Comparison of one-year efficacy and safety of atorvastatin versus lovastatin in primary hypercholesterolemia. Atorvastatin Study Group I

This double-blind study to evaluate long-term efficacy and safety of atorvastatin was performed in 31 community- and university-based research centers in the USA to directly compare a new 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (reductase inhibitor) to an accepted drug of this class in patients with moderate hypercholesterolemia. Participants remained on a cholesterol-lowering diet throughout the study. One thousand forty-nine patients were randomized to receive atorvastatin 10 mg, lovastatin 20 mg, or placebo. At 16 weeks the placebo group was randomized to either atorvastatin or lovastatin treatment. At 22 weeks, patients who had not met low-density lipoprotein (LDL) cholesterol target levels doubled the dose of reductase inhibitor. Efficacy evaluation was mean percent change from baseline in LDL cholesterol, triglycerides, total cholesterol, high-density-lipoprotein cholesterol, and apolipoprotein B (apoB). Safety profiles as determined by change from baseline in laboratory evaluations, ophthalmologic parameters, and reporting of adverse events were similar for the 2 reductase inhibitors. After 52 weeks, the atorvastatin group maintained a significantly greater reduction in LDL cholesterol (-37% vs -29%), triglyceride (-16% vs -8%), total cholesterol (-27% vs -21%), and apoB (-30% vs -22%) (p <0.05). More patients receiving atorvastatin achieved LDL cholesterol target levels than did lovastatin patients (78% vs 63%, respectively), particularly those with coronary heart disease (37% vs 11%, respectively). Atorvastatin is highly effective and well tolerated in patients with primary hypercholesterolemia with no increased risk of adverse events.

Orthodontic extrusion--a new simplified aesthetic technique

Various techniques have been described to extrude the roots of fractured teeth to facilitate prosthetic restoration. Many of these have the disadvantage of poor aesthetics, they require skill in fabrication and fitting, and there is often inadequate control over the amount of extrusion. With the technique described, root canal therapy is completed initially and a cast gold post is cemented into the root canal. The post has a channel extending from the labial to the palatal aspect. A temporary acrylic crown is fitted to restore aesthetics, and the channel is extended though the palatal and labial surfaces. An orthodontic wire framework with a horizontal strut at the level of the original incisal edge of the fractured tooth is then bonded to the adjacent abutment teeth. The amount of extrusion required is estimated and a corresponding reduction is made in the length of the acrylic temporary crown. An elastic threaded through the channel and looped over the horizontal strut of the framework provides the extrusive force. A 6 week retention period is required following the extrusion. Periodontal surgery is then carried out if necessary, and a new provisional crown is placed. The final porcelain restoration is fitted after 6 months.

A new culture method for human pancreatic islets using a biopore membrane insert

The availability of highly purified human islets has increased with the progressive improvement of isolation methods. This has provided opportunities to perform various in vitro studies on human islets. However, when islets are maintained in culture, the overgrowth of fibroblasts results in a reduced islet purity and often has an adverse effect on islet function. To reduce fibroblast growth and to maintain normal islet function, we have investigated a new three-dimensional culture technique using a noncoated transparent Biopore membrane insert (Millicell CM, Millipore). Islets were isolated from seven human pancreata and cultured for 2 months using this membrane insert. At various time intervals, the functional viability of islets was assessed by measurements of insulin released into the culture medium, static incubation assays of basal and stimulated insulin release, islet insulin contents, and insulin biosynthesis. Results were compared to those of islets cultured in hydrophobic plastic petri dishes, our standard procedure. We found that the non-coated membrane does not allow islet attachment to the surface and prevents fibroblast growth, so that islets maintain a three-dimensional structure and remain in a free-floating form. Islets cultured in a membrane insert showed a function similar to or better than that of islets cultured in plastic petri dishes.

Cerivastatin, a New Potent Synthetic HMG Co-A Reductase Inhibitor: Effect of 0.2 mg Daily in Subjects With Primary Hypercholesterolemia

BACKGROUND: Reduction of serum cholesterol, most notably low-density lipoprotein cholesterol is associated with reductions in cardiovascular morbidity and mortality. Statins have been shown to effectively reduce low-density lipoprotein cholesterol via inhibition of the hydroxymethyl-coenzyme A (HMG-CoA) reductase. Cerivastatin is the most potent HMG-CoA reductase inhibitor currently under study in the United States. METHODS AND RESULTS: A parallel group, randomized, placebo-controlled, double-blind, multicenter study was conducted to compare the efficacy and safety of three different dosing regimens of 0.2 mg/day of cerivastatin, a new HMG-CoA reductase inhibitor, in patients with hypercholesterolemia. After a 10-week diet-placebo lead-in period, 319 patients with low-density lipoprotein cholesterol >160 mg/dL were randomized to 4 weeks of treatment with one of the following regimens: cervastatin 0.1 mg twice daily, cerivastatin 0.2 mg once daily with the evening meal, cerivastatin 0.2 mg once daily at bedtime or placebo. All three active treatment groups produced statistically significant (P <.05) changes compared to aseline and placebo in total cholesterol (0.1 mg twice daily \_18.9%; 0.2 mg once daily with the evening meal: \_21.9%; 0.2 mg once daily at bedtime: \_22.1%; placebo: 0.0%), low-density lipoprotein cholesterol (0.1 mg twice daily: \_25.7%; 0.2 mg once daily with the evening meal: \_29.4%; 0.2 mg once daily at bedtime: \_30.4%; placebo: 1.4%) and high-density lipoprotein cholesterol (0.1 mg twice daily: 5.3%; 0.2 mg once daily with the evening meal: baseline and placebo, were also reduced by all active treatments (0.1 mg twice daily: \_11.6% [P =.05]; 0.2 mg once daily with the evening meal: \_11.6% [P =.05]; and 0.2 mg at bedtime: \_10.9% [P =.07]). The percentage change in total cholesterol and low-density lipoprotein cholesterol after 4 weeks of therapy for the once-daily cerivastatin groups was statistically significantly greater (P <.05) than the cerivastatin twice daily regimen. A treatment responser was seen by 1 week of therapy and was maximal by 3 weeks. The drug was well tolerated in all three dosing regimens and resulted in no significant increase in biochemical or clinical side effects compared to placebo. CONCLUSION: Cerivastatin is a novel, highly potent, well-tolerated HMG-CoA reductase inhibitor that produces low-density lipoprotein cholesterol reductions of approximately 30% when administered at 0.2 mg once a day in the evenings.

ELK and LERK-2 in developing kidney and microvascular endothelial assembly

Eph family receptor tyrosine kinases direct neuronal cell targeting, bundling and intercellular aggregation activity, yet their role in mammalian kidney development has been unexplored to date. We recently identified expression of ELK (Eph-like kinase) receptors in cultured human renal microvascular endothelial cells (HRMEC), and showed that ELK mediates their in vitro assembly into capillary-like structures in response to the exogenous ligand, LERK-2. Here we identify expression of the ELK ligand, LERK-2, in HRMEC and in primitive vascular structures of developing murine kidney. ELK and LERK-2 are expressed on endothelial progenitor cells of primitive microvasculature in a pattern similar to that of the VEGF receptor, flk-1. ELK LERK-2 and flk-1 antigens are also displayed on the branching ureteric bud epithelium; ELK and LERK-2 expression persists in mature collecting ducts, glomeruli and arterioles. To explore whether renal-derived endothelial cells may distinguish LERK-2 from the angiogenic Eck ligand, LERK-1 (B61), and whether endothelial cells from different sources may distinguish among Eph receptor ligands, we compared HRMEC and human umbilical vein endothelial cell (HUVEC) responses in an in vitro capillary-like assembly assay. HRMEC endothelial cells assembled capillary-like structures in response to LERK-2, but not LERK-1, under conditions that promoted HUVEC to assemble in response to LERK-1, but not LERK-2. Therefore, responses mediated through specific Eph family receptors (ELK and Eck) are discriminated by endothelial cells from different vascular bed sources. ELK and its ligand, LERK-2, are spatially and temporally coordinated in expression and may function in morphogenesis of the renal microvasculature.

A cephalometric study of children with chronic perennial allergic rhinitis

This study compared the cephalometric features of a group of one hundred children aged from six to sixteen years suffering from chronic perennial allergic rhinitis of differing grades of severity with those of 99 control subjects of similar age. Both samples were drawn from a Children's Hospital which has a large population of patients with chronic perennial allergic rhinitis attending the Allergy Clinic. Lateral cephalometric head films of each subject were recorded and a series of measurements made to assess and compare the craniofacial morphology. The data were statistically analysed. The study found that the children suffering from chronic perennial allergic rhinitis had longer and more divergent facial patterns as well as horizontally shorter maxillae than those in the control group. In addition, those parameters associated with increased vertical dimension and hyperdivergence demonstrated progressive expression with increasing severity of the chronic perennial allergic rhinitis.

Time-related bond strengths of light-cured and chemically cured bonding systems: an in vitro study

The immediate bond strengths achieved with a light-cured bonding system and those at selected time intervals over a 24-hour period were assessed and compared with the bond strengths produced by a chemically cured system over a similar period. Mesh-backed metal orthodontic brackets were bonded with the light-cured system to 60 teeth, and 50 teeth had similar brackets bonded with a chemically cured system. Shear/peel bond strengths for each were determined with the instron Universal testing machine (Instron Corp., Canton, Mass.) and these were compared statistically. The bond strengths for the chemically cured system were initially low, but these increased with time. The light-cured sample displayed initial bond strengths of sufficient magnitude to withstand the immediate application of orthodontic forces, and these bond strengths also increased with time. There was no significant difference between the bond strengths achieved by the chemically cured and light-cured systems at the 10-minute, 60-minute, and 24-hour intervals.

Ligand activation of ELK receptor tyrosine kinase promotes its association with Grb10 and Grb2 in vascular endothelial cells

ELK is a member of the Eph-related tyrosine kinase family that includes receptors signaling axonal guidance, neuronal bundling, and angiogenesis. We recently identified ELK expression in human renal microvascular endothelial cells and sought to identify intracellular proteins through which it signals responses. The cytoplasmic domain of ELK was used as "bait" in a yeast two-hybrid screen to identify interactive proteins expressed from a randomly primed embryonic murine library (E9.5-10.5). Among interactive products of 76 cDNAs characterized, 10 nonidentical, overlapping clones encoded the SH2 domain of the recently reported Grb10 adapter protein, and an additional 3 encoded Grb2. A self-phosphorylated recombinant, baculovirus-expressed GST-ELKcy fusion protein bound Grb10 and Grb2 from human renal microvascular endothelial cell extracts, while the unphosphorylated fusion form did not. Site-directed mutation identified Tyr-929 as a putative phosphorylation site required for Grb10, but not Grb2, interaction in yeast and recombinant protein assays. The ELK ligand, LERK-2/Fc, stimulated tyrosine phosphorylation of ELK, and recruitment of Grb10 and Grb2 to endothelial ELK receptors recovered by wheat germ agglutinin lectin and immunoprecipitation. These findings define ligand-activated interaction between ELK and the SH2 domains of Grb2 and the newly identified Grb10 protein that shares homology with a Caenorhabditis elegans gene product implicated in neural cell migration.

The lipid-lowering effects of atorvastatin, a new HMG-CoA reductase inhibitor: results of a randomized, double-masked study

This randomized, placebo-controlled, double-masked, parallel-group trial assessed the serum cholesterol-lowering effects of atorvastatin, a new 3-hydroxy-3-methylglutaryl coenzyme. A reductase inhibitor, over 26 weeks in patients with primary hypercholesterolemia. Thirty-nine patients from four centers in the United States were originally randomized to one of two treatment groups and received either atorvastatin 10 mg (20 patients) or placebo (19 patients) once daily. Atorvastatin rapidly and significantly reduced serum total cholesterol, low-density lipoprotein cholesterol (LDL-C), and apolipoprotein B levels. LDL-C was reduced 35% with atorvastatin 10 mg compared with a 0% increase in LDL-C in the placebo group. Atorvastatin significantly reduced triglyceride levels, with improvements occurring over time. At 26 weeks, triglyceride levels were reduced by 21% with atorvastatin treatment compared with a 14% increase with placebo. The drug was well tolerated and no clinically significant laboratory abnormalities were detected.

Peer review in a New York chapter of the ACNM 1987-1994

This article is an overview of peer review in Region 2, Chapter 1 (New York City, Nassau, Suffolk, and Westchester counties) of the New York chapter of the American College of Nurse-Midwives from 1987 to 1994. It includes a review of the legal and ethical issues, philosophy, process, standards, and procedure for site review. Problems, findings, and the future of peer review in New York are discussed.

The mental health of children in foster care: a comparison with community and clinical samples

OBJECTIVE

To determine whether the psychiatric profile of children in foster care is more similar to clinical or community profiles.

METHOD

Caregiver and teacher ratings of DSM-III-R externalizing and internalizing symptoms were collected for 3 groups of children: children in foster care, children assessed at a children's mental health centre, and a community sample.

RESULTS

Children in foster care approximated the numbers and types of symptoms of the clinical sample. Coming from a family on social assistance, having a parent with a criminal history, and being of the male gender were correlated with higher externalizing and internalizing symptom scores independent of group membership. Group membership accounted for less than 5% of the variance in psychiatric symptom scores.

CONCLUSIONS

The high symptom burden of children in care is substantially attributable to their high-risk histories, and treatment should be designed with this in mind.

[Controlled dermabrasion with a newly developed erbium-YAG-laser system. Report of preliminary experiences]

The reasons for the development of pulsed lasers, as well as the differences between them and continuous lasers are discussed. Both the advantages and disadvantages of such lasers, as well as the indications are presented. Furthermore, the erbium-yag laser is contrasted to the ultra-pulsed CO2 laser. Two case reports demonstrate the effectiveness of the erbium-yag laser.

Orthodontic brackets bonded to glazed and deglazed porcelain surfaces

Edgewise orthodontic brackets were bonded with a light activated composite resin to 100 glazed and 100 deglazed feldspathic porcelain blocks for an in vitro comparative determination of shear/peel bond strengths. The independent variables studied were porcelain surface preparation and the time interval between activation of the composite resin and the debonding procedure. The initial shear/peel bond strength achieved on bonding to deglazed porcelain was statistically significantly greater than that on bonding to glazed porcelain (p<0.05), but after the 10-minute interval, the bond strength in the glazed porcelain sample was greater than in the deglazed sample. Many more porcelain fractures occurred on deglazed porcelain (71%) than on glazed porcelain (36%) during bond strength determination. Scanning electron microscopy evaluation suggests that deglazing does not substantially increase micromechanical adhesion of the composite resin. Bond strength adequate to withstand the application of orthodontic forces were achieved when bonding to glazed porcelain. This study indicates that deglazing may not be necessary for attachment of orthodontic brackets to porcelain surfaces.

Probucol normalizes cholesteryl ester transfer in IDDM

OBJECTIVE

Cholesteryl ester transfer (CET) is pathologically increased in insulin-dependent diabetes mellitus (IDDM), and the resulting enrichment of the apolipoprotein B-containing lipoproteins with cholesteryl ester (CE) is believed to increase their atherogenicity. Because we have shown previously that treatment with the lipid-modifying antioxidant probucol normalizes CET in nondiabetic patients with hypercholesterolemia, we sought to determine whether the same beneficial effects could be achieved in IDDM.

RESEARCH DESIGN AND METHODS

CET was measured by both mass and isotopic assay in eight normolipidemic (triglyceride, 102; cholesterol, 192; high-density lipoprotein [HDL] cholesterol, 45 mg/dl) IDDM patients (fructosamine 495 +/- 146 mumol/l; normal 174-286) before and after 2 months of treatment with probucol (1.0 g/day).

RESULTS

Before treatment, CET was accelerated abnormally (P < 0.001). As expected, probucol decreased plasma (-13%; P < 0.025) and HDL2 cholesterol levels (-52%; P < 0.025) and the concentration of lipoprotein A-I particles (P < 0.025). In conjunction with these changes, CET fell dramatically in all subjects (mass assay: -94%; isotopic assay: -22%, P < 0.001) with no change in the mass of cholesteryl ester transfer protein (CETP) (pretreatment 2.91 +/- 0.97 vs. posttreatment 3.21 +/- 1.03 micrograms/ml). Glycemic control, however, improved significantly (fructosamine 409 +/- 85 mumol/l, P < 0.025).

CONCLUSIONS

Because it is believed that accelerated CET promotes the formation of apolipoprotein B-containing lipoproteins enriched with atherogenic CE, the capacity of probucol to reverse this functional abnormality without adversely affecting glycemic control suggests that it has a place in the therapy of IDDM.

AF150(S): a new functionally selective M1 agonist improves cognitive performance in rats

This study was aimed at evaluating the ability of a new functionally selective partial M1 agonist, AF150(S), to reverse cognitive impairments in rats. A memory deficits-induced animal model was used that involved AF64A (3 nmol/2 microliters/side) bilaterally injected ICV. AF150(S) was administered PO. The pharmacodynamic profile of the compound was established and its general toxicity was evaluated. Animals were tested on three behavioral tasks: step-through passive avoidance, Morris water maze reference memory paradigm, and radial arm maze working memory paradigm. The sign-free dose of AF150(S) was > 40 mg/kg whereas the LD50 was > 500 mg/kg. In comparison, the effective dose in reversing performance impairments on the various tasks was much lower (0.5-5 mg/kg). The data suggest that AF150(S) possesses potential cognitive enhancement abilities, probably due to a specific increase of cholinergic function.

Fetal pancreas transplantation in miniature swine. V. The functional and immunodulatory effects of ultraviolet light on fetal pig islets

We have used the pig as a large animal model for studies of fetal pancreas transplantation. Fetal pig pancreas (FPP) has also been proposed as a potential source of endocrine cells for the treatment of diabetes mellitus. Among the approaches to prevent rejection, the irradiation of donor islets with ultraviolet B light has been used for its immunomodulating properties. Our goal was to study in vitro the effects of UV-B irradiation of FPP on the function and immunogenicity of the tissue. FPP were collagenase-digested and cultured for 1-29 days prior to UV-B irradiation. Static incubation tests were used to measure glucose-theophylline stimulated insulin release. Data obtained at 300 J/m2 revealed no impairment of insulin release (78% to 129% of controls, P = ns). At 500 J/m2, a significant reduction of glucose-theophylline stimulated insulin release was observed with 50-60-day-old FPP (35% to 66% of controls, P < 0.05), but not with 80-day-old FPP (93% of controls, P = ns). At both doses, prolonged observation in culture did not show any alteration of the growth and proliferation of islet cell clusters. UV-irradiated (300 J/m2) adult and fetal pig islet allografts released C-peptide and survived > 200 days. The immunogenicity of irradiated tissues was determined in vitro with allogeneic mixed islet-lymphocyte cultures (MILC). Proliferative responses of allogeneic lymphocytes to UV-irradiated FPP were very significantly decreased by 52-91% at both 300 and 500 J/m2 doses. This effect was observed from 1 to 10 days following UV irradiation and was not modulated by exposure of the tissues to gamma-interferon. We conclude that UVB-irradiation of FPP at a dose of 300 J/m2 does not alter its endocrine function and growth and is effective in reducing tissue immunogenicity. This treatment may be a useful approach for fetal islet transplantation in large animal models.

Effect of simvastatin on Lp(a) concentrations

The effect of HMG-CoA reductase inhibitors on Lp(a) concentrations is controversial, with some studies showing an increase and others showing no effect on Lp(a) concentrations. Many of these studies have been limited by small sample size and the lack of a prospective design. We evaluated the effect of four treatments: (1) placebo, (2) simvastatin 10 mg PO QPM, (3) simvastatin 20 mg PO QAM, and (4) simvastatin 20 mg PO QPM on Lp(a) concentrations in a prospective, randomized, controlled clinical trial of 24 weeks in 343 subjects in 28 clinical sites in the United States. Simvastatin was not associated with a change in Lp(a) concentrations relative to placebo. These results were not affected by controlling for race, initial Lp(a) level, or urinary albumin excretion. Simvastatin significantly reduced low-density lipoprotein (LDL) cholesterol levels (10 mg PO QPM: -27.6%; 20 mg PO QAM: -28.1%; and 20 mg PO QPM: -34.3%, all p < 0.001). It was concluded that in a large, randomized, controlled trial, simvastatin does not affect Lp(a) levels but markedly lowers LDL cholesterol levels.

Abrogation of allospecific T lymphocyte responses in swine by ultraviolet light-B irradiation

Immunomodulatory effects of ultraviolet-light B (UV-B) irradiation were tested in pigs, using peripheral blood lymphocytes (PBL), with special emphasis on the generation of cytotoxic T lymphocytes (CTL). Stimulator PBL were irradiated with 300-1100 Joules/m2 (J/m2) of UV-B (experimental group) and cultured for 24 h prior to being placed in mixed lymphocyte culture (MLC) to determine proliferative responses against alloantigens, or placed in bulk culture with allogeneic PBL to determine the induction of CTL. PBL that received 3000 rads gamma irradiation were used as controls. Proliferative alloresponses against gamma irradiated PBL (control group) were high, with stimulation indices (S.I.) ranging from 13.46 to 81.93. The generation of allospecific CTL activity was also high, ranging from 50.78% to 95.40%. In contrast, proliferative responses and generation of allospecific CTL were markedly inhibited (> 49.77%) against the same donor PBL irradiated with > or = 500 J/m2 UV-B. These results demonstrated that ultraviolet light treatment of pig PBL can reduce or prevent allospecific T cell proliferation as well as the generation of specific CTL, similar to results obtained with UV-B irradiation of lymphocytes in rodents.

Ultraviolet light irradiation reduces human islet immunogenicity without altering islet function

Allograft rejection is the major cause for failure in clinical islet transplantation for diabetic patients. A reduction of donor islet immunogenicity is potentially a useful approach for altering recipient's immune responses. Studies in animal models have shown the immunomodulatory properties of ultraviolet (UV)-B light that are beneficial for allograft survival. However, there is a narrow window between the doses required for immunomodulation and those toxic to beta-cells. In addition, this window varies between one species to another. Our study was designed to determine, in vitro, the UV-B dose for human islets that effectively reduces immunogenicity and maintains islet viability and normal function. Islets were isolated from donor pancreas by collagenase digestion and density gradient centrifugation on Euro-Ficoll. Static incubation and perifusion tests were used to measure glucose-stimulated insulin release. Viability was also assessed by histology and function of UV-irradiated islets transplanted under the renal capsule of athymic mice. The immunogenicity of UV-treated islets was determined in vitro with mixed islet lymphocyte culture using healthy human peripheral blood lymphocytes as responders. At a dose of 300 J/m2, both functional assays detected no impairment of insulin release. At 500 J/m2, a slight decrease of stimulated insulin release was observed only in the perifusion system. At the levels of 600 and 900 J/m2, a clear alteration was observed in both basal and stimulated insulin release. Islets irradiated at 300 J/m2 and transplanted into athymic mice stained strongly for insulin and responded to high glucose challenge in in vivo perfusion performed at two weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculosis and AIDS: the impact on the hospital social worker

The second decade of the AIDS epidemic is marked by increasing numbers of people being diagnosed with HIV infection as well as mycobacterium infection (pulmonary tuberculosis). The convergence of these two epidemics presents new challenges for social workers. Serious threat of HIV infection from occupational exposure was diminished by the knowledge of roots of disease transmission. TB, on the other hand, is an airborne infectious disease. Social workers working with patients over long periods of time in confined spaces can be at risk for contracting TB. Hospital social workers must struggle and advocate for full information regarding the incidence of risk and risk precaution. They must find ways of coping with their own emotional responses to the resurgence of TB and their own fear of exposure to avoid physical and emotional withdrawal from their HIV infected patients. This paper will address the unique impact on the worker's personal safety, the impact on the therapeutic relationship with the patient, and provide action steps for workers facing these challenges.

Indications for low-density lipoprotein apheresis

Low-density lipoprotein (LDL) apheresis offers an additional approach to lipid lowering in patients with severe hypercholesterolemia who fail to respond adequately to diet and drug therapy. Well-defined criteria for patient selection have yet to be established for LDL apheresis. This study proposes guidelines based on whether coronary artery disease (CAD) is present and on the degree of LDL cholesterol elevation after treatment with diet and maximal drug therapy. It is reasonable to consider LDL apheresis therapy for: (1) patients with CAD and LDL cholesterol levels > 190 mg/dl; (2) patients without CAD, but at high risk for disease due to an LDL cholesterol level > 250 mg/dl, a first-degree relative with premature CAD, and the presence of > or = 1 additional risk factor. In addition, LDL apheresis is recommended for the management of all patients with homozygous familial hypercholesterolemia due to the very high risk of CAD and the poor response to usual lipid-lowering treatments.