Efficacy and safety of once-daily vs twice-daily dosing with fluvastatin, a synthetic reductase inhibitor, in primary hypercholesterolemia

BACKGROUND

Fluvastatin sodium is a new, entirely synthetic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor that may be an effective lipid-lowering agent in patients whose hyperlipidemia does not respond to dietary therapy. We conducted a study to evaluate the effects of fluvastatin on lipoprotein levels in subjects with primary hypercholesterolemia and to compare the efficacy and safety of two fluvastatin sodium dosing regimens: 20 mg once daily vs 10 mg twice daily.

DESIGN

We conducted a double-blind, placebo-controlled, multicenter trial involving 207 patients with low-density lipoprotein cholesterol levels of 4.15 mmol/L (160 mg/dL) or higher despite dietary intervention and with triglyceride levels of 3.38 mmol/L or lower. Three parallel treatment groups received 6 weeks of treatment with 20 mg of fluvastatin sodium once daily, 10 mg of fluvastatin sodium twice daily, or a placebo.

RESULTS

Total cholesterol and low-density lipoprotein cholesterol levels were reduced from baseline by 16% and 22%, respectively, with 20 mg of fluvastatin sodium once daily (P < .001) and by 17% and 23%, respectively, with 10 mg of fluvastatin sodium twice daily (P < .001). Fluvastatin was well tolerated, and there were no serious clinical or biochemical adverse events ascribable to the drug.

CONCLUSIONS

Fluvastatin therapy demonstrated excellent short-term safety and efficacy in reducing total and low-density lipoprotein cholesterol levels in patients with primary hypercholesterolemia. Fluvastatin sodium, the first totally synthetic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor to be used in clinical trials, appears to be both effective and well tolerated at 20 mg/d, given in either a single or divided dose.

Swine as an allotransplantation model

Because of their anatomical and physiological similarities to humans, pigs are well suited for solving technical problems associated with clinical transplantation. The availability of genetically defined strains of miniature swine is unique with this species, and has permitted the investigation, in a large animal model, of immunological and genetic aspects of allograft rejection, clinical manifestations associated with bone marrow transplantation, and the feasibility of various approaches for induction of transplantation tolerance. Immunological assays and various reagents are also available in order to pursue these studies.

Flecainide induced atrial tachycardia with 1:1 ventricular conduction during exercise testing

Wide complex tachycardias may represent a rare proarrhythmic effect of some antiarrhythmic agents. The authors describe a patient who developed a wide complex tachycardia developing during stress testing while on therapy with flecainide, and the difficulty in interpreting the electrocardiogram. This article reviews potential proarrhythmic effects of flecainide in the treatment of atrial dysrhythmias and the difficulty in differentiating associated wide complex tachycardias.

Psychiatric disorders of children "in care": methodology and demographic correlates

This paper examines psychiatric symptoms and disorders in children in the care of a Children's Aid Society. Youth, caretaker and teacher scores on the Standardized Clinical Information System questionnaire were correlated with demographic and maltreatment data gathered from the files of children from a Children's Aid Society. Mean externalizing and internalizing scores for the study group were significantly elevated above the norm on the youth, caretaker and teacher reports; externalizing more so than internalizing. Forty-one percent to 63% of the children studied scored in the pathological range for one or more disorders. Conduct disorder was the most common disorder (30% to 50%). Within the study sample, temporary wards and children with a history of having been abused had more elevated scores. The authors conclude that children in foster care have significant psychiatric morbidity reflective of the extreme adversity and maltreatment they have experienced.

Localization of endothelin receptors in the human prostate

The objective of the present study was to localize endothelin receptors in the human prostate using quantitative autoradiography. Slide-mounted tissue sections 20 microns. in thickness were obtained from the transition zones of seven patients undergoing radical prostatectomies for low volume prostate cancer. Sarafotoxin (S6C) and BQ123 have been used to distinguish endothelin receptor subtypes (ETA and ETB). The prostatic tissue sections were incubated in four different stock solutions containing the following: 0.1 nM. 125I-endothelin-1 (125I-ET-1) (total ET-1 binding); 0.1 nM. 125I-ET-1 and 100 nM. S6C (total ETA binding); 0.1 nM. 125I-ET-1 and 1 microM. BQ123 (total ETB binding); and 0.1 nM. 125I-ET-1 and 1 microM. ET-1 (nonspecific ET-1 binding). Nonspecific binding accounted for only 12 and 15% of total 125I-ET-1 binding in the stroma and glandular epithelium. Autoradiograms were quantitatively analyzed using a computerized image analysis system. Specific radioactive densities (nCi/mg.) were determined for the stromal and glandular epithelial elements of the prostate. The specific radioactive densities of ETA and ETB binding sites in the stroma were 7.57 +/- 0.65 and 2.98 +/- 0.81. The specific radioactive densities of ETA and ETB binding sites in the glandular epithelium were 1.59 +/- 0.15 and 7.87 +/- 1.35. The present study demonstrates that the predominant endothelin receptors in the stroma and glandular epithelium are the ETA and ETB subtypes, respectively.

Effect of H-2 compatibility in autoimmune destruction of islet allografts from B10 congenic lines to nonobese diabetic mice

Autoimmune diabetes involves multiple antigens, and both cellular and humoral immune responses. Using CBA (H-2k) C57BL/6 (H-2b), and BALB/c (H-2d) newborn mouse pancreata, we previously demonstrated that acute and strong destruction of islet allografts by anti-islet autoimmunity in the nonobese diabetic (NOD) mouse H-2Kd, Db) is under the influence of major histocompatibility complex (MHC) antigens. In the current study, we have attempted to confirm these results in the absence of minor alloantigenic differences using B10 congenic strains as pancreatic donors. Pancreata from B10.BR (H-2k), C57BL/10SnJ (H-2b), and B10.D2 (H-2d) were transplanted under the kidney capsule of NOD mice within 1 month of diabetes onset. These recipients were immunosuppressed with cyclosporine (CsA) in a dosage that effectively prevents rejection of skin allograft, but not islet isograft destruction that is mediated by anti-islet autoimmunity. On day 10, the grafts were harvested and examined histologically to assess viability. Pancreatic allografts from B10.D2, sharing the H-2Kd with the NOD mouse, showed the strongest lymphocytic infiltration, and neither islets nor beta cells were found in all seven grafts. C57BL/10SnJ grafts, sharing the same H-2Db, also showed severe lymphocytic infiltration, and no intact islets, and only a few beta cells were found, as single cells, in three of eight grafts. In contrast, B10.BR grafts, completely incompatible at the H-2, showed the least infiltration, and normal islets containing many beta cells were found in 10 of 11 grafts. These results again suggested the hypothesis that islet allograft destruction by diabetic NOD mice is MHC restricted.(ABSTRACT TRUNCATED AT 250 WORDS)

The relevance of scientific research about sexual orientation to lesbian and gay rights

This essay considers the way in which scientific research is relevant to questions of lesbian and gay rights. It is specifically argued that such research is not relevant to these kinds of arguments because its results about the origins of sexual orientation do not necessarily-and should not be taken to-imply conclusions about moral entitlements. Questions about the moral and civic entitlements of gay men and lesbians are not bolstered or advanced by reference to biological accounts of sexual orientation. This is not to suggest, however, that research into the origins of sexual orientation is objectionable, only that it does not have the significance for moral rights that some have claimed.

Ocular and ocular adnexal injuries treated by United States military ophthalmologists during Operations Desert Shield and Desert Storm

BACKGROUND

Ocular and ocular adnexal injuries, both combat-related and accidental, are common during wartime. In a combat setting, the eye is particularly vulnerable to serious injury from tiny flying particles that might minimally affect other parts of the body. The purpose of this study is to examine the incidence of serious ocular and ocular adnexal injuries that occurred during Operations Desert Shield and Desert Storm.

METHODS

The authors retrospectively reviewed serious ocular and ocular adnexal injuries treated by United States Army and Navy ophthalmologists that occurred during Operations Desert Shield and Desert Storm. Only those injuries that resulted in, or would have resulted in, hospital admission because of the ocular or ocular adnexal injury alone are presented.

RESULTS

During Desert Shield, 20 patients (23 eyes) suffered serious ocular or ocular adnexal injuries compared with 160 patients (198 eyes) in Desert Storm. During Desert Storm, 78% of all serious injuries were caused by blast fragmentation from munitions. More than one third of the 98 globe lacerations reported in this article were 10 mm or less in size. Of 35 enucleations performed during Desert Storm, 94% were the result of munitions fragments.

CONCLUSIONS

During Operation Desert Storm, fragmentation wounds from munitions were the most common cause of ocular and ocular adnexal morbidity. The authors' findings indicate that polycarbonate ballistic protective eyewear could have prevented many of the ocular injuries that they report.

Adrenal gland weight and suicide

The purpose of this study is to determine if there is an anatomical correlate, namely adrenal hypertrophy, among people who have committed suicide. The adrenal weights and other relevant information were collected prospectively from 118 consecutive coroner's cases of sudden death in the province of Ontario. No statistically significant difference was found between the adrenal weights of those who had committed suicide, whether violent or non violent, and those dying suddenly of causes not self-inflicted. This was true irrespective of the age of the subjects, their sex or the centre at which the autopsy was performed. This finding does not support the findings of an earlier report of increased adrenal weight in successful suicides. The incidental finding of increased adrenal weight in all subjects is of some significance.

Identification and management of heterozygous familial hypercholesterolemia: summary and recommendations from an NHLBI workshop

Heterozygous familial hypercholesterolemia (hFH) is one of the most common monogenic disorders with serious health consequences, affecting approximately 1 in 500 persons in the United States. Persons with hFH generally manifest elevations of low density lipoprotein (LDL) cholesterol throughout their lives and have a markedly increased risk of death from coronary artery disease. The hypercholesterolemia of hFH is responsive to medication and diet, and, if detected early, aggressive LDL cholesterol control may prevent or substantially delay cardiovascular disease. However, evidence suggests that many persons with hFH are undetected and inadequately treated. On July 20-21, 1992, the National Heart, Lung, and Blood Institute sponsored a workshop to assess the current understanding of the diagnosis and management of hFH, to emphasize recommendations for identification and management that are known to be effective, and to identify opportunities and needs for intervention and research.

Prevention of overt diabetes and insulitis by intrathymic injection of syngeneic islets in newborn nonobese diabetic (NOD) mice

Based on previous studies showing that allogeneic islets transplanted into the thymus can induce donor-specific unresponsiveness, we investigated in the nonobese diabetic (NOD) mouse the effect of intrathymic islet isografts on preventing autoimmunity directed against pancreatic islet antigens. Islets prepared from newborn NOD pancreata were injected into one lobe of the thymus of 10- to 11-day-old female NOD mice (experimental group) with no immunosuppression. PBS alone was used for injection into age- and sex-matched litter mates (control group). Thirty of 32 (94%) experimental mice remained normoglycemic for over 30 weeks. Well-formed islets with no indication of insulitis were found in the thymus of these 30 mice, whereas no grafted islets were found in the 2 mice that became diabetic at 17 and 19 weeks, respectively (technical failures). In the control group, 10 of 32 (31%) mice became diabetic between 20 and 29 weeks. This diabetic incidence was, however, lower than that in our colony female mice. In the pancreas of experimental mice, 90.9% of islets were free of infiltrates, whereas only 13.1% of islets were intact in control mice. The spleens of 30-week-old experimental mice contained a slightly higher percentage of CD8+ T cells (P < 0.05) than those of control mice. Cyclophosphamide injections at 30 weeks induced diabetes in 4 of 9 experimental mice. The 2 lines of evidence, (1) marked reduction in insulitis of intrathymic islet-grafted mice and (2) induction of diabetes after treatment with cyclophosphamide, suggest that both thymic clonal deletion and peripheral tolerance may play a role in preventing diabetes.

Complex pharmacological properties of recombinant alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor subtypes

The pharmacological properties of two glutamate receptor subtypes, GluR-A/B and GluR-B/D, were examined in RNA-injected Xenopus oocytes using two-electrode voltage clamp. Concentration-response relations revealed that the potencies of L-glutamate, kainate, and alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) varied slightly between the two receptor subtypes, but the rank order of agonist potency did not. The EC50 values for GluR-A/B receptors were 3.31 microM for AMPA, 6.16 microM for glutamate, and 57.5 microM for kainate, whereas the EC50 values for GluR-B/D receptors were 5.01 microM, 32.3 microM, and 64.6 microM for AMPA, L-glutamate, and kainate, respectively. The potencies of 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo(f)quinoxaline (NBQX) were quantified by Schild analysis. The potency of NBQX at blocking currents mediated by GluR-A/B receptors changed depending on the agonist used to activate the receptors (pA2 values were as follows: for block of kainate, 7.23 +/- 0.01; L-glutamate, 6.78 +/- 0.02; AMPA, 6.95 +/- 0.02). Differences between agonists were less marked in cells expressing GluR-B/D receptors (pA2 values: kainate, 7.28 +/- 0.01; L-glutamate, 7.30 +/- 0.02; AMPA, 7.35 +/- 0.01). In each case, the slope of the Schild regression was not different from unity, consistent with competitive antagonism of these receptors by NBQX. CNQX also blocked GluR-A/B and GluR-B/D receptors competitively but was less potent than NBQX and did not differentiate between agonists or subunit combination. These data suggest that L-glutamate, kainate, and AMPA bind to different receptor substructures on recombinant AMPA receptors and that NBQX but not CNQX binds to these sites with different affinities. Moreover, because the properties of these binding sites vary between GluR-A/B and GluR-B/D receptors, our findings provide a basis for mutational analysis aimed at identifying receptor domains involved in agonist and antagonist binding.

Prostate visualization studies in males homozygous and heterozygous for 5 alpha-reductase deficiency

Male pseudohermaphrodites with 5 alpha-reductase deficiency have ambiguous genitalia and nonpalpable prostates on rectal examination, suggesting the dihydrotestosterone dependency of these structures. To clearly delineate the status of the prostate, male pseudohermaphrodites with 5 alpha-reductase deficiency had transrectal sonography of the prostate performed, and the results were compared to that of age-matched male controls. In six male pseudohermaphrodites, magnetic resonance imaging studies of the prostate were also performed. Heterozygote fathers also had transrectal sonography of the prostate performed and the results compared to age-matched controls. The prostates of the male pseudohermaphrodites appeared as platelike soft tissue structures posterior to the urethra on both prostatic ultrasound and magnetic resonance imaging. Prostatic volume, as determined on prostatic ultrasound by two different methods, was significantly smaller (approximately one-tenth) than the volume of age-matched controls. Transurethral ultrasound guided biopsy of the prostate in two affected subjects revealed stromal tissue. These results correlate with undetectable prostate-specific antigen in affected subjects, suggesting atrophic epithelium or lack of epithelial differentiation. This study demonstrates the dihydrotestosterone dependence of the prostate for normal differentiation and growth. The presence of some prostatic tissue in the male pseudohermaphrodites may be due to the fact that there is a decrease and not an absence of 5 alpha-reductase activity, and/or that the increased level of testosterone in subjects with this condition partially compensates for the decreased level of dihydrotestosterone. There was no difference, however, in prostate size between heterozygous fathers and age-matched control males. The heterozygote fathers had dihydrotestosterone production sufficient for normal prostate growth and development.

Using patient reports to assess hospital treatment of persons with AIDS: a pilot study

Providing efficacious, compassionate, and efficient medical care to persons with HIV infection is one of the greatest challenges that will face US hospitals this decade. Unfortunately, there have been almost no studies of how organizational arrangements are related to the quality of care. We developed an interview protocol and conducted a pilot study to evaluate the instrument's ability to detect differences in selected interpersonal aspects of care provided to persons with AIDS. We evaluated the care received in two different treatment models in a major teaching hospital: a designated AIDS unit and general medical beds. We assessed several areas of patient care that are clinically important and that patients can evaluate: communication between patients and providers, patient education, respect for patient preferences, emotional support, involvement of family and friends, trust and confidence, physical care, pain management, AIDS knowledge, perceived segregation, confidentiality, and financial information. Patients generally were very satisfied with their hospital care, but many reported problems with certain aspects of their care. The instrument used detected differences between the care reported by patients treated in general hospital beds and in a designated AIDS unit in several specific aspects of care.