased only in the young subjects. The age-related differences in blood pressure and noradrenaline levels were markedly attenuated in the female subjects. In addition, endothelin-1 levels and power spectral measurements at low frequency were the lowest in younger females throughout the tilt. 3. Despite attenuated cardiovascular response to tilt, both systemic adrenergic 'drive' and endothelin-1 levels increase in parallel with aging. Thus, endothelium-dependent and -independent vasoconstrictive hormone levels increase with age in the resting state and in response to neurohumoral stimulation in humans.

Tractional force generation by porcine Müller cells: stimulation by growth factors in human vitreous

PURPOSE

To examine the levels of Müller cell contraction-stimulating activity in human vitreous, correlate these levels with clinical presentation, and identify, the causative growth factors.

METHODS

Human vitreous was collected from patients undergoing pars plana vitrectomy (n = 84). Müller cells were isolated from porcine retina and maintained in tissue culture. Tractional forces generated by cells incubated on three-dimensional collagen gels were measured as changes in gel thickness. Contraction-stimulating activity in vitreous (VA) was calculated from the close-response profiles of gel contraction to vitreous protein. The contributions of individual growth factors to vitreous activity (n = 10) were assessed by inhibition with specific neutralizing antibodies.

RESULTS

The mean VA of patients with retinal detachment (3.65) and proliferative vitreoretinopathy stages A, B, and C (2.06) were elevated above that of patients without retinal pathology (vitreous activity = 0.23) or retinal defects alone (0.57). Mean activities in patients with epimacular proliferation (1.22) and vitreous hemorrhage (1.40) were also significantly elevated. The percentage of this activity attributable to insulin-like growth factor 1 (IGF-1) varied from 9.2% to 84.5% with a mean of 61.3%. Similarly, the percent contribution of platelet-derived growth factor (PDGF) ranged from 6.8% to 49.0% with a mean of 26.5%.

CONCLUSIONS

The vitreous of patients with retinal detachment, proliferative retinal disease, and vitreous hemorrhage contain varying amounts of growth factors that stimulate tractional force generation by Müller cells. The majority of the activity can be attributed to IGF-1 and a smaller proportion to PDGF.

Identifying Chinese populations in the UK for epidemiological research: experience of a name analysis of the FHSA register. Family Health Services Authority

There is a paucity of research on health in the UK Chinese community partly due to the difficulties of identifying and accessing study populations. For a survey of cardiovascular disease we aimed to identify and recruit all Chinese adults aged 25-64 y living in Newcastle-upon-Tyne, UK. One thousand, eight hundred and sixty-five potential subjects were identified using a variety of methods. Of the 1702 potential subjects identified from a name analysis of the 1991 FHSA register (FHSA group), 638 students in halls of residence were excluded and the remaining 1064 were invited to participate. Non-respondents were followed up. Of the 1064, 658 (65.5%) addresses were no longer valid, 21 (2%) were reclassified as non-Chinese and no contact was made with 18 individuals (1.6%). A further 163 subjects (non-FHSA group) came forward in response to publicity, giving a total of 530 Chinese actually identified in Newcastle. Three hundred and eighty subjects took part in the study. Compared to the 1991 Census, the recruitment procedure underestimated the total population size, particularly for men and younger ages. In the FHSA group, men were significantly more likely to be current drinkers, and women were more likely to smoke and have a lower educational attainment that the non-FHSA group. There were no other important differences in the distribution of CHD risk markers in the two groups. Our experience indicates that the FHSA register is suitable for identifying Chinese but should be used alongside other complementary methods to augment samples for ethnicity and health research.

Restoration of thymocyte development and function in zap-70-/- mice by the Syk protein tyrosine kinase

The Syk family of protein tyrosine kinases, consisting of ZAP-70 and Syk, associate with the pre- and alphabeta T cell antigen receptors (TCRs) and undergo tyrosine phosphorylation and activation following receptor engagement. Thymocyte development in zap-70-/- mice is blocked at the CD4+CD8+ TCR(lo) stage. The presence of Syk in the thymus has raised the possibility that Syk may be able to mediate TCR function. To determine if Syk can play a role in thymocyte development, we generated zap-70-/- mice expressing a human syk cDNA. Syk expression restored both thymocyte development and function. In addition, Syk function required the CD45 transmembrane protein tyrosine phosphatase. Hence, ZAP-70 and Syk can play overlapping functions and exhibit similar regulatory mechanisms in mediating alphabeta T cell development.

Effects of intermittent ozone exposure on peak expiratory flow and respiratory symptoms among asthmatic children in Mexico City

In a panel study of Mexican children (5-13 y of age) with mild asthma, the authors studied the relationship between ozone exposure and the course of childhood asthma. Decrements in peak expiratory flow rate were associated with ozone, and respiratory symptoms were associated with both ozone level and ambient particulate matter (< 10 microm) level. After the authors adjusted for minimum temperature and autocorrelation in the data, they determined that an increase of 50 ppb in a daily ozone 1-h maximum was related to an 8% increase in cough (95% confidence interval = 2, 15); a 24% increase in phlegm (95% confidence interval = 13, 35); and an 11% increase in low respiratory symptoms index (95% confidence interval = 5, 19). The authors concluded that children with mild asthma who resided in the south of Mexico City were affected adversely by the high ozone ambient levels observed in this area.

The relationship of calfhood morbidity with survival after calving in 25 New York Holstein herds

The association of owner-diagnosed calfhood diseases with the length of herd life after calving was evaluated using data collected prospectively over a ten-year period in 25 New York Holstein dairy herds. Herds selected for the study were milking between 35 and 200 Holstein cows, used dairy herd improvement records, bred cows by artificial insemination unless they needed three or more services, and had regularly-scheduled herd health visits by clinicians from the Cornell University College of Veterinary Medicine. Owners recorded occurrences of dullness, respiratory disease, and scours from birth through 90 days of age for all heifer calves that lived at least 24 h and were to be kept as replacements. Milking herd life was measured as the difference between the age at first calving and the age at death or sale. Data on cows sold when the herd went out of business or still in the herd at the end of the study were censored observations. Cox's proportional hazards model was used for statistical analysis of the data. Controlling for age at first calving, study month of birth, and sire predicted difference for milk, there was no statistically significant association of calfhood morbidity with length of herd life. The estimated hazard rate ratios for leaving the milking herd and 95% confidence intervals for dullness, respiratory disease, and scours within 90 days of birth were 1.3 (0.9, 1.9), 0.9 (0.6, 1.3), and 1.0 (0.8, 1.3), respectively. Dullness was the only disease category with an estimated hazard rate ratio greater than 1, and although it was not statistically significant, may warrant evaluation in future studies of long term effects of calfhood morbidity.

Pharmacokinetic, hemodynamic, and metabolic effects of cyclosporine sandimmune versus the microemulsion neoral in heart transplant recipients

BACKGROUND

Cyclosporine is a potent immunosuppressive agent that is, however, associated with systemic hypertension and renal dysfunction. The purpose of this investigation was to study the pharmacokinetic and long-term renal and hypertensive effects of Sandimmune (Sandoz) versus the new Neoral (Novartis) formulation of cyclosporine in heart transplant recipients.

METHODS

Twenty heart transplant recipients with stable conditions and aged 54 +/- 9 years were studied in an open-labeled single-arm conversion protocol. Twelve-hour pharmacokinetic studies were performed on Sandimmune and after 4 weeks of treatment with Neoral at similar dosage. The 24-hour blood pressure monitoring, creatinine clearance, and complete biochemistry profile were studied simultaneously to the pharmacokinetic studies. Six-month follow-up with serial measurements of cyclosporine levels, and biochemistry profile was completed.

RESULTS

Conversion to Neoral resulted in a 24% increase in area-under-the-curve in spite of no significant changes in cyclosporine trough levels (165 +/- 48 [Sandimmune] vs 169 +/- 32 nmol/L; p = 0.26). Respectively, 16%, 68%, and 16% were poor, average, and good absorbers on Sandimmune versus 26% and 74% being average or good absorbers on Neoral. Averaged systolic and diastolic blood pressure were not affected by Neoral, but blood pressure readings increased in 20% of patients previously known as having hypertension. The 24-hour blood pressure data yielded no significant changes with Neoral, but the nocturnal drop in systolic blood pressure was attenuated by Neoral. Twenty-four-hour creatinine clearance was not affected by Neoral, but serum magnesium levels decreased significantly at 6 months.

CONCLUSIONS

Neoral resulted in 24% increase in cyclosporine exposure without significant changes in trough levels, and improved absorption status. This greater drug exposure is well tolerated and resulted in a slight increase in blood pressure in a subset of patients and some decrease in magnesium levels, but it had no effect on renal function.

Muscle fatigue in spinal muscular atrophy

We previously reported that patients with spinal muscular atrophy do not lose muscle strength over time as measured quantitatively. However, we noted that many patients with spinal muscular atrophy suffer from what they call fatigue. We wondered if we could measure fatigue during a single maximal voluntary contraction, whether fatigue might increase with time, independent of muscle strength, and whether increasing fatigue might correlate with loss of function in some patients. We measured fatigue during a single maximal voluntary contraction in a cohort of patients having spinal muscular atrophy using quantitative strength testing. We included only patients with spinal muscular atrophy aged 5 years or older, so they could follow instructions regarding muscle contraction, and who were followed for at least 2 years. Seventy-six children with spinal muscular atrophy and 24 untrained individuals, aged 5 to 57 years (mean, 16.8 years), were studied. There was no discernible abnormal fatigue in patients with spinal muscular atrophy compared to untrained controls using our methodology. Thus, spinal muscular atrophy may not be associated with fatiguability. Moreover, spinal muscular atrophy does not appear to cause progressive muscle fatigue with age or loss of function. It is possible that fatigue was undetectable by our methods. An alternative explanation is that what patients describe as fatigue may be caused by factors outside the neuromuscular system. Such factors may include chronic respiratory insufficiency with hypoventilation and carbon dioxide retention as well as chronic malnutrition and negative nitrogen balance.

Making treatment decisions with HIV infection: a pilot study of patient preferences

The importance of understanding patient preferences in making treatment decisions is widely recognized. This pilot study utilized a forced-choice paired-comparison method in which 28 ambulatory HIV-infected patients were given a computer-generated presentation of all possible pairs of eight different treatment options for their disease (FDA-approved medications, experimental and alternative treatments, no medication). Preferences were analyzed using binary multidimensional scaling analyses to determine the utility of paired-comparison models for the study of treatment-decision making and to identify factors influencing patient decision making. Results indicated that a three-dimensional model provided the best fit for the data. One dimension correlated with medications that raise CD4+ lymphocyte counts (r = 0.92, p < 0.001) and a second dimension correlated with frequency of dosing (r = 0.97, p < 0.0001). Patients' internal consistency of decision making was inversely correlated with severity of AIDS dementia symptoms as measured by performance on a neuropsychological test battery (r = -0.55, p < 0.0025). This finding indicates that AIDS dementia may significantly hinder patients' ability to use a rational (internally consistent) decision-making strategy in making treatment choices. Results also suggested that AIDS patients base treatment decisions primarily on the likelihood of raising CD4+ cell counts and restrictiveness of dosing regimens, but are not influenced by FDA approval status, volume of empirical support for the medications, or even possible harmful side effects. The implications of these findings for the treatment of patients with AIDS are discussed.

Purification, properties, and diagnosis of banana bract mosaic potyvirus and its distinction from abaca mosaic potyvirus

ABSTRACT Using biochemical, serological, and cytopathological evidence, we have confirmed that banana bract mosaic virus (BBrMV) is a distinct member of the family Potyviridae. Virions of a Philippine isolate of BBrMV were purified from field-infected banana cv. Cardaba. Particles were approximately 725-nm long, banded at a density equivalent to 1.29 to 1.31 g/ml in cesium chloride equilibrium gradients, and had an A(260/280) of 1.17. Yields of about 4 mg/kg were obtained from fresh or frozen leaf midrib or lamina tissue. Three major protein species with sizes of 31, 37, and 39 kDa were resolved from dissociated virions, and all reacted specifically with polyclonal antibodies to BBrMV. Infected leaf cells contained typical pinwheel inclusions. Virus-specific cDNA was amplified from field samples by reverse transcription-polymerase chain reaction (RT-PCR) assay using potyvirus degenerate primers. In plate-trapped antigen-enzyme-linked immunosorbent assay (ELISA), weak serological relationships were demonstrated between BBrMV and other members of the family Potyviridae, including abaca mosaic (AbaMV), dasheen mosaic, maize dwarf mosaic, sorghum mosaic, sugarcane mosaic, and wheat streak mosaic viruses. Despite similarities in the symptoms caused by the two viruses, AbaMV was serologically distinct from BBrMV and reacted only weakly, or not at all, with BBrMV antibodies in double-antibody sandwich (DAS)-ELISA. No cross reactions were observed when RT-PCR products from the two viruses were examined by Southern blot hybridization using BBrMV- and AbaMV-specific digoxigenin-labeled DNA probes. BBrMV was consistently associated with banana bract mosaic disease, as assessed by DAS-ELISA and Southern blot hybridization using DNA probes. The known geographical distribution of BBrMV was extended to include India (Kokkan disease) and Sri Lanka.

International Conference for the Development of a Consensus on the Management and Prevention of Severe Candidal Infections

Because of the rapidly increasing incidence of serious candidal infections, a consensus conference of 22 investigators from the United States, Europe, and Japan was held to discuss strategies for the prevention and treatment of deep-organ infections caused by Candida species. Commonly asked questions concerning the management of candidal infections were selected for discussion by the participating investigators. Possible answers to the questions were developed by the investigators, who then voted anonymously for their preferences. In certain instances, unanimity or a strong consensus was the result. In all cases, the full spectrum of responses was recorded and is presented in this report. The forms of candidal infection addressed included candidemia, candiduria, hepatosplenic candidiasis (chronic systemic candidiasis), candidal endophthalmitis, and candidal peritonitis. Prevention and treatment strategies were considered for patients who have undergone surgery, for neutropenic and nonneutropenic patients, and for patients who have undergone bone marrow and solid organ transplantation. The therapeutic roles of amphotericin B (standard and lipid formulations) and the azoles were considered.