Differing effects of low-dose estrogen-progestin therapy and pravastatin in postmenopausal hypercholesterolemic women

BACKGROUND

Most studies examining the potential cardioprotective effects of postmenopausal estrogen have been undertaken in healthy women, with doses that may not be appropriate for long-term intervention. New low-dose estrogen-progestin regimens alleviate postmenopausal symptoms with a favorable side-effect profile; however, little is known of the impact of such regimens in women at increased risk of cardiovascular disease. Hence, we have evaluated the effects of low-dose oral estrogen-progestin therapy on serum lipoprotein lipids, brachial artery reactivity and fibrinogen in hypercholesterolemic postmenopausal women in direct comparison with the effects of pravastatin, a lipid-lowering agent known to reduce cardiovascular events in women.

METHODS

In a randomized, double-blind, double-dummy, parallel trial, we studied the effects of continuous combined estrogen-progestin therapy (1 mg 17beta-estradiol with 500 micro g norethisterone acetate daily) or pravastatin (20 mg daily) in 72 postmenopausal women with fasting serum low-density lipoprotein (LDL) cholesterol levels greater than 124 mg/dl after an 8-week run-in diet, over a 24-week period. The primary end-point was percentage change in LDL cholesterol from baseline.

RESULTS

The intention-to-treat population comprised 65 women, mean age 59 +/- 6.3 years, and 29 in each group completed the trial. Diet alone reduced LDL cholesterol significantly in both treatment groups, in association with a reduction in weight during this period. Compared with respective baseline values, pravastatin decreased LDL cholesterol and total cholesterol to a greater extent than hormone therapy (p = 0.0001 and 0.003 for difference between treatments, respectively). High-density lipoprotein (HDL) cholesterol levels decreased with hormone therapy, but did not change with pravastatin (p = 0.01). Lipoprotein(a) decreased significantly with hormone therapy only (-14%, 95% confidence interval (CI) -21 to -6%, p = 0.01 for difference between groups). Brachial artery flow-mediated dilatation (FMD) was impaired at baseline, and this increased with hormone therapy (absolute mean change in artery diameter as percentage units 2.07, 95% CI 0.57-3.57, p = 0.009) versus no change with pravastatin (0.19, 95% CI -1.1 to 1.5, p = 0.78), with a near-significant difference between the two groups (p = 0.058). A significant correlation between improved brachial artery FMD and reduction in LDL cholesterol was not observed. Fibrinogen decreased significantly in both treatment groups with no difference between treatments.

CONCLUSIONS

In postmenopausal hypercholesterolemic women, pravastatin and hormone therapy exhibited divergent effects. The former lowered total and LDL cholesterol more effectively, whereas hormone therapy lowered lipoprotein(a) significantly and improved brachial artery endothelium-dependent dilatation, independent of the reduction in LDL cholesterol. The modest increase in brachial artery FMD seen is consistent with hypercholesterolemia compromising endothelial integrity, and suggests that the important effect of estrogen on the endothelial microenvironment may be attenuated in women with endothelial dysfunction.

Smoking modulates neuroendocrine responses to ipsapirone in patients with panic disorder

Reduced 5-HT1A-receptor responsiveness has been reported in patients with panic disorder(PD) and/or agoraphobia (PDA). Although many of these patients are regular smokers, it has not been examined whether psychological or neurobiological effects induced by the selective 5-HT1A-receptor agonist, ipsapirone, are affected by the smoking status of the patients. In order to clarify this question neuroendocrine challenges with oral doses of ipsapirone (0.3 mg/kg) and placebo were performed in 39 patients with PDA, and results were compared between patients who smoked (>10 cigarettes per day, n = 17) and patients who had been non-smokers for at least two years (n = 22). Patients who were smokers (but did not smoke during the challenge procedure) had significantly reduced baseline concentrations of cortisol and a significantly lower body temperature. In comparison to placebo, administration of ipsapirone was associated with significant increases of various psychological symptoms and plasma cortisol concentrations. The subgroup of PD patients who were smokers showed significantly higher cortisol responses to ipsapirone than non-smokers. In conclusion, smoking status has to be taken into account when assessing the responsiveness of 5-HT1A receptors in patients with psychiatric disorders. The prevention of smoking during challenge sessions might not be the ideal approach in heavy smokers, since sudden abstinence from smoking is likely to affect neurobiological and possibly psychological responses to ipsapirone.

Cryosurgical treatment of genuine trigeminal neuralgia

A newly developed cryoprobe for peripheral nerves allows surgeons to freeze branches of the trigeminal nerve at the infraorbital or the mandibular foramen without exposing the nerve or damaging the surrounding tissue. The probe has an outer diameter of 2.7mm, and a vacuum-insulated shaft to protect the adjacent tissue. It is designed to be inserted transmucosally. The cryoprobe was used in 19 patients to freeze the infraorbital nerve or the inferior alveolar nerve. At 4-8 months after cryotherapy sensation in the areas innervated by the treated nerve had returned, but pain was absent for at least 6 months. The pain recurred in 13 out of 19 patients within 6-12 months. However, it was possible to repeat the cryotherapy as the procedure was not stressful. Cryosurgery widens the range of methods available to treat trigeminal neuralgia.

Inhibition of duck hepatitis B virus replication by intrahepatic expression of an antiviral resistance gene

Resistance genes coding for inhibitors of hepadnaviral replication, such as ribozymes, antisense RNA, and dominant negative mutants have been shown to be effective in transfected hepatoma cells. In vivo studies, however, are not available to date. Here we expanded the use of the duck hepatitis B virus (DHBV) model for studying antiviral resistance genes in vivo. Animals were experimentally infected by intravenous injection of DHBV-positive serum in ovo. The use of recombinant human adenovirus type 5 and avian adenovirus CELO for gene transfer was evaluated. Adenovirus type 5 transduced more than 95% and CELO less than 1% of embryonic hepatocytes in vivo. Adenovirus type 5 interfered with DHBV replication (viral cross-talk), but this effect was moderate and did not preclude analysis of specific antiviral effects. Thus adenoviral transfer of a dominant negative mutant prior to DHBV infection (intracellular immunization) yielded 100-fold suppression of viral replication compared to the green fluorescent protein marker gene. Neither gene was toxic. These data demonstrate that a prototype anthepadnaviral resistance gene is functional in vivo. Duck embryos represent a useful model for evaluating gene therapeutic strategies in vivo without the need for large scale preparations of gene delivery vehicles.

[Percutaneous vertebroplasty]

PURPOSE

To describe the procedure of percutaneous vertebroplasty and to present our first clinical results of patients treated for benign or malignant painful vertebral body disease.

MATERIAL AND METHODS

We performed percutaneous vertebroplasty in 31 painful lesions of the spine. Liquid bone cement was injected into the affected vertebral body using fluoroscopic guidance through a bilateral transpedicular approach. Etiology of the bone disease was assessed by biopsy. Pain intensity was assessed before and 1 week after the procedure by standardized catalogue.

RESULTS

Percutaneous vertebroplasty was performed in 17 thoracic and in 14 lumbar spine bodies of benign (n = 23) or malignant (n = 8) disease; no clinically relevant complications occurred. All patients reported significant pain relief 1 week after the intervention. One week after treatment, patients were pain-free in 15/31 vertebral bodies, and reported mild residual pain not necessitating narcotic medication in 16/31 cases.

CONCLUSION

In accordance with the literature, percutaneous vertebroplasty proved to be a highly effective, minimal invasive interventional procedure to treat severely painful bone lesions of benign and malignant origin.

Introduction

In the 1970's researchers demonstrated air-glass fiber profiles as a possible approach to low-loss optical fiber. A few years ago, interest in air-glass fiber profiles was rekindled by the idea of creating two-dimensional photonic band gaps in optical fibers. Typically, these optical fibers have a collection of air holes that run along the length of the fiber. The discovery of a number of interesting physical effects, some not necessarily associated with photonic band gaps, has blossomed into the field of Photonic Crystal Fiber. Along with that, a potentially confusing series of monikers has developed to distinguish between the various embodiments. Fortunately, the physics describing the fibers conveniently separates them into two distinct classes, those employing photonic band gaps for guidance and those that use a type of total internal reflection for guidance. The terms holey fiber, hole-assisted fiber, microstructured fiber, and effective-index fiber refer to fibers that employ total internal reflection as the guidance mechanism. Photonic band-gap fiber, Bragg fiber, and omnidirectional waveguide refer to fibers that use photonic band gaps as the guidance mechanism. We have used the term photonic crystal fiber (PCF), the highlight of this Focus Issue, to represent all these types of fibers. Though not all of the fiber profiles contain extended periodic structures normally associated with crystal structures, most all do possess a degree of regularity in the fiber profile that imparts mechanical and optical advantage.

[Metastatic epidural spinal compression: prognostic factors and results of radiotherapy]

BACKGROUND

The metastatic epidural spinal cord compression is an oncologic emergency. Presently, there is no agreement on a standard diagnostic or therapeutic algorithm. In spite of improvement in diagnostic imaging, a great proportion of patients are plegic at the time of the first presentation.

PATIENTS AND METHODS

Therapy charts of 53 consecutive patients--31 male and 22 female--with metastatic epidural spinal cord compression treated with radiation therapy only have been analyzed. Median age was 60 years. The most frequent primary tumors were bronchogenic carcinoma (13 patients), breast cancer (ten patients) and prostate cancer (ten patients).

RESULTS

MRI was the most sensitive diagnostic tool in detecting spinal cord compression. Plain X-ray films were not useful. Pain symptoms were improved in 66% of the patients. The most important prognostic factor was the pretreatment mobility status. 94% of the ambulatory patients kept their walking ability, but only one plegic patient could walk again after radiation therapy (p < 0.001). Patients whose back pain was presented to an oncologist were more likely to keep their walking ability by the end of the therapy. Patients with bronchogenic cancer and plegic patients had a significantly worse survival.

CONCLUSION

Patients with a known malignant tumor and progressive or axial back pain should undergo MRI scan to rule out spinal cord compression. For patients without severe neurologic deficit and MRI proven epidural compression, radiation therapy is able to preserve walking ability and reduce pain. For patients with neurologic symptoms radiation therapy should start within 24 hours.

Is nausea associated with chronic hepatitis C infection?

OBJECTIVES

Hepatitis C virus is a common chronic infection that is widely associated with symptoms of fatigue and pain in the right upper quadrant. Nausea may be an underrecognized symptom. This study was designed to study the frequency of nausea in patients with hepatitis C virus infection compared to controls.

METHODS

A cross-sectional study design with consecutive outpatients was used. Three groups were administered a dyspepsia and a previously validated Nausea Profile questionnaire. Univariate and multivariate analysis was performed.

RESULTS

A total of 64 hepatitis C virus (HCV) patients, 53 liver disease controls (LC), and 64 normal controls (NC) were studied. An increased period prevalence of nausea was found in HCV patients 43% versus 29.7% in NC and 18.9% in LC (p = 0.009). There was an increased frequency of fatigue and abdominal pain in HCV patients over 1 month compared to LC and NC combined (p = 0.0001 and 0.0065 respectively). The Nausea Profile score revealed statistically higher total scores and higher subscale scores in the HCV group compared to controls. The total NP score expressed as a percentage of the maximum was 27% in HCV versus 12.7% for LC and 9.2% for NC (p = 0.0005). The odds of nausea using logistic regression were 2.1 CI (1.0-4.5) in HCV patients compared to controls (p = 0.05). Using linear regression, higher Nausea Profile scores were found to be independently associated with the diagnosis of HCV (.0005), fatigue (p = 0.0003), and abdominal pain (p = 0.0001).

CONCLUSIONS

HCV infection is associated with an increased risk for nausea. The strong association between abdominal pain and nausea may be a clue to the etiology of nausea in these patients. Further etiological studies are needed.

Systemic inflammatory response syndrome, organ failure, and outcome in critically ill obstetric patients treated in an ICU

STUDY OBJECTIVES

To determine the incidence of systemic inflammatory response syndrome (SIRS) and organ failure and to describe the outcomes in critically ill obstetric patients who have been treated in medical ICUs.

DESIGN

Retrospective review.

SETTING

A multidisciplinary ICU at a tertiary-care institution.

METHODS

We collected data on 74 obstetric patients who were admitted consecutively to the ICU from January 1991 through December 1998. Acute physiology and chronic health evaluation (APACHE) II scores were calculated. A p value < 0.05 was considered to be significant.

MEASUREMENTS AND RESULTS

Fifty-eight percent of patients were admitted to the ICU postpartum. Their mean (+/- SD) age was 25.9 +/- 7.0 years, and 64% were African American and 34% were white. Fifty percent had preexisting medical conditions. Their mean APACHE II score was 14.0 +/- 5.9, and their predicted mortality rate was 17.6%. The most common reason for admission was respiratory insufficiency. Preeclampsia was present in 38% of patients, and hemolytic anemia, elevated liver enzymes, and low platelet count syndrome were present in 7% of patients. SIRS developed in 59% of patients. Patients with SIRS had longer ICU stays (p = 0.0008). Organ failure developed in 65% of patients, and ARDS developed in 15% of patients. Invasive mechanical ventilation was required in 45% of patients, and pulmonary artery catheterization was required in 35% of patients. The in-hospital mortality rate was 2.7%. There were five spontaneous abortions and eight perinatal deaths.

CONCLUSIONS

The most common reason for admission to the ICU of critically ill obstetric patients was respiratory failure. Despite the severity of illness and the development of SIRS and organ failure in most patients, the mortality rate was low.

Movement and regeneration of epicuticular waxes through plant cuticles

Regeneration of plant epicuticular waxes was studied in 24 plant species by high-resolution scanning electron microscopy. According to their regeneration behaviour, four groups could be distinguished: (i) regeneration occurs at all stages of development; (ii) regeneration occurs only during leaf expansion; (iii) regeneration occurs only in fully developed leaves; (iv) plants were not able to regenerate wax. Wax was removed from the leaves with water-based glue and a liquid polymer, i.e. water-based polyurethane dispersion. In young leaves these coverings could not be removed without damaging the leaves. After a few days, waxes appeared on the surface of these polymer films, which still adhered to the leaves. It is concluded that waxes move through the cuticle in a process similar to steam distillation. This hypothesis could be further substantiated in refined in vitro experiments. Wax isolated from Eucalyptus globulus was applied to a filter paper, subsequently covered with a liquid polymer and fixed onto a diffusion chamber filled with water. The diffusion chamber was put into a desiccator. After 8-10 days at room temperature, crystals similar in dimensions and shape to in situ crystals appeared on the surface of the polyurethane film. This indicates that waxes in molecular dimensions move together with the water vapor that permeates through the polymer membrane. Based on these results, we propose a new and simple hypothesis for the mechanism of wax movement: the molecules that finally form the epicuticular wax crystals are moved in the cuticular water current.

Immunohistochemical characterization of the pancreatic cellular infiltrate in normal pancreas, chronic pancreatitis and pancreatic carcinoma

BACKGROUND/AIMS

Chronic pancreatitis is histologically characterized by an extended fibrosis and infiltration of leukocytes. We intended to differentiate the infiltration to evaluate the inflammatory process.

METHODS

Samples of tissues of normal pancreas (NP, n = 12), of chronic pancreatitis (CP, n = 7), and pancreatic tissues surrounding pancreatic carcinoma (CA, n = 7) were investigated by immunohistochemical staining using the APAAP technique.

RESULTS

In normal pancreas, mononuclear cells (47.1 +/- 26.0 cells/mm2) were observed with a predominance of macrophages (56.3%) and T lymphocytes (31.3%) which were differentiated in CD8+ lymphocytes (9.3 +/- 7.2 cells/ mm2) and CD4+ lymphocytes (6.7 +/- 3.2 cells/mm2). Rarely, plasma cells (5.3%) and B lymphocytes (7.1%) could be detected. In pancreatic tissue of patients with CP and in CA there was a significant increase of mononuclear cells to 264.4 +/- 120.3 cells/mm2 and 284.3 +/- 67.8 cells/mm2, respectively. In both diseases percentages of T lymphocytes (CP: 50.5%; CA: 48.1%) were higher than in normal controls. CD4+/CD8+ ratio of 0.77 in CP and 0.82 in CA demonstrated a predominance of CD8+ cells compared to the peripheral blood. In NP and CA, nearly all T lymphocytes expressed CD45R0 identifying memory cells, while only 58% of T lymphocytes were CD45R0 positive in CP.

CONCLUSION

Our data suggest that the investigated cases of CP were of a common inflammatory type rather than due to an autoimmunological reaction. CD8+ T lymphocytes were the predominant T cell subset in the inflammatory infiltrates in both CP and CA.