Vitamin A and infant mortality: beyond intention-to-treat in a randomized trial

This paper investigates the effect of one dose of vitamin A on subsequent 4 month mortality in children under 6 months of age in a randomized, double-blind placebo-controlled community trial in Nepal. An earlier published intention-to-treat analysis showed no benefit, but ignored the information on actual receipt of treatment. Structural failure time models (Robins and Tsiatis, '91) use randomization based inference and incorporate compliance information which is possibly selective. The data presented here offer some new challenges for this approach: ward-based randomization induces correlation between survival outcomes; and the actual receipt of vitamin A dose is not always recorded. To tackle the problem of the clustered survival data we consider a robust version of the structural parameter vector estimator. A sensitivity analysis captures boundaries for the estimated structural parameters reflecting a range of potential values of children whose true receipt of treatment is unknown. The analysis suggests that the effect of vitamin A was beneficial in the beginning of the trial but towards the end of the trial there was a reversal of this effect.

Late fields of the magnetocardiographic QRS complex as indicators of propensity to sustained ventricular tachycardia after myocardial infarction

INTRODUCTION

Magnetocardiographic (MCG) mapping is a new method to record cardiac signals. This study examined the association of MCG late fields with the propensity to sustained ventricular tachycardia (VT) after myocardial infarction (MI).

METHODS AND RESULTS

One hundred patients with remote MI were studied, 38 with and 62 without history of VT. High-resolution MCG and signal-averaged ECG (SAECG) as a comparative method were recorded. Time-domain parameters describing the abnormal low-amplitude end QRS activity, MCG late fields, and SAECG late potentials were analyzed. Late field parameters differed significantly between the patient groups: filtered QRS duration was 137 +/- 26 msec in the VT group and 110 +/- 18 msec in the control group (P < 0.001), and root mean square amplitude of the last 40 msec was 260 +/- 170 and 510 +/- 360 fT (P < 0.001), respectively. The optimal MCG parameter combination yielded a sensitivity of 92% and a specificity of 61% in classification to the VT group, whereas those for SAECG were 63% and 66%. In a subgroup of 63 patients with marked left ventricular dysfunction and comparable stage of coronary heart disease, only MCG (sensitivity 73%, specificity 67%) but not SAECG could assign a patient to the VT group.

CONCLUSION

Late fields of the MCG QRS complex indicate propensity to life-threatening arrhythmias in post-MI patients. This discriminative ability persists in the presence of severe left ventricular dysfunction where ECG late potentials lose their informative value. MCG late field analysis is a potential new method for noninvasive risk assessment in post-MI patients.

Very low birthweight, bronchopulmonary dysplasia and health in early childhood

The impact of very low birthweight (<1500g) and bronchopulmonary dysplasia (BPD) on respiratory morbidity, on need of medical resources and rehabilitation at 2-8 y of age, and on the everyday life of the child's family was evaluated by means of a questionnaire addressed to parents of 143 very low birthweight children, 36 of whom had had BPD at 28 d postnatal age, and 131 term controls. In the preceding year, respiratory symptoms provoked by exercise, use of inhaled medications, regular follow-up visits and hospitalizations, need for physiotherapy, occupational therapy, technical aids and financial support from society had been more common in the very low birthweight groups compared to children born at term. Children with BPD suffered respiratory infections and needed antibiotic courses more frequently than term controls. Repeated antibiotic courses, physiotherapy and occupational therapy were more common among very low birthweight children with BPD than among those without. Concern for the child and the impact of the child's health on his or her everyday life and the parents' work and education were more often reported in target families than in term controls. Compared to term families, more parents in the BPD group felt that the child's health affected the pasttimes of other family members. To the families concerned, very low birthweight and BPD constitute a significant burden far beyond the neonatal period. Validated scales for the assessment of their quality of life are needed to develop supportive measures and to evaluate the effects of such interventions.

Regulation of PTEN expression in neuronal apoptosis

PTEN phosphatase is a tumor suppressor gene that dephosphorylates phosphatidylinositol phosphates. PTEN restrains the function of a major antiapoptotic and survival pathway involving phosphoinositide 3-kinase and Akt kinase. Our purpose was to find out whether apoptotic inducers affect the expression of PTEN in cerebellar granule neurons and neuroblastoma 2a cells (Neuro-2a). PTEN mRNA expression showed a major 5.5-kb and a lower abundance 2.5-kb transcripts. In Neuro-2a cells, serum withdrawal induced a prominent, continuous decrease both in 5.5- and 2.5-kb transcripts of PTEN mRNA. Simultaneously, the expression level of 56-kDa PTEN protein decreased in Neuro-2a cells. The decrease in PTEN expression precedes apoptotic changes observed after serum withdrawal. On the contrary, okadaic acid and etoposide only slightly affected the expression of PTEN although they induce a prominent apoptosis in Neuro-2a cells. In cerebellar granule neurons, okadaic acid treatment induced a prominent increase in PTEN mRNA expression after 6-h treatment, both at the 5.5- and 2.5-kb transcripts. The early response in PTEN mRNA expression disappeared in 5.5-kb transcripts already at 12 h and in the case of 2.5-kb transcripts it lasted up to 24 h. Potassium deprivation, known to induce apoptosis in cerebellar granule cells, did not affect PTEN mRNA expression but together with serum deprivation induced a clear decrease in the 5. 5-kb PTEN transcripts. It seems that the changes in PTEN expression level and neuronal apoptosis are not related to each other in general but the expression of PTEN phosphatase seems to regulate certain apoptotic signals affecting phosphoinositide 3-kinase function.

Bioelectromagnetic localization of a pacing catheter in the heart

The accuracy of localizing source currents within the human heart by non-invasive magneto- and electrocardiographic methods was investigated in 10 patients. A non-magnetic stimulation catheter inside the heart served as a reference current source. Biplane fluoroscopic imaging with lead ball markers was used to record the catheter position. Simultaneous multichannel magnetocardiographic (MCG) and body surface potential mapping (BSPM) recordings were performed during catheter pacing. Equivalent current dipole localizations were computed from MCG and BSPM data, employing standard and patient-specific boundary element torso models. Using individual models with the lungs included, the average MCG localization error was 7+/-3 mm, whereas the average BSPM localization error was 25+/-4 mm. In the simplified case of a single homogeneous standard torso model, an average error of 9+/-3 mm was obtained from MCG recordings. The MCG localization accuracies obtained in this study imply that the capability of multichannel MCG to locate dipolar sources is sufficient for clinical purposes, even without constructing individual torso models from x-ray or from magnetic resonance images.

Nonfluoroscopic localization of an amagnetic stimulation catheter by multichannel magnetocardiography

This study was performed to: (1) evaluate the accuracy of noninvasive magnetocardiographic (MCG) localization of an amagnetic stimulation catheter; (2) validate the feasibility of this multipurpose catheter; and (3) study the characteristics of cardiac evoked fields. A stimulation catheter specially designed to produce no magnetic disturbances was inserted into the heart of five patients after routine electrophysiological studies. The catheter position was documented on biplane cine x-ray images. MCG signals were then recorded in a magnetically shielded room during cardiac pacing. Noninvasive localization of the catheter's tip and stimulated depolarization was computed from measured MCG data using a moving equivalent current-dipole source in patient-specific boundary element torso models. In all five patients, the MCG localizations were anatomically in good agreement with the catheter positions defined from the x-ray images. The mean distance between the position of the tip of the catheter defined from x-ray fluoroscopy and the MCG localization was 11 +/- 4 mm. The mean three-dimensional difference between the MCG localization at the peak stimulus and the MCG localization, during the ventricular evoked response about 3 ms later, was 4 +/- 1 mm calculated from signal-averaged data. The 95% confidence interval of beat-to-beat localization of the tip of the stimulation catheter from ten consecutive beats in the patients was 4 +/- 2 mm. The propagation velocity of the equivalent current dipole between 5 and 10 ms after the peak stimulus was 0.9 +/- 0.2 m/s. The results show that the use of the amagnetic catheter is technically feasible and reliable in clinical studies. The accurate three-dimensional localization of this multipurpose catheter by multichannel MCG suggests that the method could be developed toward a useful clinical tool during electrophysiological studies.

QRS amplitude and volume changes during hemodialysis

BACKGROUND

According to several studies the QRS amplitude of the ECG increases during hemodialysis. The detailed background to this phenomenon has not been defined. Two main mechanisms have been suggested: myocardial ischemia and volume changes. New noninvasive technologies make possible a comparison of QRS complex changes synchronously with myocardial ischemia and extracellular water (ECW)/blood volume (BV) changes during hemodialysis.

METHODS

In this study hemodialysis-related changes in body weight, biochemical blood variables, BV, ECW, ST segment and QRS complex were analyzed in 15 patients (age 36-76, time on dialysis 0-6 years) undergoing chronic hemodialysis treatment. QRS complex and ST segment changes were measured using a dynamic vectorcardiographic monitoring system. The ECG parameters measured were QRS vector difference (QRS-VD) and ST vector magnitude (ST-VM6). Bioimpedance analysis was used to detect changes in the ECW. Continuous measurement of BV changes was implemented using an on-line optical reflection method based on the reflection of infrared light by erythrocyte membranes. Blood hemoglobin (B-Hb), hematocrit (B-Hcr), plasma sodium (P-Na), chloride (P-Cl), magnesium (P-Mg), potassium (P-K), ionized calcium (P-iCa), phosphate (P-Pi), creatinine (P-Crea) and urea (S-Urea) were monitored.

RESULTS

The mean QRS-VD increase during the dialysis session was almost fourfold (372 +/- 300%) from 4.16 +/- 2. 40 to 15.60 +/- 7.0 microVs (p < 0.001). This change was due to a change in amplitude, since the duration of the QRS complex did not alter significantly. The correlation between the changes in QRS-VD and body weight from the start to the end of the dialysis session was moderate and statistically significant (r = -0.55, p < 0.05). The correlation between the changes in QRS-VD and ECW varied from r = -0.67 to -0.97, being statistically significant in all patients (p < 0.001). The correlation between BV and QRS-VD was assessed at one minute intervals during the dialysis and varied from r = -0.22 to -0. 98, being significant in 14 of the 15 patients (p < 0.001). Significant ST segments alterations (ST-VM6 elevation > 100 microV) did not occur during dialysis. Laboratory parameters reflecting volume and osmotic changes during hemodialysis correlated with QRS-VD change: B-Hcr (r = 0.56, p < 0.05), B-Hb (r = 0.63, p < 0.05), P-Na (r = 0.62, p < 0.05) and S-Urea (r = -0.62, p < 0.05).

CONCLUSIONS

The increase in QRS complex amplitude during hemodialysis is correlated to reduced ECW. The mechanism involved is most probably augmentation of electrical resistance of the tissues around the heart caused by loss of interstitial fluid.

Frequency and risk factors in bronchopulmonary dysplasia in a cohort of very low birth weight infants

Frequency and perinatal risk factors in bronchopulmonary dysplasia (BPD) were retrospectively evaluated in a cohort of 242 infants with birth weights less than 1501 g born in one hospital in 1990-1994. At 28 days' postnatal age, 30.7% (59/192) of the infants alive received oxygen supplementation and showed typical radiological changes in chest X-rays. At 36 weeks' corrected gestation, 13.0% (24/184) of the survivors fulfilled these criteria. In multivariate analysis, low birth weight and gestational age, male sex, packed red cell infusions and long duration of ventilator therapy were correlated with an increased risk of BPD at 28 days' postnatal age. Only 49% of the infants with BPD had had respiratory distress syndrome, and 49% of them recovered from BPD by 36 weeks' corrected gestational age. Preeclampsia, low birth weight, rapid birth weight recovery, packed red cell infusions, long duration of ventilator therapy, patent ductus arteriosus and hyperoxia were associated with BPD beyond 36 weeks' corrected gestation. No infant born small for gestational age recovered from BPD before 36 weeks' corrected gestation. The frequency of BPD at 28 days' postnatal age seems to be increasing, but half of the patients recover before term. Factors other than respiratory distress syndrome, especially small birth weight, early weight gain and possibly intrauterine growth retardation are becoming more important risk factors of BPD beyond 36 weeks' corrected gestation.

Expression of transcriptional repressor protein mSin3A but not mSin3B is induced during neuronal apoptosis

mSin3 proteins have an important role in transcriptional repression mediated by histone deacetylation. Our purpose was to find out whether apoptosis affects the expression of mSin3 proteins in neuroblastoma 2a cells. We observed that neuronal apoptosis, induced by serum withdrawal or by treatment with etoposide, okadaic acid or trichostatin A, induced a prominent increase in mSin3A protein expression but did not affect the level of mSin3B protein. Trichostatin A, an inhibitor of histone deacetylases, induced the most prominent upregulation of mSin3A protein. Metabolic labeling and immunoprecipitation of mSin3A showed a marked increase in the synthesis of mSin3A protein in agreement with the immunoblotting results. Interestingly, the expression of mSin3A preceded the activation of caspase-3 and the execution phase of neuronal apoptosis. These results suggest that the expression of mSin3A proteins may provide a regulation mechanism to enhance transcriptional repression or silencing of genes during neuronal apoptosis, as well as during degenerative diseases.

Magnetocardiographic pacemapping for nonfluoroscopic localization of intracardiac electrophysiology catheters

The purpose of the study was to validate, in patients, the accuracy of magnetocardiography (MCG) for three-dimensional localization of an amagnetic catheter (AC) for multiple monophasic action potential (MAP) with a spatial resolution of 4 mm2. The AC was inserted in five patients after routine electrophysiological study. Four MAPs were simultaneously recorded to monitor the stability of endocardial contact of the AC during the MCG localization. MAP signals were band-pass filtered DC-500 Hz and digitized at 2 KHz. The position of the AC was also imaged by biplane fluoroscopy (XR), along with lead markers. MCG studies were performed with a multichannel SQUID system in the Helsinki BioMag shielded room. Current dipoles (5 mm; 10 mA), activated at the tip of the AC, were localized using the equivalent current dipole (ECD) model in patient-specific boundary element torso. The accuracy of the MCG localizations was evaluated by: (1) anatomic location of ECD in the MRI, (2) mismatch with XR. The AC was correctly localized in the right ventricle of all patients using MRI. The mean three-dimensional mismatch between XR and MCG localizations was 6 +/- 2 mm (beat-to-beat analysis). The co efficient of variation of three-dimensional localization of the AC was 1.37% and the coefficient of reproducibility was 2.6 mm. In patients, in the absence of arrhythmias, average local variation coefficients of right ventricular MAP duration at 50% and 90% of repolarization, were 7.4% and 3.1%, respectively. This study demonstrates that with adequate signal-to-noise ratio, MCG three-dimensional localizations are accurate and reproducible enough to provide nonfluoroscopy dependant multimodal imaging for high resolution endocardial mapping of monophasic action potentials.

Neuronal apoptosis induced by histone deacetylase inhibitors

Histone acetylation has a key role in transcriptional activation, whereas deacetylation of histones correlates with the transcriptional repression and silencing of genes. Genetic repression may have an important role in neuronal aging, atrophy and degenerative diseases. Our aim was to study how histone deacetylase inhibitors, trichostatin A (TSA) and sodium butyrate, affect the metabolism of cultured rat cerebellar granule neurons and mouse Neuro-2a neuroblastoma cells. Cultured cells were exposed to 1-3 microM TSA and 1-10 mM butyrate for 1-2 days. Both of these inhibitors induced a prominent neuronal apoptosis characterized by morphological changes as well as by the activation of caspase-3 protease and subsequent cleavage of poly(ADP-ribose) polymerase, one of the caspase-3 targets. Caspase-3 activities reached the highest level on the second day after treatment, higher in the proliferating neuroblastoma cells than in the cerebellar granule neurons. Caspase-3 activation and morphological changes were prevented by cycloheximide treatment. Histone deacetylase inhibitors increased the DNA-binding activities of AP1, CREB and NF-kappaB transcription factors. These observations show that an excessive level of histone acetylation induces a stress response and an apoptotic cell death in neuronal cells.

Glutamate-induced changes in the DNA-binding complexes of transcription factor YY1 in cultured hippocampal and cerebellar granule cells

Transcription factor YY1 is a zinc finger protein which can interact and form complexes with several proteins. Depending on its binding partners, YY1 can either activate or repress the transcription of several genes. We have studied whether the regulation of YY1 is affected by glutamate-induced excitotoxic insult in cultured primary hippocampal and cerebellar granule cells. Using electrophoretic mobility shift (EMSA) technique, we observed that glutamate treatment induced a dramatic increase in the YY1-binding activity of the smallest of three complexes both in the hippocampal and cerebellar granule cells. Two larger complexes disappeared after glutamate treatment in cerebellar granule cells. Supershift assays with specific YY1 antibody showed that all three complexes contained YY1 protein. Western blot assays did not show any changes in the nuclear levels of YY1 protein. Our results show that excitotoxic treatment affects the regulation of YY1 transcription factor and suggest that YY1 is a significant nuclear target for stress-related signaling pathways in neuronal degeneration.

Down-regulation of Ku autoantigen, DNA-dependent protein kinase, and poly(ADP-ribose) polymerase during cellular senescence

During aging and cellular senescence mutations accumulate in genomic and mitochondrial DNA. Ku autoantigens, DNA-dependent protein kinase, and poly (ADP-ribose) polymerase have an essential role in DNA damage recognition. Our purpose was to find out whether cellular senescence of fibroblasts affects the protein components that recognize DNA damage and induce the repair process. We compared presenescent and replicatively senescent human WI-38 fibroblasts with each other and with SV-40 immortalized and serum-deficient quiescent WI-38 cells. Our results showed that replicative senescence significantly decreased the nuclear level of both p70 and p86 components of Ku autoantigen. SV-40 immortalization and cellular quiescence did not affect the level of the p86 component but slightly increased that of p70. Both replicative senescence and cellular quiescence decreased the activity of DNA-dependent protein kinase in WI-38 fibroblasts. On the other hand, SV-40 immortalization increased the activity of DNA-dependent protein kinase. The protein level of poly(ADP-ribose) polymerase (PARP) was strongly decreased in replicatively senescent fibroblasts. Quiescence of early-passage fibroblasts also slightly reduced the protein level of PARP. Apoptosis was not observed in replicatively senescent fibroblasts. Our results show that replicative senescence and to some extent cellular quiescence down-regulate the recognition system of DNA damage involving Ku autoantigens, DNA-dependent protein kinase, and PARP and hence could enhance the accumulation of DNA damage during aging.

Intake of fatty acids and risk of coronary heart disease in a cohort of Finnish men. The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study

The relation of intakes of specific fatty acids and the risk of coronary heart disease was examined in a cohort of 21,930 smoking men aged 50-69 years who were initially free of diagnosed cardiovascular disease. All men participated in the Finnish Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study and completed a detailed and validated dietary questionnaire at baseline. After 6.1 years of follow-up from 1985-1988, the authors documented 1,399 major coronary events and 635 coronary deaths. After controlling for age, supplement group, several coronary risk factors, total energy, and fiber intake, the authors observed a significant positive association between the intake of trans-fatty acids and the risk of coronary death. For men in the top quintile of trans-fatty acid intake (median = 6.2 g/day), the multivariate relative risk of coronary death was 1.39 (95% confidence interval (CI) 1.09-1.78) (p for trend = 0.004) as compared with men in the lowest quintile of intake (median = 1.3 g/day). The intake of omega-3 fatty acids from fish was also directly related to the risk of coronary death in the multivariate model adjusting also for trans-saturated and cis-monounsaturated fatty acids (relative risk (RR) = 1.30, 95% CI 1.01-1.67) (p for trend = 0.06 for men in the highest quintile of intake compared with the lowest). There was no association between intakes of saturated or cis-monounsaturated fatty acids, linoleic or linolenic acid, or dietary cholesterol and the risk of coronary deaths. All the associations were similar but somewhat weaker for all major coronary events.

Age-related changes in the regulation of transcription factor NF-kappa B in rat brain

Aging process involves an increase in stress at cellular level. We studied whether aging affects the regulation of stress responsive transcription factor NF-kappa B in brain samples of Wistar rats. Hippocampus, cerebellum, and temporal and frontal lobes of cortex were studied. We observed a significant up-regulation in the constitutive, nucleus-located NF-kappa B binding activity in 30-month-old Wistar rats compared to young and 18-month-old rats. The increase was most prominent in cerebellum and in frontal cortex, but age-related changes did not occur in hippocampus. Inducible, cytoplasmic NF-kappa B binding activity was not affected by aging in any of the samples studied. Western blot assays did not show any age-related changes in the nuclear level of p50, p52, and p65 protein components of NF-kappa B complex. Cytoplasmic level of inhibitory I kappa B-alpha was also unaffected. The increase in nuclear constitutive NF-kappa B binding activity during aging may be related to the NF-kappa B driven cellular response to adapt neurons against apoptotic pressure, as observed recently in several apoptotic conditions.

Validity of diagnoses of major coronary events in national registers of hospital diagnoses and deaths in Finland

We validated diagnoses of acute myocardial infarction (AMI) and death from coronary heart disease (CHD) found in the Finnish National Hospital Discharge Register and the Register of Causes of Death from a sample of the 29,133 men participating in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. The cases were traced to hospitals and institutes performing medico-legal death cause examinations and all relevant information was collected. The cardiac events were re-evaluated according to the diagnostic criteria of the Finnish contribution to the WHO MONICA project, i.e. the FINMONICA criteria. Altogether 408 cases of non-fatal AMI (n = 217) and death from CHD (n = 191) were reviewed. In the re-evaluation 94% of them (95% confidence interval 92-96%) were diagnosed as either definite (57%) or possible (37%) AMI. Non-fatal cases were more often classified definite AMI in the review, whereas fatal cases were more often classified possible AMI. Age or trial supplementation group did not affect classification, and no secular trend was observed. In conclusion, the diagnoses of AMI and death from CHD in the registers were highly predictive of a true major coronary event defined by strict criteria, thus their use in endpoint assessment in epidemiological studies and clinical trials is justified.

Down-regulation of transcription factors AP-1, Sp-1, and NF-kappa B precedes myocyte differentiation

Terminal differentiation of myocytes involves withdrawal from the cell cycle, induction of myogenin expression, and finally formation of myotubes. To study the factors that regulate the initial phase of muscle differentiation, we analyzed the binding activities of transcription factors AP-1, Sp-1, and NF-kappa B in L6, C2C12, and rhabdomyosarcoma BA-Han-1C cells. Temporal changes in transcription factor binding activities were compared to the activation of myogenin promoter-driven CAT reporter gene and the expression level of myogenin, a master gene of myogenic differentiation. We observed a prominent decrease in the nuclear binding activities of AP-1, Sp-1, and NF-kappa B already 12 to 24 h after the transfer of cells to differentiation medium. The response was very similar in L6 and C2C12 myocytes and in BA-Han-1C rhabdomyosarcoma cells. The down-regulation clearly preceded the activation of myogenin promoter and the induction of myogenin and retinoblastoma expression, as well as the initiation of myocyte fusion. Cholera toxin and okadaic acid, established inhibitors of myogenin expression and muscle differentiation, strongly up-regulated the binding activities of AP-1, Sp-1, and NF-kappa B in differentiation medium. Myogenin expression and myocyte fusion were also inhibited. Levels of nuclear c-Fos and c-Jun proteins, components of the AP-1 complex, showed a prominent decrease already after 12 h in differentiation medium. These results show that the down-regulation of the proliferation-promoting transcription factors is a prerequisite to the initiation of myocyte differentiation.

Intake of dietary fiber and risk of coronary heart disease in a cohort of Finnish men. The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study

BACKGROUND

Even though dietary fiber has been hypothesized to reduce the risk of coronary heart disease, few large epidemiological studies have examined this relation with good methodology.

METHODS AND RESULTS

The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study was a randomized, double-blind, placebo-controlled trial with daily supplementation of alpha-tocopherol and/or beta-carotene. Of the participants, 21930 smoking men aged 50 to 69 years who were free of diagnosed cardiovascular disease and had completed a validated dietary questionnaire at baseline were followed for 6.1 years. We monitored the incidence of major coronary events (a combination of first nonfatal myocardial infarction and coronary heart disease death; n = 1399) and mortality from coronary heart disease (n = 635). Both entities had a significant inverse association with dietary fiber, but the association was stronger for coronary death. For men in the highest quintile of total dietary fiber intake (median, 34.8 g/d), the relative risk for coronary death was 0.69 (95% confidence interval, 0.54 to 0.88; P < .001 for trend) compared with men in the lowest quintile of intake (median, 16.1 g/d). With an adjustment for known cardiovascular risk factors, intake of saturated fatty acids, beta-carotene, vitamin C, and vitamin E did not materially change the result. Water-soluble fiber was slightly more strongly associated with reduced coronary death than water-insoluble fiber, and cereal fiber also had a stronger association than vegetable or fruit fiber.

CONCLUSIONS

These findings suggest that independent of other risk factors, greater intake of foods rich in fiber can substantially reduce the risk of coronary heart disease, and particularly coronary death, in middle-aged, smoking men.

The effect of entacapone on the disposition and hemodynamic effects of intravenous isoproterenol and epinephrine

BACKGROUND

Entacapone is a potent, selective catechol-O-methyltransferase (COMT) inhibitor. Entacapone could potentiate the hemodynamic effects of exogenously administered catecholamines, which are substrates of the COMT enzyme.

DESIGN AND METHODS

Originally, the study was to follow a placebo-controlled, randomized crossover design. Because of two cases of ventricular arrhythmia, a decision was made to terminate the study before its completion. Six subjects went through the isoproterenol and epinephrine infusions while taking placebo and five other subjects while taking entacapone. The actual design was thus one with two parallel groups with random allocation and double-blind drug administration. The subjects were given either a single dose of 400 mg entacapone or placebo 30 minutes before the start of isoproterenol or epinephrine infusions. Four dosages of epinephrine (1.5, 3, 6, or 12 micrograms/min) and isoproterenol (0.5, 1, 1.5, or 2 micrograms/min) were infused (5 minutes for each level). Heart rate and blood pressure were measured and ECG was monitored. The concentrations of isoproterenol and epinephrine in plasma were determined by HPLC.

RESULTS

The maximal increase in heart rate during isoproterenol infusion after entacapone administration (40 +/- 11 beats/min, mean +/- SD) was statistically greater (p = 0.0496) than after placebo administration (27 +/- 7 beats/min). The increase in heart rate during epinephrine infusion was 25 +/- 13 beats/min after entacapone administration and 14 +/- 9 beats/min after placebo administration (p = 0.127). There were no statistically significant differences between entacapone and placebo in blood pressure or in plasma concentrations of isoproterenol and epinephrine.

CONCLUSION

We conclude that entacapone may potentiate the chronotropic and arrhythmogenic effects of exogenously administered isoproterenol and epinephrine.

Clinical equivalence of a novel multiple dose powder inhaler versus a conventional metered dose inhaler on bronchodilating effects of salbutamol

In this study the bronchodilating effect of salbutamol (CAS 18559-94-9) after administration a single-dose (100 micrograms) from a novel multiple dose powder inhaler (MDPI; Easyhaler) and from a conventional metered dose inhaler (MDI) was compared. Forty adult asthmatic patients participated in a double-blind, randomized, cross-over, multicenter study with double-dummy technique. The study comprised two study days with a 4-h follow-up period of spirometric indices and measurements of blood pressure and heart rate. Both the powder and aerosol treatments caused a clear increase in spirometric parameters. The mean (SD) maximum forced exspiratory volume in one second (FEV1) after powder delivery was 2.82 (1.13) l and after aerosol 2.77 (1.03) l. The mean percentual change from the baseline in FEV1 was equal after both preparations. The mean area under the curve (AUC) of the absolute FEV1 values was 616 (264) and 609 (240) l x min after the powder and aerosol delivery, respectively. The treatments had no clinically significant effects on blood pressure or heart rate and were equally well tolerated. Thus the clinical effects indicate therapeutical bioequivalence of the powder and aerosol treatments. Furthermore, most patients found the handling of the MDPI device easier than or equal to that of the conventional MDI, which in all probability increase the patient compliance, which is one of the corner stones in the inhalation therapy of bronchial asthma.